HomeMy WebLinkAbout0025 JOBY'S LANE - Health Osterville P
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PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
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UNITED STATESMPIT *pli u.r
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• Sender: Please print your name, address, and ZIP+4 this box • a I
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Town of Barnstable
I �c Health Division
200 Main Street
Hyannis,MA 02601 f I
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.t;l ?11i it l!?IFll� 11111it11i}1 Hitt III-SlASb!!�_E111
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Town of Barnstable Ban"suable
oF_HEro� a
Regulatory Services Department ,
I�,RARNSTAULE,
1,:90`\MA� . Public Health Division_639. a�0
- ""A� 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 7007 3020 0001 3429 8080
April 13, 2009
Marie Souza
175 Sunset Lane
Barnstable, MA 02630
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 25 Joby's Lane, Osterville was inspected
on March 18, 2009 by Jaime Cabot, R. S., a Health Inspector for the Town of Barnstable,
This inspection was conducted on the basis of the rental registration in accordance with
Chapter 170 of the Town of Barnstable Code.
The following violations of the state sanitary code were observed:
105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements:
Hole in cellar stairs drywall.
105 CMR 410.482- Smoke Detectors:
Carbon Monoxide Detector provided does not work properly.
105 CMR 410.501: Weathertight Elements:
Basement window broken.
You are directed to correct the Smoke Detector Violations within twenty-four hours
(24) hours of your receipt of this notice by installing smoke detectors in accordance
with Mass Fire Codes.
You are directed to correct.the violations listed above within thirty (30) days of
your receipt of this notice by repairing the broken glass in the basement window,
and fixing the damaged wall.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure'to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations,please contact the Town
Health Division and sk to speak with the inspector who performed the inspection.
P ER E BOARD -HEALTH
s McKean, R.S., CHO
Director of Public Health
Town of Barnstable
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIEONMENTAL AFFAIRS
DEPARTMENT O.F.ENVIRONMENTAL PROTECTION
tiLNIAR0
D
05
TABLETITLE 5T.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
t .
CERTIFICATION
Property Address: , " �
A
Owner's Name:
Owner's Address: A. ow,,
Date of Inspection: _--
Name of Inspector please print) O Jrrrl ✓�
Company Name:
Mailing Address: O `
Telephone Number: 6C)R--`7-7l• �'-�� ci
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information mported
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 a
Needs Further Evaluation by the Local Approving Authority
Is
Inspector's Signature: 7 , • Date: c3�d
L .
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 %
µ ****This report only describes conditions at the time'of inspection am—d 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.
_ I
Title 5 Inspection Form 6/15/2000 page I-
` 0
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �� _ Ka
167. ✓ .;, A
Owner: '` led
Date of Inspecti N1
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 3 10 CMR
15.303 or in 310 CMR 15.304 exist.Ary.failure criteria not evaluated are indicated below.
Comments:
BeSystem Condit' .
y tonally Passes:
One or more system component-,as described in the"Conditional Pass"section need to be replaced or'
repaired.The systern,_upon completion of the replacement or repair, as approved by the Board of Health',will pass.
Answer yes, no or not determined(Y,NND)in the for the following statements. If"not determined"please
explain:
The septic tank is metal and ove=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.complykig 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 2.0 y-ars old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with..
approval of Board of Health):
broken pipe(s)are replaced
obAruction 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):.
broh2n pipe(s)are replaced
obstruction is removed
ND explain: .M
\ 2
Page 3 of I']
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continue-d)
Property Address:
Owner.
n �
Date of Inspect' n: 5 / S
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.
L . System will.pass unless.Board.of Health determines in accordance.with 310'CMR 1.5.303(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 rVetland or a salt marsh ..
2. System will fail unless the Board of Health-(and Public Water Supplier, if any) determines that the
system is functioning in a.manner that.protects..,the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS-)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has aseptic tank and.SAS and the SAS is within E Zone ] 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 cr.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:
i I
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Page 4 of 11
OFFICIAL.INSPECTION FORM—NOT*FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property.Address: 'S Da�V_'Q Y&
Owner' -� —
Date of Inspectiad
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N9
1/ Backup of sewage into facil.ty or system component due to overloaded or clogoed:SAS or cesspool
Discharge or ponding of effuent to the surface of the cr
ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the dis7ibution.box.above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is Mess than 6"below invert or available volume is less than %z day flow
U Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
ed
7V t d
Any:portion of the SAS,cesspool or privy is below high ground elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
Vwater.supply.
Any portion of a cesspool o privy is within a Zone 1 of a public well.
Any portion of a cesspool cc privy is within 50.feet of a private water supply well.
Any portion of a cesspool or.privy is'less than I00 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 tie analysis must be attached to this form.]
N� (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.
Al
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•
You must indicate either"yes"or"no"n each of the following:
(The following criteria apply to.large systems in addition to the criteria above)
yes no
the systemis 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 nitro-gen 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 failzd 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 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B'.
CHECKLIST
Property Address: �
-
Owner:.... ..,. ',/
Date of Inspect n: 5� f
Check if the following have been done.You must indicate"yes"or."no"a:to each of the following: _
Yes
' Pumping.information was provided by the owner, occupant, or Board of Health
V Were.any of the system components pumped out in the previou3 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 fora signs of sewagebackup.? �. .
_ Was the site inspected for signs of breakout"?
-Were all system components, excluding the SAS,`located on site
Were the septic tank manholes uncovered,.opened, and the interior of the tank inspected for the condition
of tthhe�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-he site has been determined based on:
Yes no
Existing information. For example, a plan.at the Board of Heahh.
Determined in the field.(if any of the failure criteria related to Fart C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
r
Page of l I
OFFICIAL,INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION
Property Address: �zQ
Owner:. , zap
Date of Inspecti ; 9 7 S
/ FLOW CONDITIONS
RESIDENTIALt/
Number of bedrooms(design):_,�_ Number of bedrooms(actual): 3.
DESIGN flow based'on 3 10 =C 15203 (for example: 140 gpd x#of bedro0ms):2
Number of current residents:
Does residence have.a garbage grinder(yes or no):'
Is laundry on a separate sewage system.(yeas or no): _ [if yes separate inspection required]
Laundry system inspected(yes p no)-/1/0
Seasonal use: (yes or no): ..
G
Water meter readings. if available(last 2 years usage(gpd)):lf�; � 00® .3
Sump pump(yes.or no): / U
Last date of occupancy: < p,� �'�6 ✓'[ '�G�XX� � i
COMMERCIAL/INDUSTRIAIW (/12a✓O
Type of establishment:.
Design flow.(based on 310 CMR.15.-�3): gpd
Basis of design flow('seats/persons/sg=t,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:i1,ph')7,11y 4- /1/1/7t-7
Was system pumped as part of t e ins_ tion(yes or ) �
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for.pumping-
TYPE OF SYSTEM
eptic 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 copyof the DEP.approval
—Other(describe):
Approximate age of all corn onents date ' tailed(if known)and source of information:
Were.sewage odors detected when arrving.at the site(yes or no)
,z
Page 7 of l 1
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION(continued)
Property Address:C, i .�
e4
Owner _
r - .
Date of Inspecti'n:
BUILDING SEWER(locate on site plan
Depth below grade:
Materials of construction:_cast iron _40 PVC • other(explain):-
Distance from private water supply well or suction line: A. }
Comments(on condition of joints,venting, evidence of leakage,-etc.): i
SEPTIC TANK: (locate on site plan)
Depth below grade:_
Material of construction: L/ 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) ij
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: �4
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 71
Distance from bottom of scum to bottom of outlet tee or baffle: t}
How were dimensions determined: �Qhj ,Lzziz M ge:�Z�
Comments(on pumping recommen a�f tion , inlet and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert,evidence of leaks e,etc.): ,
,A uth „
S& 6V /Ot ram► &4tp
4e
GREASE TRA1! locate on site plan)
.Depth below grade:_
Material of construction:_concrete._metal_fiberglass Polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet-,tee,or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle ca_ndition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
f
i
K
7
Page 8 of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owne :
Date of Inspecti n;,�j&�Z . .oC>b�
TIGHT or HOLDING TANi% (ink 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: gallor s/day
Alarm.present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:Zif present must be.opened)(locate on site plan)
Depth of liquid level.above outlet invert_
Comments(note if box is level and distributiA�outle'
equal, any evidence of solids carryover, any evidence of
trace into or out of bo , .):
PUMP CHAMBER (locate on s e 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):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEN\1 INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address:
Owner'
Date of Inspects n: Z^ !�
SOIL ABSORPTION SYSTEM (SAS): t__Ikocate on site plan,excavation not required) ,
If SAS not located explain why:
Type
�eaching pits, number:
eaching chambers,number: c
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 hydrauliCfail6re, level of ponding, damp soil; condition of vegetation,
etc.): _ _
ICJ/' e
CESSPOOL$ (cesspool must be pumped aspart.of inspect ion)(]ccate on site plan)
Number and configuration:
Depth—top of liquid to inlet.invert:
Depth of solids layer: -
r
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of Groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,,conditi.on of vegetation,etc.):,
t • 1
PRIVY (locate on site plan)`'
Materials of construction:
Dimensions: A
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition.of vegetation,etc.): .
9
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Page 10 of l 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM,
PART C
SYSTEM INFORMATION(continued)
Property Address: 5- `
Owner:,Z /
Date of Inspecti is � Gs
SKETCH OF SEWAGE DISPOSA3,SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
,e, 4
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Paae 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
.Property Address:
Owner:
Date of Inspectio . "- J r
SITE EXAM
Slope
Surface water
Check.cellar
Shallow wells
Estimated depth to ground water 1- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan_reviewed:
Observed site (abutting property/observation hole within 150 feet o:SAS)
Checked with local Board of Health-explain:
�hecked with local excavators, installers-(attach documentation)
,✓Accessed USGS database-explain-
You must describe how you established the high ground water elevation: o
y
11
i
Permit Number: Date:
Competed by: �
HIGH GR_)UND-WATER LEVEL COMPUT:`TION
Site Location:. gFJ C�J= rS '��l/ Lot No.
Owner: Q9 l Address:
Contractor: e� I6 Address:
Notes: Cllf
STEP 1 Measure depth to water table
to nearest 1/10 i. ......................................................... ........_. .Date month.idaylyear /J
I
STEP 2 Using Water-Level Range ?one
and Index Well Map locate
site and determiner
�. I
OAppropriate index we*)....................................................
OWater-level ranee zone ..................................................`....{
STEP 3 Using monthly report"Current
Water Resources Conditicns"
determine current depth to
water level for index well ...........................
month./year
STEP 4 Using Table of Water-levu Adjustments
Tor index well (STEP 2A)_ current depth
to water level.Tor index "Pall (STEP 3),
and water-level zone (STEP 2B) i �p
determine water-level adjustment ................:.........................................................................
STEP 5 Estimate depth to high vwmter
by subtracting the water-
level adjustment (STEP 4--
Trom measured depth to water
level at site (STEP 1) ...... ...............
....................................... .......
.........................................
Figure 13.--Reproducible computation tom.
15
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TOWN OF BARNSTABLE
I-OCATIOP4,OS�L? 64Lk SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT/W•yb o�
alSpPFZl101S'NAME&PHONE NO �/��1 1�2 60� f-177/'�J,�
SEPTIC TANK CAPACITY �2t�
LEACHING FACILITY: (type) (size)
OF BEDROOMS
DER OR OWNED- ( .loit,
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Id bit. i
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TOWN OF BARNSTABLE °C
L
LOCATION SEWAGE # �-��.
VILLAGE- U1aJ ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. RPOW RYO
SF �f IC TANK CAPACITY /Q0c)
L'EAC'HING FACILITY:(type) �� G /-/ (size) 44 13
NO.OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER
AN f
BUILDER OR OWNER3��.� �L�IZ - -
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/`
/r oo GALP Tor` Ago-
ANT
_ l
.57
No. Z Fee ,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplicat(on for MiopooAl *pgtem Cun!5truction Permit
Application is hereby made for a Permit to Construct( )or Repair(V)an On-site Sewage Disposal System at:
Location Address or Lot No. 015 jV15915 LM, Owner's Name,Address and Tel.No. ► 14RRq
1-iXk6 q1-(1ZZ 90� �JV T 6
'20.- 08 2 W011P ev10Miuo P0. Dim S09-3S5
Installer's Name,Address,and Tel.No. /q A910TZ Designer's Name,Address and Tel.No.
QJ Tw-Talo al"k.
MAAErow5 - C26M �����'� AYo-T-Ta
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Buildings. No.of Persons Showers( ) Cafeteria( )
Other Fixtures {
Design Flow 3?0 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Z!SiC 6`162 Lta
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 viron a tal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued. thi Bo d f
Signed Date f 2
Application Approved by ! 55
Application Disapproved for the following reasons
Permit No. 2 Date Issued
No. 2 ... Fee
THE COMMONWEALTH OF MASSACHUSETTS f�
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Migoal *p.5tem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(L/)an On-site Sewage Disposal System at: /�
Location Address or Lot No. a5 308yS LM Owner's Name,Address and Tel.No. 9 r vt'7 p /' 6rK�/�
Ko. J
"_2 d 08 2 f s c ! r 4vA014110 MIT D! S09-3S8-fff
Installer's Name,Address,and Tel.No. iA,& AyoTT6 Designer's Name,Address and Tel.No.
ao TM4 7UP a& r�
M tq�rgk6 ins QaW A Y o-r7 e
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 Number of sheets Revision Date
Title
F
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 provisions of Title 5 of the -nviron a tal Code and not to place the system in operation until a Certifi-
cate of Compliance has been issuedM this Bo d '�f He
'j Signed ' Date 2.
Application Approved by 2 ? �iS.
Application Disapproved for the following reasons
i
Permit No. �f Z Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repai;ed/replaced`('t- on'
by E-_5'r,'2wt P�A rs44 for 25 s L-nc
as has ben constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. :39 -6 2 dated -2 4; tl�;
Use of this.system is conditioned on compliance with the provisions set forth below:
� No. 9 � —/„2 ———— Fee �50 OJ
v THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwi ozal *p5tem Construction Permit
Permission is hereby granted to r,eA �, ni7�
to construct( )repair(\K )an On-site Sewage Systern located at �7011 CA ���,i►n_ � /t r+
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 construction must be completed within two years of the date below.
Date: // ?A CI Approved by
- 1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated ,��- , concerning the
_ t
property located at �!� �g'(j[�'t�S LAY, r, aVllfl meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
i
• There is no increase in flow and/or change in use proposedi'
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following: P
A) Top of Ground Surface Elevation(using GIS information) 2
B) G.W.Elevation +the MAX.High G.W. Adjustment 3,6 = if .
DIFFERENCE BETWEEN A and B
SIGNED : DATE:
[Sketch proposed plan of system on back].
q:health folder cert
i
�;;2NG trams �' �Nr
d �
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TOWN OF BARNSTABLE
LOCATION 2, JO,8yS' j,�(/, SEWAGE
VILLAGE ASSESSOR'S MAP & LOT ''VO
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITYA ype) a`? 6 1-P {'�' (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER -.&�6
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
76'9 o��"C K
B
wo/
L.00ATION � � SEWAGE PERMIT NO.
VILLAGE
C,fS �� irU
I N S T A LLER'S NAMES i ADDRESS
(74✓C/ C d k<�-7,
0J U I L D E R OR OWNER
`DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED_ � r j�
/LlA�-
No. /5 FEs....r,.....................
)ZO THE COMMONWEALTH OF MASSACHUSETTS
,RCEt Trp�2� BOARD OF HEALTH.
CT 1 ...................... ...................OF............. .....................---
a - --
Appliration for Biopo,ial Marks Tonoarnr#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
1.1..'!...... ...................
Location Address or Lot No.
Qt. .!..0. . .. . ............................................................... ..................................................................................................
n Owner Address
a ✓x�� .----.......-•................................................................I..... ..------•---.....-----------•-•---
Installer Address
Q Type of Building Size Lot./ .................` S .
U Dwelling—No. of Bedrooms........................................Expansion Attic ( ) Garbage Grind r )
Other—Type of Building ............................ No. of persons....L/................... Showers
( ) — Cafete is
Aq Other fixtures -------------------------------- .
w Design Flow......y.AZS.........................gallons per person per day. Total daily flow--....1.1.0.........................gallons.
0 Septic Tank—Liquid capacity.I.00CA..gallons -. Length..V.&.!.�'. Width................ Diameter................ Depth...y...........
Disposal Trench—No. .....J............ Width.... '—........ Total Length.................... Total leaching area2.4?.®......sq. ft.
Seepage Pit No........I....,........ iameter.................... 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......--................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
py
X x Description of Soil........................................................................................................................................................................
w
VNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complianc/hbe
issued by the board of Health.
iJ". .. �= .................. �_I ...�.� ...._....
DApplication Approved By--- ----- -- ------ ---------------•--------•------•-•----••------------•- .....7 .
Date .....
Application Disapprove or a following reasons:............................................•------•--......-•----------------...........-:.....-----.....------
--------------------------------------------------------------------------------------------------•••••--'---.......................•--------•--....---------------------=---------------......-•••--•---
Date
PermitNo......................................................... Issued........................................................
Date
- .No.19_?... zy Fps.... .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................OF..........................................................................................
Appliraffou for BiupuiiFal Vorkg Toastrurtiun rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-•-------------
..J 0 b.y..'.......... .. �s/ .. a1�..'r' 3.................. - -
Location-.Address or Lot No.
............. ...............::
Ownez Address
aAp(k...................................................................................
Installer Address
Type of Building Size Lot.0_0j D V ......5 .
Dwelling—No. of Bedrooms...._............... Expansion Attic ( ) Garbage Grin r )
Other—Type e of Building No. of persons -------------------- Showers
a YP g P ( ) — Ca
fete is
Q' Other fixtures ........................................
W Design Flow....... .........................gallons per person per�da3' Total daily flow-----3.31)........................_ 1lons.
WSeptic Tank—Liquid capacitv_1000..gallons Length._14X.L�.- Width................ Diameter................ Depth............
x Disposal Trench—No. ......I.._......... Width.... Total Length.................... Total leaching aiea.,29.Q......sq. ft.
Seepage Pit No-------/............ iameter....::.............. Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box N J Dosing tank
Percolation Test Results Performed by-•••-•-•••••••••••-••••••-•-•.........................••---•-• ........... Date........................................
Test Pit No. 1................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........................
R+ --------------------- --•---•-•••-••....••••••-•....-•----••-•--•--••-•.._..........---•----....•••......•-•--•--...------...........•---............---•----
ODescription of Soil........................................................................................................................................................................
w
..........................-.............................................................................................................................................................................
VNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of health.
tgned. .._.../..J O�-�y �......A V'f�G ................... .".!- .... . .-----•.
C D /,
Application Approved By .- �.....~ `.................................•--..........-•---••-------------- ----. _-/�_�........••--
Date
Application Disapprove or a following reasons------------------•------------------------------....-----.........----------••------------.........•............
.........................................................••••••-••••-•-•••••...
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............I.............................OF.....................................................................................
C9rrtif iratr of fauutpliatta
,THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....... r!;k^ ..C..Q ?s. .f._d t::...e. '.........................................................................................................................7...
Installer
w ..........................••••--•-•-•.....••--...---••--••••-••-•••.............-••--.•• ••----•. -•-••---•••••....
'3 s------------- „
has been installed in accordance with the provisions of TITLE 5 of T State Sanitary Code de to the
application for Disposal Works Construction Permit No.___. ' -_ '� ..__._____ dated_... ...�'' ..�.__-C.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................. Zs .................................. Inspector..4 12AA�...------•--••--•--......-•--•----.....---------•--------•--...--
THE COMMONWEALTH OF MASSACHUSETTS
1 BOARD OF HEALTH
...........1..'L........................OF..... `.��4,..........................................................
N _......../.---........ FEE........................
Disposal Tuns#rur#iun f rrntit
Permission is hereby granted----------•-••Fqhii
I ...... .......-----•------- ------------------
to Construct or Repair ( ) an Individual Sewage Disposal, System
Street r� R
as shown on the application for Disposal Works Construction Permit No: ` .._ ated....... .....•.
---------=------ --•p--- ..../ _.P
. Board of Health
v�..�DATE-M••t-�-�---�- `y •-�-Y-����9,�
FORM 1255 A. M. SULKIN, INC., BOSTON
St►.1G .AMtL`C - BGO2ooM
i o G'A2BA(,E• �jtZNDE2
DRILY FLDW .: Ilox.3 = 33oG.PQ I .., 10V 7
5EPTAr, TA•►-JK = 330x15C>*/- 5G.Po �3� 202
U5c- t000 GAL. 177,7
ot•5Po5AL PIT U.5 I000 6AL• OO �,
,5 t j)GWALL A2Ea - 1 JO S.F lol
DOTTOM AREA= ,
..T oT A 1-. D E S I t;N = .4 2 5 G.P. D.
-To�AL- DA► ►-`( Fk-ova! = 33oG.Po ='- 91 ` /o�
PE2Cot_ATtON RATE l"IN 2MIN
Pco�
Rf jt P`SH OF k�
P.ICH A�N 4G
�1A BAXTER JONES ; /sir
No.2.1048 No. 251
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STfcR�OQ' p� / T d\ �
TOP FNP =too•0
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loA,yf'_7 loop INV.
3 rfSa[� f' P 16T.
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1 poo INY. 94-G TANK
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4&ZX PIT INV. INY.
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WITH 942 9'4
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PRvFIL t_ocA� ►oN vst�t�✓i
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*, C'E czT1FY THAT 'TNE SNoW►J f
NE12EoW COMPL`(5 rlITN LOT (3
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AuD SETQe.GK R..6RutR.>✓MENT� N 1 /
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D AT E 2=l-83
BAxTEczt t,.l`(E INC. I
QE6 I SZ�2��II-A"D'S u FLY EYoe'S i
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I w,5TR.0 M E NT S v 9-V e`( -T NE o I�F5ET'5 6WOUL D
N0T t>E U5E.0To L.o-r APPLIGAN•r l�AI2-� J_C +h��70N