HomeMy WebLinkAbout0223 HICKORY HILL CIRCLE - Health 223 HICKORY HILL CIRCLE, OSTERVILLE
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Commonwealth of Massachusetts
/o?/_03DTitle 5 Official Inspection �T
;
Subsurface Sewage Disposal System i~ rr,--NO, forVolrintary ss„s,., As e ;rnents c
c�c�3 c!-o i H� if__..... : i r
operty Address
information is Owner's Name Q—
requQedfor every OS ►�l/%� �l/ �''/� Qoj V a0 ��
page. Cdylrown date Zp Coe Date of Ins pection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
the computer,
fllfi out forms ?0
on the - c7� .
use only the tab 1. Inspector
key to move your
cursor- not a y 0 � li
u�the return Nance of Inspector /
Company Name
o d
Company Address
� 4,-,
QSVA7 oa(a q �.
Catyllown go— 2790 State
o Zip Code
Telephone r License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CINR 16.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2"
Inspects 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 DER 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.
t5ns•3113
Tdle5orficial Inspection Farts Subsurface Sewage Disposal system•Page 1 of17
Commonwealth of Massachuseft
Title 5 official Inspection Form
Subsurface Sewage. Disposal System Forth -Not for Voluntary Assessments
Property Address
Ow her ( •� do &I
Om information is ref S
required for every �S ✓tip l�({ �4 Da16.� Co
page• CitylTown OZ b /b
State Zip Code Date Ins tion
1:3. Certification (cone.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for des "no"or"not determined"(Y,.N, ND) for the following statements. If"not
determined,"please ex0ain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
a
t5ns•3M 3 Title 50fficial Inspection Form Subsvface Sewage Disposal System-Fie 2 of 17
Commonwealth of Massachusetts
Tide 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ONtnBf
information is �"ner's Name information
required for every D.s7-t KV1 Ile- NA Qd-ku c ao /('
page. C itylrown State Zip Code Date of rhspecOon
B. certification (corn.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.): '
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ,❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N• ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ .Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):, .
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a mannerwhich 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
15rs•3H3 Tifie5Official I spectonForm Substrface Sewage Disposal System*Page3of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10�
Property Address J7r
arrn� CON J19�
information isOu ner's Name /required for every O ,1 /S ✓��v l� A14 04&5� (p/,-a 0//`
page. CdylTown State ZIP Code We of IhSFmc7Gn
B. Certification (cont.)
2• System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well";.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
colifbrm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this ibrm.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 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 day flow
t9rs•S13
Tile 5 Official lrepecQmFart[SubsufeceSewdge(Asposal System-Page 4of17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments
Property Address
ON rrer rO k1 CjtO�
Information is Owner's Name O$ V /
equiredforev ✓ ` D� 6 5 :Po "
page. Cityf raw n State Zip Code Date of inspedtion
Bo Certification (coat.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
/obstructed pipe(s). Number of times pumped:
❑ L 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.
❑ t5 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 1� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered A copy of the analysis
and chain of custody must be attached to this form.]
❑ he system is a cesspool serving a facility with a design flow of2000gpd-
10,000gpd.
❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no°to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes'to any question in Section E the system is considered a significant threat,
or answered `yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t`na-3113 Title50ffiaA ImpeabonFomt Subsurface SevageDisposal System.Page 5017
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner o�
infommUon is ON nWs Name
requ'vedforevery OS4✓yt .e
page. CSty/Town State ZiP Cade Date ofInspection
C. Checklist
Check if the following have been done. You must indicate'yes"or"no"as to each of the following:
Yes -
❑ umping information was provided by the owner, occupant, or Board of Health
❑ ere any of the system components pumped out in the previous two weeks?
❑ as 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 WA)
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, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 for example: 110 `,�
( p gpd x#of bedrooms):
t5ins-W13 Title 5Official lnspeclion F am Suburfaee Sexaage Disposal System•Page 6of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a3 1,
/ T c4,or
Property Address
Cc7v1 . p�J
Ow ner ON pees Name
hfomati isrequiredfore very O ✓vl
page. Cdyfrown State Zip Code Date of ftWctbn
D. System Information
Description: / GyA.7
i3 xC)
Number of current residents: - C;� _
Does residence have a garbage grinder? ❑ Yes No
Ls laundry on a separate sewage system?(include laundry system inspection ❑ Yes Q�fVo�
information in this report.)
Laundry system inspected? ❑ Yes�M-lQo
Seasonal use? Ull s ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: 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:
tSns-3M3 Tile50ffidal InspectionForm Subsrface Sewagel)isposdl System-Page 7017
Commonwealth of Massachusetts
Title 5 Official Inspection Form
WJ Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments
o 1 61 r
Property Address
h J.
Ow ner ON ner's Nameh1offnation is
// l
required for every OS-4VVI `lam /4
page. Ckyfrown State Zip Code Date f Inspefetion
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
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 Sy ,
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/Altemative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval. ` =
❑ Other (descri be):
15ns-3f13 Wa S Official Irspection Form Submeace Sew ge Disposal System-Page 8017
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c� a3 1�t c 4,o il 11 Ccr
Property Address
tanf ner
arformation is Ow ner's Name / // l c ll
required for every �J V f/6`( o
page- CityrFawn State Zip Code Date of tristpecticifi
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes a-,TO
Building Sewer(locate on site plan):
Depth below grade: /�4
feet
Material of construction:
❑ cast iron 40 PVC ❑ other(explain):
l �
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): !/
Depth below grade: feet
:Material construction:
oncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years -
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ns•3H 3 Title 50ffidat Inspection F oms Subsurface SSM90 Disposal SYMM•Page 9 of f 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not fbr Voluntary Assessments,
Property Address
Owner ON na's Name do
�S'tG✓ IT infonnation islrequiredforevery fib r�oZ 6
4
page. Cdyfrown State Zip Code Date of Inspeotio
®. System Information (cont.)
Se .
ptsc Tank(coat.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness /
Distance from top of scum to top of outlet tee or baffle
� q
Distance from bottom of scum to bottom of outlet tee or bag e
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, elidence of leakage, etc.):
i'4 c�7 l K /!O J^ � p/C/� G h R Hc--/ lS
l✓1 0 0 N 60 r, of i A00 .
�d 1ec
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
tyre•3H3 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'=2 0-3 Ado- x/, // C�►.
Property Address C��
owner Owner's Name
mquiredformabfo is for �
reu�edf 5V 1d'11-;
���
page. City/Town State Zip Code, DateOfIns ion
D. System Information (coat.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, e%idence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in worldng order; ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). is copy attached? ❑ Yes, ❑ No
tsm-3h3 Tft50tfidai ImpWtionForm Sulaufaae SawageDispasal System-Page 11 d 17
i.
i
Commonwealth of Massachusetts '
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C�-;3
Property Address
ON ner Owner's Nam Ndo
e T/ c
/�information is
required for every Os kv v6 1 /j4 /C2 0 /,1
page. Cky/Town State Zip Code Date of N tion
D. System Information (cost.)
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.):
�o f
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No*
Alarms in working order., ❑ Yes ❑ No;
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
' 4
` If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:'
1Frns.3/13 Tiaesof5bal InspectionFmm:Subugece Sewage Disposal System*Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�IcZ3
RoPerty Address /
owner C�Hc�0 V7
information is Ow net's Name
required for every l S 7'�I/Imo//l'e � t� pZA-Z
Page. Cdy/Town State Zip Code Date Inspec n
D. System Information (corn.)
Type: 6� Soo . 6Z71/ld.1 CAG61144f
❑ leaching pits number. "
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovativetaltemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
i
(� ✓I �ra l a 41i/`C
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan)., -
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
16ns•3ff 3 Title 5 official Inspection Form Subsuface Sew
age Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address IC'
Owner Coo 60 -
bfonnftn is Owner's Name OS
requiredforevery _ A/VY
page. utyllown — O`o /_e
--------------
State Zip Code Date o Inspec' n
Do System Information (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
t
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
tins•3M 3
Tiue5otficial InspeetionFWm Subsuface SewageDisposel Sim-Page 14 of 17
f
Commonwealth of Massachusetts
L Title 5 official Inspection Form
Subsurface Sewage Disposal System
Form -blot for Voluntary Assessments
�- C�� 6l-or Y`.
l
Property Address
Ow ner O►� tO lit
information is ON Name
requiredforevery t�s I11/l //10 Q o?C> �Y
page- 2W lawn State Date of nspection.
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below.
❑ hand-sketch in the area below
❑ drawing attached separately
T--Q o/V 7—
o� -
/4/
Aj 3 - W,6
A3_
t5ns•3M3 Tile 50fficiet IrepectonFmrz subsuface sexrageDispcset System,Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System//Form -Not for Voluntary Assessments
Property Address
Aff
ON nef CO dl C� N
information is Owner's Name
required for every
page. UpIown State Zip Code Date of Inspection
De System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells / /f/pnle--
Estimated depth to high ground water. feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ served site(abutting property%observation hole within 150 feet of SAS)
Checked w�i�t local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS'database-explain:
You must descn!)e w you established the high ground water elevation: J R
�G/Ll G CG A l U' / A' l/
c7 ✓� 7 G 01 C
S4,e- l Lc/ /e. Jt
14d S
O Un J(00%-r-,J4�
Lj
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5m-3M 3 TWe 5 0fficlal UtspeofiM Farr[Subsurface Su me Disposal s)om•Page 16 d 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Fortin
Subsurtace Sewage Msposal System
//Forne-Not for Voluntary Assessments
a-a3 /�i��ov
Roperiy►A ddress
awnw Cofer o ✓I
�fometions raer's Name .�-/
re4uffedforevey Of'"� yr/E O�A, (v 33 G �o l
page. C�y/Town State Zip� Oate orinspeoft
E. Report Completeness Checklist
M Inspection Summary: A, B, C, D, or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
stem Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
*a-3H3 Ti0e50f idd UspectlmFaM&JbM9faW S9vMe0isposel Sp*M-Page 17 d 17
TOWN OF BARN/STABLE
LOCATION Z 2- SEWAGE #
VILLAGE ASSESSOR'S MAP&LOT �?-/'-V
INSTALLER'S NAME&PHONE NO. ,eel-le Ze % CA*0- 77/-1
SEPTIC TANK CAPACITY aw 4 L4 L
LEACHING FACII.TTY: (type)sod CxI ImeAY4S L/A"Ld M(size) /3
NO.OF BEDROOMS
BUILDER O OWNE lash t�f�i�
PERMI TDATE:�g '7;?Q,,-=COMPLIANCE DATE: �•—
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility J 7� 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 fi/L,4 Feet
within 300 feet of leaching facility) � ;y;
Furnished by
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No. �. .' +# Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Miow5aY *proem ComarUction Vermtt
Application is hereby made for a Permit to Construct( )or Repair( /n On-site Sewage Disposal System at:
Location Address or Lot No Owner's Name,Add res and Tel.No.
223 1)) yy 41//Gl4G16 rt��t
O5�-e✓' /�/C /�� Zz 3 f c��c1e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Bvl"`.4491`l° C®as�; -77/-9�r9 �6/L-4 -�
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(140
Other Type of Building ee fl G�9GG No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow f/ gallons per day. Calculated daily flow �Km gallons.
Plan Date Number of sheets Revision Date
Title dS��
Description of Soil
Nature of Repairs or Alteration(Answer when applicable) J kf l LB ,,,-40 ►�
Zee
a,3 1P — ®o /66.nos
u f
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 provisio of Title 5 of the Env
iron ntal Co and not to place the system in operation until Certifi-
cate of Compliance has been ' ue b this Board of Hea e Z11990%Signe O Date
Application Approved byA
Application Disapproved for the foll 'ng reasons
Permit No. Date Issued
7
No. / - ; �. +:._.��. Fee
THE COMMONWEALTH OF MASSACHUSETTS ,
PUBLIC HEALTH DIVISION -TOWN OF bARNSTABLE.,MASSACHUSETTS— �
01pptication for Migpoot *pztem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( n On-site Sewage Diposal System at:
-Location Address or Lot No. Owner's Name,Add and Tel.No.
i
ZZ 3 A))2 ,4eI/ l el,(e leGo��
zz.3 vY.1,
C
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-7/-
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(.-to
Other Type of Building. tG.?i' CNGG No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow l/e gallons per day. Calculated daily flow' 3?f gallons.
Plan Date Number of sheets -Revision Date '. {
Title .
Description of Soil j
/ I
Nature of Repairs or Alterations(Answer when applicable) 10"e-ea
Z-341 ' x Z `Oeel,7 s
Date last inspected:
I
Agreement-. j
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisio of Title 5 of the Env
iron ntal Co and not to place the system in operation until Certi -
cate of Compliance has been' ue b this Board of Hea Q
If
Signe 0 Date
Application Approved by
Application Disapproved for the foil ng reasons
Permit No. .— .'`} Date Issued
---- ------`f-� '� ----------- `� 1r .� =--
----- --- -----�--- _ _ w-------�— ---- ---
YHE COMMONWEALTH OF MASSACHUSETTS
PUBLIC°HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance - -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or reps'ired/replaced on
by for !D 0 Gva •�
as 2,3 16C Gi G v/�111 s 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 belo
No. Fee
THE.COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS j
Dfi5pont *pgtem Construction Permit
Permission is hereby granted to
to construct( ')repairiv)an On-site Sewage System located at 7-7-3 %G�Dj� �i�/yGr✓
n Ste
I'!/ l�P
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:
All constt
must b co pleted within two years of the date below.
Date: �(/ Approved by
h f ,
Y
vo
c,2c
(A pat
S y
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
Wol(KS CONS HIUCHON 1'[;R(11CI'(1VI'I'1[VU I'llESIGNEll PLANS)
j
1, �Q���y�� y �,o ,4B4q�hereby certify that the application for disposal works
construction permit signed by me dated L130��� , concerning the
property located at ��J /i�lG /� r /�G!`r�Gc meets all of the
following criteria:
/There arc no wetlands within Soo feet of the proposed septic system
/There are no rivate wells within 1So reel of theproposed septic system
/ p
✓ he observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no increase in flow and/or change in use proposed
/There
are no variances requested or needed.
SIGNED:— DATd3: 9�
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(ANch a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted].