HomeMy WebLinkAbout0063 CAPTAIN ALDEN'S LANE - Health 63 Captain Alden's Lane
Osterville P
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No. <� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB.LE, MASSACHUSETTS s
3 ZIpplication for �Bi Y ps;tem Con0truction Permit
P4 Applicatio for a Permit to onstruct�( �) Repair(Upgrade O Abandon O ❑.Complete System El Individual Components
Location Address or Lot No. �iUs�%A�.l��°�'r zA, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel,,,0��®4F,6
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons ! Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ������
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bo Health.
�' _
Signed , Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. r Date Issued
———————————————————————————— —— —— —'
: -�°.-
No Fee /_ s
'' Entered in computer
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC.HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
ZIppricat on for �hgpoal�&Pgtem Con0truction Permit •
C'/+
Applicatio for aP/rmit to Const N Individual Components
Repair(Upgrade O Abandon O Complete System ❑ ,
Location Address or Lot No. 6l C4,pvl r z , Owner's Name,Address;and Tel.No.
cfz�liL�`
`Assessor's Map/ParcelIW- o 47�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons - Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature.of Repairs or AlteratiSns(Answer when applicable)
! r
Date last inspected:
f9y Agreement:
The undersigned agrees to ensure the construction and maintenance.of the afore described on-site sewage disposal system in
"accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Bo Health.
Signed /J Date
` r /
Application Approved by / Date
Application Disapproved by: Date y
for the following reasons
r
Permit No. Date Issued
1 THE COMMONWEALTH OF MASSACHUSETTS95
-
V BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (+v) Upgraded ( )
Abandoned( )by t._r__1007 I---
at ,(�J�/1✓ �'L.��� Lam, D�'T ha b en o struct ordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer Designer I
#bedrooms Approved des ow ( gdd {
The issuanc ,,; i pe it sh1J of be construed as a guarantee that the system will fti n s desig ed� �?
Date �� Inspector
U
No. / Fee
HE COMMONWEALTH OF MASSACHUSETTS v
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Mmigoml *patent Construction Permit ,p�
Permission is hereby granted to Construct ( ) Repair (114 Upgrade ( ) Abandon ( ) w
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction st/be c m fete within three years of the date of this t•er'�tnrt. (7
Date Approved by i 7 ' /
1
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h V V
Page 1.of Yl l .a`
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6
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A ._ �._.
`--.D
CERTIFICATION
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE LR
� ® � Z� �
OF 13ARNSTABLE
Owner's Name: DANIEL JOHNSON EALTH DEPT,
Owner's Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Date of Inspection: 12/12/0� p 4., i
Name of Inspector: DANIEL B.JOHNSON
Company Name: DOMESTIC SEPTIC DESIGN,INC.
Mailing Address: 804 MAIN STREET,SUITE B,OSTERVILLE,MA 02655 PARCH., ®.U L ® 6 1
w
Telephone Number: (508) 420-1904
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
_ Fails )-
Inspector's Signature: �/ Date: of- 5/4-
The system inspector shall submit a copy of this inspection report,to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments:
****This report n p rt 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. -'
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Page 2.of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON
Date of Inspection: 12/12/03
Inspection Summary: Check_A,B,C,D or E%ALWAYS complete all of Section D t
A. System Passes:
i
X 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.
t
Comments: i
B. System Conditionally Passes: N/A
_ 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.
s
Answer yes,no or not determined(Y,N,ND)in the_ for the following statements. If"not determined"please
explain.
_The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial 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.
ND explain:
_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
- broken pipe(s)are replaced f3
obstruction is removed
1
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON -
Date of Inspection: IV12/0� D t,
C. Further Evaluation is Required by the Board of Health: N/A
_ Conditions exist which require fiuther 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
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 I of a public water supply.
— The system has a septic tank and SAS.and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria
and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVELLE
Owner: DANIEL JOHNSON
Date of Inspection: 12/12/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for a inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than V2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO (Yes/No)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: N/A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or
answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered
a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11 F.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Property Address: 63 CAPTAIN ALDENS LANE,OSTERYILLE
Owner. DANIEL JOHNSON
Date of Inspection: 12/12/03
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner, occupant,or Board of Health
1
X Were any of the system'components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period? t
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwellinginspected for signs of sewage back u ?
P '� g P
X _ Was the site inspected for signs of break out?
I
X _ Were all system components,excluding the SAS,located on site?
• t.
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems? }
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example, a plan at the Board of Health. i
r,
_ X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
F
Page 6-of I 1
OFFICIAL INSPECTION F0RM5-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
Property Address: 63 CAPTAIN ALDENS LANE;OSTERVILLE
Owner. DANIEL JOHNSON
Date of Inspection: IV12/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 TITLE V REGS
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no):N/A
Seasonal use:(yes or no): NO
IF Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no): NO
Last date of occupancy: 12/1/03
COM IER CIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: SPRING OF 2003
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained'
from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information: 1999-AS-BUILT PLAN
Were sewage odors detected when arriving at the site(yes or no)` NO
t'
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued):
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON
Date of Inspection: IV12/03
BUILDING SEWER(locate on site plan) YES
Depth below grade: 2' (EST.)
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: -
Comments(on condition of joints,venting,evidence of leakage,etc.):
CONC.JOINT.
SEPTIC TANK: YESlocate on site plan)
Depth below grade: 18"
Material of construction:X concrete_metal_f iberglass_polyethylene _other(explain). .
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _ (attach a copy of
certificate)
Dimensions: 8'L X 5'W X 49"H(EFFECT.)
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 23"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 21"
How were dimensions determined: SEPTIC MEASURING POLE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.): NO NEED TO PUMP TANK. INLET CONCRETE TEE
APPEARS TO BE IN GOOD CONDITION: OUTLET PVC TEE IN GOOD CONDITION. ZABEL FILTER IN
GOOD CONDITION(CLEANED AFTER THE INSPECTION). LIQUID LEVEL AT OUTLET INVERT.
TANK APPEARS TO BE IN GOOD CONDITION. NO SIGNS OF LEAKS.
GREASE TRAP: NONE(locate on site plan)
Depth below grade:_
Material of construction:_concrete metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,_structural integrity,liquid levels as
related to outlet invert, evidence of leakage,etc.):
Page 8 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM'
PART C
SYSTEM INFORMATION(continued)
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON
Date of Inspection: 12/12/03
TIGHT or HOLDING TANK: NONE (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: YES(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 LEVEL WITH EVEN DISTRIBUTION(ONLY ONE OUTLET
LATERAL EXISTS). NO SIGNS OF SLUDGE IN D-BOX. SLIGHT SCUM IN LATERAL AND ALONG
SIDES OF D-BOX(SCUM REMOVED FROM OUTLET LATERAL AFTER THE INSPECTION). D-BOX
APPEARS TO BE IN GOOD CONDITION. NO SIGNS OF LEAKS.
PUMP CHAMBER: NONE (locate on site plan)
Pumps in working order(yes or no);
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Page 9 of 1 I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON
Date of Inspection: 12/12/03
SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required)
If SAS not located explain why: ,
Type
_ leaching pits,number:
X leaching chambers, number: 4 INFILTRATOR LEACHING CHAMBERS(AS-BUILT PLAN)
— 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.): NO SIGNS OF HYDRAULIC FAILURE OR PONDING. STONE DRY WITH NO SIGNS OF EFFLUENT
STAINS AT END OF INFILTRATORS. SAS VENTED.
CESSPOOLS: NONE (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.):
PRIVY: NONE (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON
Date of Inspection: 12/12/03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
PEAK ffcost C-�r?T'/"j
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Page 11 of i 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 63 CAPTAIN ALDENS LANE,OSTERVILLE
Owner: DANIEL JOHNSON
Date of Inspection: 12/12/03
SITE EXAM
Slope LEVEL-2%
Surface water N/A
Check cellar DRY-NO SUMP PUMP
Shallow wells N/A
Estimated depth to ground water >6 feet
Please indicate(check)all methods used to determine the high ground water elevation:
1
_ Obtained from system design plans on record-If checked,date of design plan reviewed:
_ Observed site(abutting property/observation hole within 150 feet of SAS) g
_ Checked with local Board of Health-explain:
X Checked with local excavators,installers-(attach documentation)
_ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
AS-BUILT PLAN INDICATES GW>5 FEET BELOW GRADE. ACCORDING TO THE GROUNDWATER '
OVERLAY MAP FOR THE TOWN OF BARNSTABLE SHOWS THAT GW IS 20 FEET BELOW GRADE
AT THE SUBJECT SITE. NO GW WAS OBSERVED IN SAS DURING THE INSPECTION. BOTTOM OF
SAS AT 5.5' -6' BELOW GRADE. BASED ON THE ABOVE,IT APPEARS THAT NO HIGH GW
INTERFERENCE EXISTS WITHIN THE SAS.
NOTE THAT THE ONLY DEFINITIVE MEANS TO DETERMINE HIGH GW IS TO PERFORM A SOIL TEST s
ON THE PROPERTY BY AN APPROVED SOIL EVALUATOR.
III
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1
1
_V J�
' 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)
I, � l
0��� � `�O �, hereby certify that the application for disposal works
construction permit signed by me dated �l �lQ� , concerning the
property located at �J / G/e�15 meets all of the
following criteria:
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
t✓ There are no wetlands within 100 feet of the proposed septic system
IV 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
y There are no variances requested or needed.
y 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,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) Groundwater Table Elevation Z� max. adjusted g.w., "Z- _. b
DIFFERENCE `.
SIGNED : DATE:
[Sketch proposed plan of system on back].
q:health folder:cert
TOWN
- .. TOWNOF BARNSTABLE
—AION �3 � le, �
SEWAGE #
A-LAGE ®�1 ��✓0le ASSESSOR'S MAP& LOT/y4-OV0,40/
INSTALLER'S NAME&PHONE NO. !i®r/'Zelrl
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) L•d�L�. � (size �D iC 0 r�o7
type ) 3
NO.OF BEDROOMS 3
BUILDER ONO 9 M_�
PERMUDATE: / COMPLIANCE DATE: l ��
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 t/J�
on site or within 200 feet of leaching facility) "' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist y/�4
within 300 feet of leaching facility) Feet
Furnished by
-}(3
Side
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o C ved
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No. �® r.l Fee t/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Miopozaf *p5tem Conotruction Permit
Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) O Complete System L+ Khvidual Components
Location Address or Lot No.�7 C�� /�f pes /0 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. / 4� Designer's Name,Address and Tel.No.
L' I ,v 4�v/,,/-/6;0P1f1.5iJ11_
7 7/-11:� �
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow d/O gallons per day. Calculated daily flow _3 3a gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank%�E�E''9� .1'%5�`�/i`� Type of S.A.S. q SX ,3D;5—,i'
Description of Soil 00�/
Nature of Repairs or Alterations(Answer when applicable) OF
"��GZ` �i� ��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y th' B rd Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. 0�( --. Fee
3 Entered in computer.
e THE COMMONWEALTH OF MASSACHUSETTS 4 Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Di-4pont *patent Con.5truction Permit
Application for a Permit to Construct( ')Repair(1�)Upgrade( )Abandon( )' "El Complete System IJ Individual Components
Location Address or Lot No. C' ` O�� /� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel O51-41 f 10
,f✓ 6
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4
3t 7`44,9//6;0P0.eP
Type of Building
Dwelling No of Bedrooms Lot Size sq.ft. Garbage Grinder( )
w g. No of Persons Showers`
Other T e of'Butldiri"' Rev �'!fiG'�`' . ' � � ��""�_' (tom) Gafetena '-
Other Fixtures at
Design Flow -7 gallons per day. Calculated daily flow -33D gallons.
Plan Date ° Number of sheets Revision Date
Title
Size of Septic Tank ®��'9� .�X�S f�/9 Type of S.A.S. q 3
Description of Soil y �r C4Gi�y
t Nature of Repairs or Alterations(Answer when applicable) �fi^e, /�^
1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system;. ;
in accordance with the provisions of Title 5'of.the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y th . Boy, Health.—
Signed Date /
Application Approved by Date l�
.w�--,:.Application-Disapproved-for the following:reason:s
Permit No. Date Issued
4
THE COMMONWEALTH OF MASSACHUSETTS ���j O�l�• �D�
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal.System Constructed( )Repaired ( V)Upgraded( )
Abandoned( )by Dr 7� o "o>o`•
at b�7L G ��'?- /n'r : ✓` fly/. has been constructe inordance
with the provisionsof Title 5 and the for Disposal System Construction Permit No. dated j
Installor� �� lJ Designer
The issuance of this permit shall pot be construed as a guarantee that the syst will'f nctiop�-s desi ne
Date f — `/ / Inspector / (/G �-'•
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Digogai *potem Con5truction Permit
Permission is hereby granted to Construct(�/)Repair( �Upgj3ade( )Abandon( )!
System located at 65 6V /¢ ���1.5 71
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
gbegcompleted within three years of the date of this QQ
Date: �— / / Approved by _
d u'MiY .e.Y w _N•..w
CAT ION _ SEWAGE P RMIT NO,
VILLAGE.. 00 1
INSTA LITER'S/ NAME b ADDRESS
B U I L D E R OR OWN ER
loe
DATE PERMIT ISSUED
DAT E C 0 M P L I A N C E ISSUED /--�-1'7
V
ry
o(�
1
� ��
No..7 Fizz........................
THE COMMONWEALTH OF MASSACHUSETTS
Vo
BOARD OF HEALTH
�
-.7ow-A)...............OF.......S*9.k./V... &.6...........................
Appliration for llhipwial Warkfi Tomitrurtion ramit
4�3 Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
....... ......... .......Ond..............................................
14 ation.-Address 'M '/0q 1h Lr-11 13ar-3/0
........... .................................. owl ....................
jW ... ..........................
er Address
nstall er Address
Type of BuildingSize Lot.Z.53/2,>......Sq. feet
U
Dwelling—No. of Bedrooms.--........................................Expansion Attic*0 Garbage Grinder (Va
�4
A4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
P4 Other fixtures ......................................
------------------------------**---------------------------------*------------
Design Flow........... ...................gallons per PWe ay. Total daily flow........37.3.'xQ...................gallons,,,,
9 Septic Tank—Liquid capacity/&M.gallons Length6..,i:L Width.14.Ze."'Diameter................ Depth—S.."06...
Disposal Trench—No .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----- _—Diameter.6?............ Depth below inlet.le5............. Total leaching area tQ__6W---sq. f t.
-------------I
Z Other Distribution box V) Dosing tank
Percolation Test Results Performed e-�I,;�P&0.......615.f....... Date.....((191'>6------------
Test Pit No. l...,.e,'_..1—.minutes per inch Depth of Test Pit../..'A .......... Depth to ground water./Iia.ev.4.......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------- ----------------- ......................."-------------------**---------------------------------------- ---------------
0 Description of Soil....... ...........4.1�'W. .....elwp....... ..................................................................
.............m4ed�..eN.......... p.........................................................................
U ....................................... ....... ...g
.....................................................I...................................................................................................................................................
4i
U Nature of Repairs or Alterations—Answer when applicable.-.............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig ...... .............................................................. Date..............
Application Approved By......... 'Mw. ................. . ......................... n
Date
Application Disapproved for the following reasons:....... ......................................................................................................
.............................................................. ................. .. ..........................................................................................................
Date
Permit No........................ .1............. i Issued_.P=..Z•.../i------
/_/-------------------
a e
No..�9. �� - Fps... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
W..JV...............OF.......C J. .0 -.. .; - .1, ........_..............
Appliraatiou for Bis us al Works C oui3tratrtiou Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
. �..33. ,C^��1 1 /' ��` ,L. y,� .��•,,g»/���i ................../' !_
`..1 'C..— •-��I `_/,may'}
o do ddress � e
... 1 8 , A
---------------- .... . .......... ....r.. - f' ........... -...........
Wr. Owner Address
a ......... .......
Installer Address
Type of Building Size Lot./$ l.-_k>......Sq. feet
Dwelling—No. of Bedrooms.-
..........................................Expansion Attic !(IO) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) = Cafeteria
Otherfixtures .......................... ...- ' N------•------- a--•-----•--•-- ----•--------•--.---------•------------
Des>gn Flow..... XZ2................... pear. Tota da>1y flow........ -----•-•----.......gallons.h WSeptic Tank—Liquid capacity/,*W.gallons Lengthd_ Widt !..;-r1.. Diameter................ Depth.. _ ._-
.
x Disposal Trench—No .................... Width.................... Total Length ....... .... Total leaching area.... ...........sq. ft.
3 Seepage Pit No...... ._..... lameter. _. .......... Dep-h below inlet.4 .. .._._ Total leaching area ...sq. ft.
Z Other Distribution box Dosing tank
'-' Percolation Test Results Performed by?Z&N 4 4 h:.....A"-6.Ze*5PfZR.... ...... Date.. f r�� .�.a.............
�7
Test Pit No. 1.. .!?---:cmmutes per inch Depthf`of Test Pit•-e! __...._... Depth to ground water.Ajo.11A.4"........
44 Test Pit No. 2................minutes per inch Depth' of Test Pit.................... Depth to ground water........................
................................................. --- ....._i.......................................-...............................
O Description of Soil------ -----
.......Av
UW •--•-•----------------------------•-•---•-....--------------------------------:....--.---------••-••--•--- -------------------•......-...............................................................
Nature of Repairs or Alterations-Answer when'applicable_,.......................................:...........:...:.....................................
---------------------------------------•--------------•-----------------•--.........-•--•---....--••--•--..;•-----------•---`-•---....................................................................
Agreement:
The undersigned agrees to install,,the aforede c-ibed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig • . ..........................................•............................ ------.............--
Application Approved B e � /e
Date
Application Disapproved for the following reasons-------------•--------------...........------------------•--•----------------------•-----•-•--••--..........._._
---.....•------------•------------------------------------------------------•-•--------.....---------••-.--------------.....----•---------------...-••----•-----•-•------------------------•------..----
Date
Permit No.................. -•-- Issued....-----•-----------...................
.__._...... --•--------•-------- � Date ------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF......... ,/' .,N...��a � G:. ....................
Trrtifirab of Toutplitattrr
THIS I VOC SFRT hat the Individual Sewage Disposal System constructed ( �r Repaired ( )
by - ..--.. .. -- ........
has been installed in accordance with the provisions of ` of The State SanitaryC de as described in the
application.for Disposal Works Construction Permit Ndg.-�7�-------------- dat ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL F TION SATISFACTORY.
DATE. _r-------------------------
Insgector.._--•---------------------- .. ......................................
yw.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� I .C :a.R"' .............OF.........d„.3a. 11: / r .1 ................... �+r1+`+� ..
O..::..... ............ 'FEE
�t��ro� o �oatutrttrttion �erntit ;
Permission is ereby granted....... ..LL.------•------••------••------•...........................•=•--.....•----...............•-•-•-
to Construct ( ) or Repair ( ) an Individual SeMr a isposal System
at No.. Q:.r`• --------------1916,211) .......
Street
as shown on the application for Disposal Works Construction P t No. ,___ .._.._;:.'_" ated...c1.. - ,li.............
�
Board of Health.,... ...................._ �r
DATE................................................................................
FORM 1255 HOBBS,& WARREN. INC.. PUBLISHERS ��.,,,; •.::
--A/ TEST N o � E
s NOV, G , l q 7B
PRUL MURRAY- INSPeCTOR
`77
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