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M ,.�,;�,, ",��, ­1- i.,,i�,',�,,l,,i­ , ,, - I���,�,� �111 � " , , ,� ,�'Yi , ,��. , , ,� � . V 1 �-----------------------. i� Y! " ,,.,'j�_ �­ ,��,6,'r K,i4 , ,� 4,ii,;� ,­,�,,��r�� �'j`�,.`,� "I'll 11�.....?��-, , �� ... L'1� R 11101 1 � L�." _�i� -U,�,P,,�a ��4L�'i.� ,� -" �� 4,,�1-uwwx�A­000 3,�,P,,�a ��I DATE 10175106 PROPERTY ADDRESS 18 Ta-i2w"indz D,,z ive �GS 0zte'zv.iiie • mazz 02655 / On the above date, the septic system at the address above was Inspected. This system consists of the following.: 1., 1.-1500 ga-Uorz 3ept"ic tank.i 2.1 1-Diit2-igut"ion Box.i 3o 4-In/iitzato2e 10'X40'X2' Based on inspection, I certify the following conditions: 4.! 7h.ia "i.6 a 7.itie Five 'sept"ie zyztem.' 5., Septic eyztem. 1,6 in p zopea wo zk.ing o zde2 at the R2ezent time., SIGNATURE Name: Robert A.'Paolini Company: Joseph P. Macomber & Son Inc . Address: P. 0. Box 66 Centerville, Mass 02632 7 - , Phone: 508-775-3338 or 508-775-6412 -n v JOSEPH P. MACOMBER & SON, INC. - Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 . Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ..DEPARTMENT OF ENVIRONMENTAL PROTECTION b , TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: anme-3 can yw¢y Owner's Address: 2042 Otz t e2 71a2 7 one Date of Inspection: 10 15 0 h Name of Inspector: (please print) Robert A Pao.l'ini Company Name: g, l—Naco n�.ea & ..5oon Inc. Mailing Address: ---.: aen e, a.�..s. 02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 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.13:340 of Title 5(310 CMR M600). The system: Passes °Conditionally Passes Deed Further Evaluation by the Local Approving Authority Fa' 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title S Tnenvr.#inn Pnrm 6/15/1000 Daee I Page 2 of)1 OFFICIAL INSPECTION,.FORM—:NOT- FOR VOLUNTARY ASSESSM NTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �— PART A CERTIFICATION(continued) Property Address: 17 Ta.i zw.ind¢ Dz i.ve Ozte2y-G-�-Qe e Owner: lame- Lan gwau Date of Inspection: 101 7 5/0 6 Inspection Summary: Check :A,B,C,D or E/ALWrAY&tomplete all of Section.D A. System Passes: qEs, NO I have not found any information which indieates'thatany 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: SeRt.ic hubtem -&3 in /2/Lo/7e/t wo-,zkirzg o2de2 at the /22ebent t.ime.l . B. System Conditionally Passes: NO 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic tank is metal.and.over-20 years old*or the septip 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.j 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: ND Observation of sewage backup*or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection,.if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled br replaced ND explain: NO 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: 2. Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 18 f a i�w� zcl�s �2 give Owner: lamez Langwau Date of Inspection: 1 Q/1 5/0 h C. Further Evaluation is Required by the Board of Health: NO Conditions.exist which.require further evaluation by the Board.of Health in order to determine if them 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: n 0 Cesspool or privy is within.50 feet of a surface water n o 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: no The system has a septic tank and soil absorption system(SAS).and the SAS is within 100 feet.ofa surface water supply or tributary to a.surface water supply. n o The system has a.septic tank and SAS and the SAS is within a Zone 1 of a public water supply. pLO The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. 1�2 The system has a septic.tank and SAS and the SAS is less than 100 feet.but 50 feet or more frorfi 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: - 3 — - I Page.4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 18 la i2windz Da ive z e/tVi-ete Owner: lame, Langwau Date of Inspection: 10115106 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following;for all inspections: Yes No v Backup of sewage into facility or system component due to overloaded.or clogged SAS or cesspool y 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'h•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. v Any portion of a cesspool or privy is within a Zone I of a.public well. v 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 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 mast be attached to this forte.] 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.sfi aWd 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.afacility with a design flow of.1.0100.0 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 _ X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply _ X the.system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. 4 Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM PART B CHECKLIST, Property Address: 18 T-az2w�ihd s D z-ive Owner: lame.6 Lanawau Date of Inspection: 10175106 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 X 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? 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 dwelling inspected for signs of sewage back up ? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site? 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? X _ 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>he Board of Health. 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 18 [hive Owner: name, Lanyway Date of Inspection: 10/15/0 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no):_�&z Is laundry on a separate sewage system(yes or no): n o [if yes separate inspection required] Laundry system inspected(yes or no):_ap Seasonal use-(yes or no): y e z 2004=708, 000 yaeeonz ryPD=295.i89 Water meter readings, if available(last 2 years usage(gpd))2005=1151 006 yaUonz G%D=315.i07 Sump pump(yes or no): n o Last date of occupancy: unknown COMMERCIAL/IrODUSTRIAL NIA Type of establishment: Design flow('.Wd 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: 5/6/04 m.ian.t a! Naeom&ea Was system pumped as part of the inspection(yes or no): n o 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 ob_tained 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: 9 yeaaz a,3 9u.i-ft Were sewage odors detected when arriving at the site(yes or.no): n o 6 e Pag7 D f1l OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 ;1a i.,zwihd,3 DIt ive et env. P.�e Owner: games .Lanerwau Date of Inspection: 10115106 BUILDING SEWER(locate on site plan) Depth below grade: 18" 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.): Joints a1212ea2 tight no ieakagP iVn #vr/ 1hnn1ii7h hoiL4 lignt SEPTIC TANK:�Le.6(locate on site plan) 7500 ga P.4 o n z Depth below grade: z 4" Material of construction: X concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_.(attach a copy of certificate) r u i1 �' n Dimensions: (� 0 ) 5 )C Sludge depth: Distance from top of sludge to bottom of outlet tee.or baffle: e' ' Scum thickness:�scum t�= Distance from top of o top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: !RX-C._ How were dimensions determined: n'-C-Ca-_-`o f C Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _- %umR tank eve.¢u unna u arzadaye •Ci6pg6aC E3 -Tank i'3 .6tAuctulta-eeil bound Iniel R oul ief foa s n4,2 :., ^BE6E$.T-- GREASE TRAP:&L(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,inlei and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): g2eabe t/ta/p i.6 not pytebent 7 ' r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 18 7a i¢wind. D t ive ,3 t e 2 v.c e. Owner: jamez Langwau . Date of Inspection: 7 Q/15/0 6 TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: - Material of construction: concrete metal fiberglass polyethylene othef(explain): Dimensions: Capacity: Qallons 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.): 7.ight oa ho.2d.ing .tank ate not p1te,3en.t.1, DISTRIBUTION BOX: g e_-s(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.): Box .ins eeveio Kays I iate zaio No zo P.id eaaa oven o2 .Peak¢ e .in on out o ox.1 PUMP CHAMBER: iVO (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.): 1 uml2chamPUIL -i.3 not Raehent 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C'. -SYSTEM INFORMATION(continued): Property Address:18 4a i zw rod s -DIt ive 0.s.teay.i.e.ee Owner: Jame,3 Langwau Date of Inspection: 10115106 SOIL ABSORPTION SYSTEM_(SAS): (locate on site plan,excavation not.required) If SAS not located explain why: Located .see /Rage 10.E Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: 4_.n a pt,?n t n j 10'X 4 0'X2:.' 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.): �. Loamy to medium hand no z.igaz o� Oa.iiulte oa /Rond.ing., So.iea ate d2y v.egeta.t.ion .i.6 no2mae., CESSPOOLS: NU (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(yeior no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce,3,3/2oo e s aae not a/tezen.t PRIVY: NO (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.): l R.i.vy i,6 no t /22e.6ent 9 Page 10,of 11 OFFiICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISP,OSAlJ SYSTEM INSPECTION FORM PART C.. SYSTEM INFORMATION(continued) Property Address: 18 ,3 g zV' ,g Owner: �amge Lan e/wa y Date of Inspection:I Q/15/0 6 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at Ieast two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters.the building: I - o 3 Iayz 10 Page 1 Lof 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION,(continued) Property Address: 18 Fa.t2winde Dlz-ive Owner: aame,3 angway Date of Inspection: I P/15/0 6 SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: N 0 Obtained from system design plans on record-If checked,date of design plan reviewed: y e 3 Observed site(abutting property/observation hole within 150 feet of SAS) r�e.6 Checked with local Board of Health-explain:�� u i P t �� / no Checkedwith local excavators,installers-(attach documentation) e,3Accessed USGS database-explainAtt/2 t own.'&aanz;t a ma.-u,3 /—. You must describe how you established the high ground water elevation: /1,6ed : Cape Cod Comm.i,6.ion ldatea 7agie CoAtouaz And P ua&c /Vatea Supl2iy Ueii head Raotec•t.ion aaeaz oa/z , Se,t 1995 Vate2 ze,30u2ce,6 o-1,l.ice cape cod corm-Lion , ru • Leaching Pit feet Groundwate35 Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method 3,z Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is �� feet: 11 .,,�.,.�.-�,•..r..*-.;�.-a.,,.�....,....�...�.�,•. �I1�.S �� I30ATtD QF 11EA'L'1'II TOWN OF � y a91JUSURFACR s9KAGE DISPOSAL SYSTV INSPEOTI.ON FORM - PART D.•- CERTIFICATION ""'"''''`'"''"""``°"'h""�,n+..,....�•• -TYPt OA PAIHT,ClAAI,Y- PROPERTY rvPm7'FO STREET ADDRESS A'SS.ESSORS MAP, BLO-OK_ AND 'PARCE'li OWNER'a NAME 24 PART'- D CRRTIFICAT3ON , NAME '0'F INSPECTOR Rob,ert Pa o_ii:rii COMPANY NAME Jo'sen p � ri�hPr Eor�, .iic --- - COMPANY AUD.RESS 6�'.C -. 0 ox=" rx ville- M'A1'0.;�63-2-0068 Str• Town-or City.. ItaLP• ZIP COMPANY TELEPHONE t 508. 07.5 3338 FAX (' 508•1.1790 f 578 CERTI'FICATION. STATEMENT I .certify that. I hava personal-lY .Ins-peoted ..the � 1 eewege 'diepop . ByStem at this address and that t>`IQ' information reported •is true,. a.ocUra.te-, arid omplete' as of the time atf inspection, The in,qpeQtiorn was per•Fo.- med and any recommendAtfons regarding .upgrade•, .ma•intenanee 1, abd irepalr •aie• ooneis'tent with my trainip,9 and experience in the proper functi,'on- acid maintenance of on- site sewage dtaposal systems. Check one; ' �6�Syste�i PAS92D The inspection which ..I. have .•eonduQted has .,n-vt found any information . which indicateg- that. the system' fads to ' adecivately.. protect .public = health or the envi.ropment as defined in- .310 CMR. 16•;30.3•, 'Any feilure criteria r)6b evaluated' are as stated in the VAI•LUIM CRI•TCRIA .section o•f this form. System FAILED* The inspection which I have o66dtttted ,has ••found that the eYstem fails to rrotec.t the public heAlth Rnd tho enY4ronmen•t ' in agoo'rdemce with Title 61 310 CMR 16 , 303, and as • specif iCally noted -on .PART 0 FAILURE CRITERIA of this inspec'ti.on orm, Inspector 6ignature' D4 to* ju WON ne• copy of this cer fi..oat•i'ar inu'st 'be rovi'ded :to the .QWN99.1 t•h� BU`fER' where appll.awbla) and teh? I3QARD OV 11EA Tll, .. ; * If the inspection FAIL'Eb•, thb .owne�' •oroperator -a:h4L13, . upS-rade'•ths eyetem. within o'ne year of the dat-e of the inapection, unloas. a]-lowed Qr- req k#,red - THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M P�c� C DATA No. t� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Migoa pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. O��I✓iLV t�l.t= 1,AA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. STEPHEN J. DOYLE & ASSOC. "Z—�.-, 42 Canterbury Lane Type of Building: lJ Telephone: 508/540-2534 Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow - gallons per day. Calculated daily flow d4-0 gallons. Plan Date 0 _Number of sheets °Z Revision Date Title Sim ?J.A)�4 D� OCD.--Q1t� TMCt�C t�XUZS,�SLZ Description of Soil r-t-- IS;tlL "44 c SAE 'z �F �Gr-tom Cl LaM 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 ystem in operation until a Certifi- cate of Compliance has been issued by this Board of Heal ._ Signe c� Date Application Approved by Application Disapproved for the following reason6L___�L Permit No. Date Issued TOWN OF BARNSTABLE LOCATION �l o� � � fX 9/' SEWAGE # y7 a y VILLAGE Ofter•v;& ASSESSOR'S MAP & LOT •Gal INSTALLER'S NAME&PHONE NO. T)A SEPTIC TANK CAPACITY /S i:2 LEACHING FACILITY: (type) (size) `�•1' `��X a NO.OF BEDROOMS BUILDER OR OWNER I PERMTIDATE: 5' COMPLIANCE DATE: d' J, A Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by v I', y 33 ay z TOWN OF BARNSTABLE / WAGE# y - "7 7 G, lv SE LJ LocATION C � S `vIL,AGE OsrP;v. le ASSESSOR MAP& LOT -6a l-dB 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / S LEACHING FACILITY: (type) ��ra�o�"S (size) ALL `/0 1°? NO.OF BEDROOMS BUILDER OR OWNER ��.S7 �� �. ✓%�AP� S PERMTTDATE: S-14 `✓ 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist of 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 Fumi-shed by t L/ 1£ ,e l ..�A THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatton for Mtgoot pgtem Congtructton .Verm it Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. _ Owner's Name,Address and Tel.No. Ig �A�tr,�J 1F�►vS IL�V F.. �sTtc(LYtLI.. MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. e y ��! N DOYLE ASSOC. 42 can 42 canter bury Lane tast Falmouth, MA 02536 ''' lenhone: 540-2534 508 Type of Building: � Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date kfta�126, Number of sheets Z Revision Date Title SM Qr- LA'S'-1 Dg3kw uE IiFn_ C�r.�irS IAR>iAl��(.D Description of Soil S Sott_ L.4�,at - Sut•E--T - ei� �� gMY&ram LAM Nature of Repairs or Alterations(Answer when applicable) Date last inspected: E 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 by this Board of Heal&114 � �-.Signe � ` ` Date Application Approved by Application Disapproved for the following reason d Permit No. DateIssued -----_—__—_—— __=_=_= _= e®==sa-------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certiftcate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( )on by for as has bioeb constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below. 1 ' , No. / Fee X0_0 r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS x1i6pogat 6 *gtem Congtructton Permit Permission is hereby granted to o to construct( )repair( )an On-site Sewage System located at /�e 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. r All construction must be completed within two years of the date below. ' - In - �'/7 Approved by Date: .. . r 4. �' SOIL EVALUATOR& PERCOLATION TEST FORMS Page I of 4 Town of Barnstable t i Safety, and Environmental Services • BARNsrAB Department of Health, Sa ty, MASS. lf019. `� Public Health Division 367 Main Street, Hyannis MA 02601 O f rice:. 508-790-6265 FAX: 508-775-3344 Soil Sul id12 1 rAssesslnelltfo SC71 AS.ESWRS MAP NU 2 PARCa NO. ��" �' � � Date: Performed By: Gs4e, Date: Witnessed By: rl�Gi !�zwne s Location Address 0D�LL ms-t-� G i ft 16q M tx(Ct�,6l R0 L*- Lot p: Address,and Assessor's Map/Parcel: /`� �� 1 � q � Telephone# �� NEW CONSTRUCTION REPAIR _ Office Review Published Soil Survey Available: No Yes Year Published 1 — Publication Scale l: Soil map unit �L Drainage Class _ Soil Limitations / Surficial Geological Report Available: No / Yes Year Published Publication Scale Geologic Material(Map Unit) ou Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Wetland Area: National Wetland Inventory Map(map unit) Wetlands Conservancy Program Map(map unit) 6V Current Water Resource Conditions(USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: DEP APPROVED FORM-12/07/95 "_. Me 5: Draft Printed September 20, 1993 Appendia#Page 2 On-Site Review Deep Hole Number Date:/V Time:.164M / Weather C Location (identify on site plan) 5.� �'► SAP Land Use ... Slope M Surface Stones Vegetation AA l Landform Position on landscape (sketch on the back) Distances from: Open Water Body .J✓/f- feet Orainageway feetf Possible Wet Area /l✓1 feet Property Ling -meet 60 A/� f/e Drinking Water Well Y� feet _ Others ' DEEP OBSERVATION HOLE LOG on- -6eTt-FtorlZtiit Soil Texture Soil Color Soil Mottling Other -4+ntftz37 dep (USDA) (Munsell) (Structure.Stones. Boulders. Consistency % Gravel) C'7 l b•-3 Z S 4,a Goy.- /o yA S16 C1 Z -/Its, MA S.L,,.k lop--- c� 72-12o z sY`/y Parent Material (geologic) GI .�°'`' `��``' Depth to Bedrock: Depth to GroundWater:- / Standing Water in the Hole:/filaN. Weeping from Pit Face: "A-A Estimated Seasonal High GrCund Water: NOarE -- 6 64 S I F � 224.95' ' � I J N LOT 2 AtZEA-44, 1.012 AC7 SL1.FT.= ��y-V_� ✓ .i �_1 i v v - o ^ O i ti.= IV` G� N a SAPE FACTOQ• 18 to u° w UGC / � '! ti F v W ,� d z S 'LOT 1 + 1.086 AC . 13 �. U OSWAPE FACTOQ• 2.1 v � •2 WA Y n1 g47 P •, 12.E 30.00'. pQivs 7 A•25.2�'7(o'OO'14'E 21.31.1 �. uCI t .gin•` V� — - LOT G 3 G Al2EA• a5 A3r. - I.045 AC c � t n C N FAGTOQ° 17 Q pOO ql Q ry n1� °.0 s2 1CVQ i n' 0 ; Q•30.001 ._ SLEYa NlE ' �•.ic:np.. LA r,�'J•h�noJs�u-fo:c' •mac r.�.-„ a>.-_ SI FOvE� . C 2 p l�-31'-. Af ar wol of me plon—cj boon• F3ACNSTABLE PLANNING F30APID Heorino: FORM I - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No. LeT" Detennination for Seasonal. High '91ater Table Method Used: ❑ Depth observed standing in observation hole................ inches ❑ Depth weeping from side of observation hole ....... . inches ❑ Depth to soil mottles inches gvd we4ri,/7 ❑ Ground water adjustment ...- feet p/jft� Index Well Number .,V/J— Reading Date .........._.... Index well level .. . . . Adjustment factor ................... Adjusted ground water level ................. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all yeas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification certify that on (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR.15.017. Signatur Date 0AL'+ DEP APPROVED FORM-12/07/95 I FORA? 12 - PERCOLATION TEST Location Address or Lot No. _ jg- COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test` ' i Date: .falZY�g�. Time: Observation Hole # #Z o Depth of Perc t�$ -'/I;#AZ Start Pre-soak End Pre-soak n4/" /14,�A Time at 12" Time at 9" Time at 6" Time (9"-6") Rate Min./Inch Minimum of 1 percolation test miist he- nerfDrmed in both the primary ar`B AND reserve area. Site Passed Site Failed ❑ ..............................................................................................:............................................._........ Performed By: Witnessed By: Comments DFP APPROVED FORM-12/07195