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HomeMy WebLinkAbout0023 FORTES WAY - Health 23 For Way, Osterville A = 142 - 136 l" 1 r I 4 ° 4 TOWN OF BARNSTABLE LOCATION SEWAGE # AA V !,AGE ( / �t�rlJt�LA. ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY iLEACHING FACILITY: (type) (size) 1a0.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished by ���►_ a '�� r \q ,r 2 I'(�" �, o ,� �� �� � �� 3 ii �� L / / � �-\ Commonwealth of.Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6115/2000. Inspection forms may not be altered in any way. A. Certification Important: �'l'O` �lOp� ♦ �� When filling out 1. Property Information: forms on the computer,use 23 FORTES WAY, OSTERVILLE only the tab key Property Address to move your DAWN MCKENZIE& FERMIN OSBORNE cursor-do not use the return Owner's Name key. 23 FORTES WAY Owner's Address OSTERVILLE MA 02655 Cityrrown State Zip Code Date of Inspection: JULY 4, 2006Date 2. Inspector: LISA C LYONS Name of Inspector Company Name 62 W. HYANNISPORT CIRCLE Company Address HYANNIS MA i 02601-= Cityrrown State ; Zip Code= - (508)790-9270 Telephone Number �yY 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Nee# Further r- Eva ation by the Local Approving Authority � n�a Inspt91s 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. Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form.`Subsurface Sewage Disposal System- Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 23 FORTES WAY, OSTERVILLE Property Address City/Town State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection 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 cf 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: SYSTEM IS FUNCTIONING FINE WITH NO SIGNS OF HYDRAULIC FAILURE 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. 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: Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form A. Certification (cont.) 23 FORTES WAY, OSTERVILLE Property Address CitylTown State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 'Owners Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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 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: 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 Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form' Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 23 FORTES WAY, OSTERVILLE Property Address Cityrrown State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (coot.): 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 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: Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 4 Commonwealth of Massachusetts , Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 23 FORTES WAY, OSTERVILLE Property Address CitylTown State ZipCode DAWN McKENZIE&FERMIN OSBORNE JULY 4, 2006 'Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No. ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow ® 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. ❑ E 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 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.] 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. Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 5 f Commonwealth Of MassachUsetts.' . Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form A. Certification (cont.) 23 FORTES WAY, OSTERVILLE Property Address city/-rown State Zip code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owners Name Date of Inspection 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. Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ug Subsurface Sewage Disposal System Form B. Checklist 23 FORTES WAY, OSTERVILLE ' Property Address Cityrrown State Zip Code DAWN McKENZIE& FERMIN JULY 4, 2006 OSBORNE Date of Inspection 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 break out? ❑ ® Were all system components,,4�61uding the SAS, located on site? AD�-4°kv,� ® ❑ 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(3)(b)] Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 7 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 23 FORTES WAY, OSTERVILLE Property Address City/Town State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 'Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2005- 175GPD g ( y 9 (gpd)): 2004- 150 GPD Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(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: Last date of occupancy/use: Date Other(describe): Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address Citylrown State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address City/Town State Zip Code DAWN McKENZIE & FERMIN OSBORNE JULY 4, 2006 Owners Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1.4' feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 8 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 ❑ Yes ❑ No certificate) Dimensions: 8.5'x 4'10" 1000 gal Sludge depth: 311. Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 27" How were dimensions determined? tape and sludge judge Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address City/Town State Zip Code DAWN MCKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: �( feet f Material of construction: ❑ concrete ❑ metal ❑ fiberglass' ❑ lyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top/outlet Distance from bottom of scum tobaffleDate of last pumping: Date Comments(on pumping recom , tlet tee or baffle condition, structural integrity, liquid levels as related to outle nvert, 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): Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11.of 11, Commonwealth of Massachusetts Title 5 Official Inspection dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address Cityrrown State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallogs-per day Alarm present: /� Yes ❑ No Alarm level: AIararm in working order:' ❑ Yes❑ No Date of last pumping: Date Comments condition of al m a` nd float switches ,s, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Unable to access dbox as it is located under large bush. Based on effluent in pit, no evidence of solids carryover or evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No I . Alarms in working order: ❑ Yes ❑ No Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address Cityrrown State Zip Code DAWN MCKENZIE&FERMIN OSBORNE JULY 4, 2006 Owners Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 5 ® leaching pits number: 1 6x6 with 2.5'stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system - Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydraulic failure. 35"of effluent in pit. 2' riser with H2O cover within 6"of grade. Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 13 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address Cityrrown State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owners Name Date of Inspection 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 i/sof ❑ Yes ❑ No Comments (note condition ailure, level of ponding, condition of vegetation, etc.): Privy(locate on site Ian): Materials of con ruction: Dimensions Depth of olids Comm nts(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont 23 FORTES WAY, OSTERVILLE Property Address Cityrrown State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection 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. A • r r ��N �J��Q N 4-2 Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 w Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 23 FORTES WAY, OSTERVILLE Property Address City/Town State Zip Code DAWN McKENZIE& FERMIN OSBORNE JULY 4, 2006 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar lL Shallow wells Estimated depth to ground water: j 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: Performed perc test at nearby property 7/28/04 at 218 Old Mill Rd. NGWE at 128". Previous inspection report refers to Micah Pond and two other nearby properties at approximately same elevation. NGWE at 156". Copy of t5insp-template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 pieta Kct.5,tmowV wtcn eStIT04 ea«c MAIL u+e pr t:tsrece etch DECK DECK `i� raG�.ea rwG6P u' Ms -- ecrwvc { �� W•.n�c+atn r47[ZGeR ogee r DINETTE BATIi ! tut� —j ✓ V-zc 1} -Sw z• ��% C.45 t tc"e' _ �; GUf 5T RM + .. 5,GNr.4 1I1n11` S1r 1'J 1 - D•: ,fj. 1G'1��.:,PCan4Gn Gt0 1 -- —' - • tip CLCLSiSL iti;;rC # ( Q - t 1 i 2 - ^057 C.5 9TptaGS �� p..Sts:G rp5r co aj '' rJ KITCHEN FAMILY ROOM i r L� Jy/ '� -3 2.=• � ,� � DINING LIVING':RM �- 71 i '.F'�'GCu:51!i 2i7i "yitamG c"Si u-'17, ' FIRST FLOOR PLAN ,CZ«. . ,_o. 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Y--..+ ..�{ ..• - - � - _ ..- -_..«-...., _ �. .. - ....w�- �.. ,..., _. .,y: ,f i -. --,.-4. ..w� ..n..-..-+- Message Page 1 of 1 McKean, Thomas From: McKean, Thomas Sent: Wednesday, June 07, 2006 5:01 PM To: Taylor, Madeline Cc: Desmarais, Donald Subject: RE: Amnesty Septic Updates Here are the updates: 3 Franbill Road-Approved for 5 bedrooms_. _ - 1 23 Fortes Way- The"sitting" areas/rooms shall not contain-privacy-a minimum 5 feet opening to the room shall be provided (a door shall not be provided at the main doorway). Also, an up-to-date inspection report is requested; the report on file is nine years old. No more than 3 bedrooms are allowed onsite. 600 Phinney's Lane -There is a questions regarding the submitted floor plan: - Is the family room totally open or does it have a door? -The current floor plan shows 4 bedrooms as follows (office, master bedroom, upstairs bedroom, family room). Only three bedrooms are allowed. I will ask Judith to FAX that information over to you. -----Original Message----- From: Taylor, Madeline Sent: Wednesday, June 07, 2006 12:52 PM To: McKean, Thomas Subject: Amnesty Septic Updates Importance: High Hi Tom Can you let me know as soon as you have any update for me. I need to get site approval letters issued asap for the applicant for the July hearing as I will be on vacation shortly. Also, I have sent Judith numerous emails over the last few weeks regarding 87 Suffolk Ave in Hyannis and have had no response. If there is a recent septic report on file for that proeprty can you please have someone fax it to me. I would really appreciate it. My fax is 862-4782. Thanks as always for your assistance, Madeline 6/7/2006 Town of Barnstable Health Inspector Office Hours Regulatory Services 8:30-9:30 Thomas F.Geiler,Director 1:00—2:00 anxxsTnst.E. i MASS. Public Health Division i639• �� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 ' Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT -SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: Address: l9 F (N D S tt,-e v X U, Map t42— Parcel 0 4 Z a 0 3 Name: D�^'Y' /q' K Qi7\2.LQ- Phone#: q 2A 2a. How many bedrooms exist at your property now? 3 . 2b. Are you planning to add any bedrooms? Ao If yes; how many? T i 2c. How many bedrooms total are proposed at this property (including the amnesty unit).?. � . 2d. Please include a copy of the floor plans for the entire property - showing the ex_rsting rooms in the home plus the proposed amnesty apartment and/or addition. .Please label 4 each room clearly on the plans. k 3. Is the dwelling connected to public sewer? YE , or NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or �TSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to P . C WATE5,9, 6. Is a disposal works construction permit on file? l YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES. or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected:by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY j//CJQ 7r��� The Public Health Division has no objection to bedrooms at this property. Special Conditions: e i ` ii N► Shy ( or'QC, Signed: Date: ��7b Q;/health/wpf les/amnestyapp �-\ COMMONWEALTH OF N ASSACHL SETTS `. y EXECUTIVE OFFICE OF ENVIRONMENTAL ,-VV !_I i }� DEPARTMENT OF ENVIRONMENTA ,,,P'ROTECTIO.N 1 ONE "'INTER STREET. BOSTON. NIA 02108 61"- 92•:5��A 9<?lr4 WILLIAN?F.WELD �,'4; 9 9y f7, W TRUD1'COS Govemo: OFpl� Secretan ARGEO PAUL CELLUCCI 44 AVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION O Commissioner PART A 9 CERTIFICATION Property Address: Z- Fc�R`�� titld.�� Address of Owner: Date of Inspection: Ci j i'7 '7 (if different) Name of Inspector: A t-L 4 I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �' �!(-Ct� A­12,S C.G��'��-S Mailing Address: t--=ZJJ5iQQ e5 &VA-1 • 621—e(� A ' Telephone Number: ,�pe- F3,-� CERTIFICATION STATEMENT 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ ^reeds Further Evaluation By the Local .Approving Authority Inspector's Signature: `C � � Date: The System Inspector shall submit a copy of this 1pection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. t INSPECTION SUMMARY: Check A, B, C, Or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnetstate.ma.us/dep Printed on Recyded Paper i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM », PART A CERTIFICATION (continued) Property Address: 2� �'O\�"�S v` `��t Q. �1�-1-i � M-44 Owner:, C- NZ1 / F l`✓�i�� GS��t� Date off IIr spection, 9 J 1,� B] SYSTEM CONDITIONALLY,PASSES (continued) !. R A +'Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe4s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the y, Board of Health). 'Describe observations: ��-71r broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A114 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the f public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER NENVIRONMENT:WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Ze'1 Owner: T)kz� ,i lML'rL"�i�iZi�r 1==��l lii le OS L7�1J� Date of Inspection: 9/17( T- D] SYSTEM FAILS: 1 You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil Absorption Svstem, cesspool or privy is below the high groundwater elevation. Am, portion of a 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 pricy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Amy 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. if the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow.of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 Svstem is located in a nitrogen sensitive area (Interim Wellhead Protection Area:IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properth Address: V3 '� as L01=�4 I Owner: N 'PAC- Date of Inspection: '7l!7 f T7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, e rd#ng the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field iif anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) (revised 04/25/97) Page 4 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z� rn�' �A�; ��` E ��f( Owner: Date of Inspection: Q f i i J 1?7 BUILDING SEWER: / (Locate on site plan) Depth below grade: Material of construction: —cast iron _40 PVC— other (explain) a Distance from private water supply well or suction hn Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) �J Depth below grade: Material of construction: concrete _metal _Fiberglass _Polvethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: ' Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0es !/ Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom of outlet tee or battle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) lAI,cET/dclt::) 6V7 4 �--. i c� A.C.C. f��G ��/ G-60-D L:GlU 7? %o/V �A,10 �! - - GREASE TRAP::4 (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: (VC t / 1=�Ztii �►� 0� ,(`�`1� Date of Inspection: 9/1-7/q-7 FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.d. room for S.A.S. Number of bedrooms: 3 2 Number of current residents: Garbage gri..:der (yes or no): �%O Laundry connected to system (yes or no):YES Seasonal use (yes or no):`FS Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):Ald Last date of occupancy: COMMERCI.AUINDUSTRIAL• /1 ` Type of establishment. Design flow: sallons/day Grease trap present: (,yes or nol_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title 3 system: (yes or no)— Water meter readings, if available: Last pate of o cupancy: OTHER: (Describe` Last date of occuoancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �C4,) System pumped as part of inspection: (yes or no)--k'!7 If yes, volume pumped: ,allons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: /�� (`' Sewage odors detected when arriving at the site: (yes or no) lU (revised 04/25/97) Page 5 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r -, Loq r( ®t —, Is 0Lk,L` f\&A , Owner: DAWtil C Date of Inspection: TIGHT OR HOLDING TANKQ//,4 :'Tank must be pumped prior to, or 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: gallonslda� Alarm level: Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition o;alarm and float switches, etc.) DISTRIBUTION BOX: >4- (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) i::'?it��:� / t s -7-.i,1 ._Cn . �t r 1 i.�c + T* ft_. � * PUMP CHAMBER: (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.) i (revised 04/25/97) Page 7 of 10 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � ic�i7 ` t A C— Owner: I�c�l� VC, i �L�/ Date of Inspection: 1 J �*q 7 SOIL ABSORPTION SYSTEM (SAS):-. (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) if not determined to be present, explain: Type: i leaching pits, number: leaching chambers, number:__ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system:. Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pond ing,,condition of vegetation, etc.) �XCGi iL�iy'T 4,FACA1/+ice G�t��G y__ 'TY' . g 'i' 1��/5 4-­z 0,A/ 7—,,a/4 Cal/_ I�iT 4L1 i 77 14 110 S/,--iVI 6 CESSPOOLS: (locate on siteepin 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition.of vegetation, etc.) PRIVY: (locate on 3itfe plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 cZ�j t..J L I,-L Z VVt k Owner: '� �� 1V�G\ Date of Inspection: 7/7/'7-7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) j r r, \� X a /4 i � 4 (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater Feet ��U3 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Daps Check pumping records Check local excavators, installers Use USGS Data Describe in your own "•ords ho%•, you established the High Groundwater Elevation. (Must be completed) i yt,/i✓ -13�5�0 %a'06-JE i S% O/A/ 0AZ) M-e4.4.- c / �S a-; "� TN 7-0 (reviBed.04/25/97) ii(� 1 - Pig• 10 of 10 APPLICATION FOR PERCOLAT-,ON TEST AND OBSERVATION PITS l� . _ Nf 12, ,vie Lam; 9•G• No. / O V i1OCATZ � G � �- ...—• :.�.qN ,DATE /ILLA F JEE r ? •/ . (1ion-refundatile, A 1DDRESS f"'' QS% TELEPHONE NO. . r1 t l TELEPHONE NO.;� -U%;�� � .NGINFEIt 4[,i_ Cap' /=-.1� 2 /� /21 t: SATE $.CHEDULED 3 / (, (Applicant' s signature . • • • �•V! •.�'o.• • • • •. e o e o • • o o • • o 0 0 0 • o 0 0 • • • • • • o • i o o • • • e • • • o 0 0 0 0 0 • • o • • • o • o • • • • • s s • o • • • . 1�SSE$SOR'S bi�� & �.OT NO: 14L/13G, SOIL LOG j 46 4� lb 9�TIME� /z Nooy 3UB-D, VISION NAME LC ) �r DATE 3XPAN5ION AREA: YES NO �;�. /�'�� - ENGINEER . rOWY WATER PRIVATE WELL BOARD OF HEAL'TF EXCAVATOR dimensions of lot S2C ETC H.:- (Street name,etc. , , exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: Z rl 1 ,;•� 1� a �\ w—9� 77 o{ fy la r ?ERCp Tg N RATE. -z k j TEST`IOLF .NO: ELEVATION: TEST HOLE NO: ELEVATION: 3 3 6 10 i 10 11 5 > 11 12 12 13 _ 13 14 : All ;0 14 15 15 • 16• 16 ;UITABJ,,E••F•OR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TREN'CHE5 1NSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: IOTE: ' ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION COMPLETED N ENT R •T` Y P AN ETURNED TO BOARD OF HEALTH )RIGINALt n11 nnnT•T( AMT APPLICATION FOR PERCOLATION `PEST AND 013T10N P ' 'S SERVA _ NO. !i LOCATION_ / V DATE VILLAGE Q c_ FEE APPLICANT (Non-refundable TELEPHONE NO. ADDRESS TELEPHONE NO.__ ENGINEER - DATE SCHEDULED A �` (Applicant' s signature . . . . . . . . .; . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . ... ASSBSSOR S l�t�P 6: p`7 S LOG / DATE Z� ' �a � TIME � .��� SUB-DIVISION NAME . ENGINEER l EXPANSION AREA: YES,NO — BOARD OF HEALTH TOWN WATER_,PRIVATE WELL EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact �- sto tholes)es and percolation tests locate wetlands in proximity ' NOTES: 1 60, f j (Idt S 2 8oM (2,V s i n 1'S w,►�1 p a n, N 1 1 1 0 ` a_ Iti Of 1f��� A rz L A �0 04" CIVIL No.30M F9FCISIE � 1 6 0 I. t L L- 2 ►��� �I n — PERCOLATION RATE:_ ELEVATION:� ( TEST HOLE N0: ELEVATION• TEST HOLE NO: 5 Y2 Z 5/2 1 DUFF /OeG LOAM 2 \\\Z" nu�r-/oRv 1p41"� O. 2 z.5 S Z 3 3 ra LOAM`( So.ND l- 4 51' LnAw��' sAh1D 4 YQ Y, 5 6 - 12" Lc,,& V 5AN1> A 6 - 32" L�e,r�� sa,ti►rJ 13 7 7 COAM4L SAw1�D 8 2`t3" l_OAM ! SAhFu I3 1 b Y2 6�G 9 9 GLEN �oA2SE SA1JO 10 Teoce c.2Av F-L- G Z% 10 T>z U QAv --- 11 _ 12 12 13 13 14 14 15 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD,-SEACHING PITS�� LEACHING TREN UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERIN G PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ETED IN ENT RET Y P AND ETURNED TO BOARD OF HEALTH ORIGINAL: COMPL Copy: RETAINED BY APPLICANT u7,-�osl =b 1� Sewer Permit No. Name c e !� Cp 2 0 03 Location- (� h1staller's Namc and Address �✓r/G O A/ Builder's Name and Address -Wj - � A W, 9,0 r.v s ib/e , Date Permit Issued: — i ^ ' Date Compliance Issued: '`� — _.tee .. '.�^_.w .-. f. �� SON �� � o�S�. s P i ►��� �' � ' `i- �� ! �D T� rr �� �, �.� � �I 3 J cif N. Fss.. ....... THE COMMONWEALTH OF MASSACHUSETTS a7rc O R® AL..T .... .. --- ... F........ ............ . / . .......6 Appliratiou for BilipmFal IVOOP ft rVou Vrrmit Application is hereby made for a Permit to Construct 9) or Repair ( ) an Individual Sewage Disposal System at Location-Ad r ss or°Lot No. o •'� p�yr /�f`eAyp A J' p ��!.. l..:.`'Y Owner Lie J _ Address ---...-•-------.._.. .....--••- Installer Address Q Type of Building Size Lot-36:�,731....Sq. feet U Dwelling—No. of Bedrooms...........-`--5..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---------------•------------ P ( ) — Cafeteria ( ) � Other fixtures ---------------------------------------------------------------------•---••-------•-••----•--•••----•------------------- •-•--- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity.) .gallons Length................ Width................ Diameter------.......... Depth................ xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area—..................sq. ft. Seepage Pit No....1---------------- Diameter.--..........--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 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 to ground water.....-.................. P' -•-----•--•-......-•-•-•-•..---- .................•----............................................................ p O Description of Soil...................... •5..---......__�.. e...----....------ .......... ----------------------------•----------------------------------.........---- x W 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'T T IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ,n issue the of heal . Signe ..... ----- ... .. -••-••----------------- Application Approved BY _i '� •-----------•--- ..-�1 00 Date Application Disapproved for the following reasons:------••------•---------------•--•---------------------•------......--------•............................... --•.----------------------------------------------------------------•-•---.....----...----------------•---------•-.......-•---•-----------------•••--•-•-•------••-------•--------•-------•-------•---•. Date PermitNo.-- CJ._ ---------•-.. Issued_....................................................... 1 No. Fizz.... .......... THE COMMONWEALTH OF MASSACHUSETTS R® F H . ALT 2 /" ,f ._. . ApplirFatinn for Dispaii ai Wor i RnM Minn Vatnit Application is hereby made for a Permit to Construct 9) or Repair { } an Individual Sewage Disposal Systemat: �,....-� ---------------------------------------------- , -.....STD - �-- Location-Address or Lot No. lA.! ._.. �... !.[.�1 r!'�r1;ZS= p= 1.1.��_., 'lr'.�{I_._ .... �15 Owner Address a .C1_.. 1. .._. ................... Installer Address Type of Building Size Lot... ----Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) - Cafeteria ( ) p-1 ' Other fixtures ............................-................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity_I(,a.gallons Length................ Width................ Diameter---------------- Depth................. Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....I---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-------.-____________--. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-__--_--_____________- -------------•-•----------------.- -----.........__.._.......................................................... Description of Soil....................... ----------- 1' �Gc � x W ----------------------------- ------------------------------------------------- -- U Nature of Repairs or Alterations—Answer when applicabl ______________________________________________________________________________________________ -----------------------------------•-----------------------------------------------....--------------------------------------.---------------------------.---.-.------------•••---•..-••------......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TILL 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. Signed .........._ 1 t_.... ------ - Application Approved ByI� = =. ' .... . . ------------ Date Application Disapproved for the following reasons______________________________________________________________________________________•----•-----•..._._.__._._ - } ........... O.!✓S.t- _ Date PermitNo.--LJ---- ---••----- ----- ------------- Issued.--------.._..-------------------------------------•---- Da'_- THE COMMONWEALTH OF MASSACHUSETTS ......... &!. 1... '...OF..... r.:.. .. 1....!: ..................... Trrtif iratr of Tnrntphaurr �p THt T,9 CERTI/FY� T t h@ Individual Sewage Disposal System constructed � ) or Repaired ( ) bY-•---•---•--! -- ----•- ( ------•-----••------------------------------------------------------------------•--------.........---•-----------------•- 7 L b.{ rf ! has been installed in accordance with the provisions o7aller V _ 5 0. T e tate Sanitary C de s d in the application for Disposal Works Construction Permit No._ "'/�!? �}.�'_____ dated_..... _ __`. __ �_esc_ ______________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A f UA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. i DATE.................. f -�-'X �.�-•--------•-•--•---------- Inspector.. ,�.-----------•----.....--•••••.._........-----••-- THE COMMONWEALTH OF MASSACHUSETTS .......... ........ V oFR <'�'1..!':... " — NO._`�..` .,...4C 1.�'_. FEE....... Permission is a t to Construct �r� pa"i '( an I dividual Sewa e isposal Sys �-- ` - wig- -- .......................... Street (]� .� as shown on the application for Disposal Works Construction Permit No._�)_4�___.__ _ Dated. � _ __ �r.�J__________________ .................................................................................................... Board of Health DATE................................................................................ FORM 1255 HOSES & WARREN. INC.. PUBLISHERS �s Z� `0 J 973 w 'S,5510 s. r c s s ` o . VA A rd MIES t i T� o 'T toi-1 0� 'TUE. g r . d ► - : rt :. A .lc>AL - cow ' e. rx: rare 2�G•4�`Z�E' >�t�'t7 L,�J� +��:/ oazS:: - a.. " � V LOIG S f, _ czesrnarneL Zrxa� .2G� ,� 2 0, 67 AA (1 pwEt,vN� • ,• FRO Pose z if J,; ti�dot qll ID a � ,r "