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Home My WebLink About0099 KING ARTHUR DRIVE - Health 99 KING ARTHUR DM STERVILLE A - a Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments W.r g 99 Kin Authur -,g M hab Property Address Michael and Beverly Hill w;a Owner Owner's Name ' information is required for every Osterville. Ma. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections � . Company Name ' 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 Si3938 Telephone Number 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 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07/22/2017 -. �nsapectoes 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /_ � J 0 Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville ' Ma. 02655 07/21/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 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 ❑ 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 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 l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 99 King Authur Property Address p Y Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. Cityrrown State Zip Code Date of Inspection 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 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 must be attached to this form. 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 El ® 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 1/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 King Authur M Property Address Michael and Beverly Hill Owner Owners Name information is.required for every, Osteryille Ma. 02655 07/21/2017 page. City/Town State Zip Code, Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® 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 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ®. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: 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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection C. Checklist 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 theprevious 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, 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 (if 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#.of bedrooms): <220 I ` l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 s Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection 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 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval., ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Cisterville Ma.. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were w e e sewage e odors detected when arriving h i att este. Ye s No 9 9 ❑ Building Sewer(locate on site plan): Depth below grade: 19"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.): t Septic Tank(locate on site plan): 'Depth below grade: 12"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 certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon septic tank Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El-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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Cisterville Ma. 02655 07/21/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, 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): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is Osterville Ma. 02655 07/21/2017 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): There are two H-10 D-Box both had no visible signs of leakage. 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.): * 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is Osterville Ma. 02655 - 07/21/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: One appx. 22' ❑ 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.): At the time of the inspection there were no visible signs of past hydraulic failure in the leaching trench. Both of the leaching pit had less than one foot of ponding water. 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is Osterville Ma. 02655 07/21/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) . 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 a _ 3 oZ3 — 3f 37 O Z 2 6 (� 3 ,5 y = 3S ' y S - 2 6 :_- I q t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 99 King Authur Property Address Michael and Beverlly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 page. Cityrrown State 'Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet 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 ® 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: I augered a We to fourteen feet to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 1 5 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 99 King Authur Property Address Michael and Beverly Hill Owner Owner's Name information is required for every Osterville Ma. 02655 07/21/2017 . page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file y c�4 e- RilTrurq of .S 9, S y 1 Jj A. o l�Z, l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 N�. No. V 7 Fee v' THE COMMONWEALTH OF MASSACHUSETTS Entered m computer: '3�Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippffcatiou for 30igozal *pgtem Con5truction Permit Application for a Permit to Construct( air( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.WKt V Vn Owner's Name,Address and Tel.No. Assessor's Map/Parcel _ i 2- -7 I er's ddress,and Tel.No. Desig er's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ffOt '' l VAN 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 provision tle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ed b s Bpat of He th. Signed 1 Date ®/ Application Approved by Date /e Application Disapproved for the following reasons 17 Permit No. Y Date Issued /0" o" No. Fee i Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC-HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z[ppYication for 3Diopaal *pgtem Construction Permit Application for a Permit to Construct( -)lee�pr( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot tNo,. �R Owner's Name, Address and Tel.No. SQ tQ1J1 _ W Assessor's Map/Parcel YYY 11rtt1 ttt"`rrr 1 1 OR-34,77 I sNamcAjddress,and Tel.No. `( ��,4 Design is Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 5 ' Design Flow gallons per day. Calculated daily flow gallons. A . Plan Date Number of sheets Revision Date Y Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer wh n applicable) y - i kyy uu_rV�i�S U3 4 Ste' /sir' 14k)z1r1 33X/ ?x Z_ Date last inspected: I Agreement: / The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provision tle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ed b s B ar f He h. Signed Date 4 0 I Application Approved by �- Date Application Disapproved for the following reasons Permit No. 29_C yy Date Issued ✓G — �' --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of QCompliance THIS IS TO , t site Sewage Dis sal System Constructed( )Repaired( Upgraded( ) Ab d( )by at has been constructed in accordance with the ovis s o the for Disposal System Construction Permit No. — y dated /U ` Installer Designer 'n` The issuance of this p rmi shal not be construed as a guarantee that the sy ill f nction as desgned.��1 Date Inspector ✓ l� � f ��r� ,� L, No. �/ 7 y --------------------------Fee 0, J` THE COMMONWEALTH OF MASSACHUSETTS 7 -ys PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi6pog;ar *pgtem (Construction Permit Permission is hereby to to Construct )Repair( � ade( . )Abandon( ) System located at 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this e Date: �G— / / Approved b l 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 1co concerning the property located at f meets all of the following criteria: • The failed,system is connected to a residential dwelling only. There are no commercial or business •`s 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 • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B),G.W. Elevation +the IM AX. High G.W. Adjustment . _ 2 a DIFFERENCE BETWEEN A and B 25 r 14 SIGNED : DATE: l [Sketch proposed plan of system on back]. q:health folder:cert - - �. `��. Q _ �-� � ! �� i �\ ,t�� \ i � . �'� � - � '� _ '.; �, f -•.. � ; .- .. \ � �__ _ - - - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '°.gin . ......:...........OF.....1& la� ......... Allp iration for Bi4pnlia1 Works Tnnitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal System at: ....qil...ki►. .....�r: l•W.Jar.: -Q B �r..s�t�l�......•------- ---------------------------------- --------------------•-------------------------............ - Loga'tion•Address �r Lot No. ` ........�E4 lT e1_... !(1�. ?�L .. . . .. .I n�C. !' ..w' . l til.,�....Q s �!'t t\�.lxL..... Owner Sara /Y1li�n._ Address a � •-t-------------------- ---------------------- .. � � g .......... Ins aller Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................ ..........Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons............................ Showers YP g -------•--•----•-------•---- P ( ) — Cafeteria ( ) A4Other fixtures ----------------•--------------•------------------•--..----•-•-•--•-•---------------------•......•-••---•-•-------•••••-•------••-••---.......-••--•-- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.-._----_____-• Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... 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........................ a -------------------------------------------------------------------------------------•-•----......--......................................................... 0 Description of Soil.........................................................--•---•-•----•----••-•----•---•------------•-•-----------------............ ................................. ------------- w x U Nature o Repairs or Alterations—Answer when applicable.7'.sna.. ....�i Do-_ /,--- ...e-------•------•--_-. W Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIME 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the b and of health. Signed --......................................... - !6_-64a._ . Date Application Approved B ---•••-•----. = `................... •--••--- `--7 _1 Date Application Disapproved for the following reasons---------------•----------------•-•-••----•-------------••------••-----------•--•-------•---••-••--...----....._ .............................•-•-•--•••••----•--...••-----•...-•-•--•--------••----........._..._.__.............•••.....•-•---•-•-•-•--•...••-----••-----•--•---•...................................... Date PermitNo , --------------------- Issued....................................................... Date�' N 1'11L Fxx...... a:..._ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH dawn. ....................OF.... �?ilQc, ! ............... .....-.... ........................ 'Appliratiun for ..OF.... arks Tonstrurtion rrrntit Application is hereby made for a Permit to Construct ( ) or Repair (*, ) an Individual Sewage Disposal System at: .. .... r- — Location-Address .............. ...................•..............---•----or Lot No.........---••-........................... .................................................. . .4` .� ti nor... ..r.. u- r�_)� P-. .......... . . ... .... . . ....... .. Owner Address !..n � t;Q;!�:....(;cara- :�,?r rho ........... Installer Address Type of Building Size Lot................ Sq. feet aDwelling—No. of Bedrooms.............................3..........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures .-.-.-----•--•----------------------------------------.---•------..-----.----••----•--...-.--.-------•---•-------•--•-------.------------------.------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►." Percolation Test Results Performed bY.......................................................................... Date........................................ a Test Pit No. I................mmutes 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........................ a ........-•--------------•----••-------......-----......-•---------••--........------......---•-......--•--•-•--•------.....-•--------•-•-------•.....-----•-• 0 Description of Soil........................................................................................................................................................................ ----------------------------••------------....--••----••-----------------------••-•-•--•-----.....------------..--- U Nature f Repairs or Alterations—Answer when applicable .F�� _._.. Oo._. _L��e�d f 1 Y---------- •- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITI. 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by thLo health. Signe '. 1 ??�.... 2:. F,;r�?------- ....... ---•............... Application Approved B -- :-- _--------- ._. - t�- ......--•-- •.... / Date --- Application Disapproved for the following reasons:................•-••--•---••---...........--•-•-.......-•--•------------......-----•-•--....----------......_- ----•...............•----•----•--•-------------.............-----•--------------------•.....------........._.....-------•---•-----•---------•-......_._......-----------------------•--....--•--••----.- Permit Na 0..."' Date ..�.�................. Issued................-------•-........---•-..... ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...... ar �xnnM v10•a ....... ....................................... Tntif irate of Tomplianu TIES S TO CARTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----• .......... ........................ ...........................••--.......................:.........--•--•..............._..............----..........: ......._ 1Ins ller at................ ! S ! _ Ir ..-- --- ------.--- -------------------------------------•---------.... ......------.....-- has been installed ce with the provisions of TILE 5 of The State Sanitary Code ja desc 'bed in the application for Disposal Works Construction Permit No......_. C .=!.71_(...... dated.-..._ I ...........THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARNTEE THAT THE SYSTEM WILL FU A ISFACTORY. DATE........................... ..... n .... .................. Inspector_...---............. ....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH.' /2 I NO .�.� �5 .4�c1.?....................O F.....! : ! t`I{:....{ :.....------............----................... .. FaB.. ................ Di po Ml Iforks Tunstrurtiun f rrmit Permission is hereby granted ..............•`�.--- - ........ to Constru ( ) or R air ( an dividual ewage Disposal S stem _ at No..-----.�T. .._....i. ... . �� ...!.'�`..�. C- a, ............. Street p as shown on the application for Disposal Works Construction Permit Nb?0_'2 L._ Dated. � >.............. \� •.-• Board of Health DATE....---. 1 S AA. . SULKIN, INC., BOSTON' t� Li ` TOWN OF BARNSTABLE VY LOCATION ArkUr' L�r• SEWAGE # VMLAGE O Sr{N� �� ASSESSOR'S MAP & LOT Sys INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY QW-2 LEACHING FACILITY: (type) 1��5 (size) (OXL NO.OF BEDROOMS L (� BUILDER OR OWNER U/��T-c `rAM►Iy rU S PERMITDATE: 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 GAG Al - 3a - u t33 - 3GI y Ay - 3Cl, . 3 f TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE Q0Q If—,. ASSESSOR'S MAP & LOT INSTALLER'S.NAME&PHONE NO. SEPTIC TANK CAPACITY t LEACHING FACILITY: (type) (size) X a NO. OF,BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well Leaching Facility _(If any wells exist ,Nl� on site or within 200 feet of leaching facility)''_ Feet Edge of Wetland and Leaching Facility(If any wetlands exist t within 300 feet of leaching facility Feet Furnished by l a Z -. R.SSt �OR'S MAP NO y� PARCELS-j�-(, LOCATION SEW AG_ E' PEMIT NO.R VILLAGE INST.A LLER'S NAME 8 ADDRESS 6 of c e U I L D E R OR OWNER DATE PERMIT ISSUED PL I A NC E I S S U DATE CO M ED S � •t rb r� O r TOWN OF BARNSTABLE t. LOCATION °I�► k� r�Ue- -0r. SEWAGE # -VILLAGE O ST ASSESSOR'S MAP & LOT:,y=s INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY if OUD LEACHING FACILITY: (type) 1�� 1 S , (size) wx(, qx(o NO.OF BEDROOMS L BUILDER OR OWNER UJ� T"c �AM Iy rU S I 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) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet Al Ct o a 3a. -,�( U ✓13 - a3, 93 - Y1 y A4 - 3`1, ray - a L 3 TOWN OF BARNSTA.BLE LOCATION�� 1 11 SEWAGE # VILLAGE J� l.' ' c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 1� l (size) NO. OF BEDROOMS BUILDER OR OWNER a A PERMTTDATE: . COMPLIANCE DATE: Separation Distance Between the: j Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility !� 4 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 t within 300 feet of leaching facility Feet Furnished by +� sJ � . A-2 J4 4 '41 r33 'A.4s6ISOR'S MAP NO. � PARCE(oI:� " -? / LOCATION SEWAGE PE, MIT NO�. _ 1 VILLAGE INSTALLER'S NAME i ADDRESS. B U I L D E R OR OWNER DATE PERMIT ISSUED ,� _��° r. OAT COMPLIANCE ISSUED -7777-7 ML Y r -3 i i ; I i } i ........... No................A....... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HE,5LTH ............OF....... . . ...... ......... -------- Appliratiou for Elhipasal Works T, trurtion ramit Application is hereby m e r ormil 10 Construct or Repair an Individual Sewage Disposal (qq Syst at: ... . . .............. _K............................................ ... ........ ...... 7Ard� cati - d re F X) ,,o or Lot 0 ... . . . . ...... . ............. . .. . ... . . ......I............................................ ..................... .............. & 0 ner ddress ........... ....................... .......... . ... ............ ......... .. ..... ... ................. . ............... ............................... Installer Address Type of Building Size Lot_---1, ......Sq. feet Dwelling—No. of Bedrooms--------�?...............................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria PL4 Other fixtures ........................................... .............. ............................................ < -------------------------------------------- 7 W Design Flow.............50......................gallons per person per day. Total daily flow..............O.-V......................gallons. P4 Septic Tank—.Liquid capacityt/400..gallons Length................ Width._____.._......_ Diameter____.__......... Depth.....__......__. Disposal Trench—No. .................... Width... .............. Total Length.......__... ... Total leaching area....................sq. ft. h below inlet...... ..... I? j Seepage Pit No._/.'417t_�----- Diameter_. ....... Dept Total leachi ea-2.01....sq. ft. Z Other Distribution box (64 Dosing tank ( ) let'- /; - /,9-11115F Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................... IT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____.______........._... 9 .....................................................................................................I........................................................ 0 Description of Soil........................................................................................................................................................................ ---------------------------------------------------------------------------------------------------------------------------------------I-------------------------------------------------------------- -------------- -----------------------------------------........................................................................................................................................... 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 TL I Ti 11 LE 5 of the State Sanitary Code— The undersigned further agrees not I to place the sy,§,teffi in operation until a Certificate of Compliance has been issued by the board of health. Sign/ed.. ....... 0jM*.,. ........ ................................ Signed-- Date -7 Application Approved By.._------ ...... ...... .. .. ..... ........................................ -- ------------ Date Application Disapproved for the following reasons:............................................................................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date No. THE COMMONWEALTH OF MASSACHUSETTS B�'' �!R® F I-I E LT H ,.. ' :OF • ,fop iratilfu f ui Bi"viial Works Tomuurtion rantit Application is h b,,y�I�'a e;f`'r':'.Permit,to Construct ( epair ( ) an Individual Sewage Disposal Sys em a :CU!� . '`- - -• ..... ��-�--------------------------------------- --- - -- Addres 1 or Lot No........................................... o. ............------------.........._...._ Owner Addre W .. ....................................... Installer y Address Q Type of Building d. Size Lot___Y' } ____Sq. feet V Dwelling—No. of Bedrooms.......... ____ ------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of.Building _____-______________________ No. of persons......................._..... Showers ( ) — Cafeteria ( ) a Other fixtures --•------'•:•-••------------------•--•--•. ----• - Q W Design Flow___________ __ _____________________gallons;per person per day. Total daily flow.............. .__Q" _.__._______.gallons. WSeptic Tank—Liquid capacity.��gallons Length;_______________ Width................ Diameter................ Depth................ x Disposal Trench �No_____________________ Wid Total Length .__.___ Total leaching area__.___:_________.___sq. ft Seepage Pit No/6 -2 __ Diameter ________ _______ Depth`,l7elp �rll G` ` 1 Liinea_. d 'sq. ft. Z Other Distribution box ( 'Dosing tank �+ Percolation Test Results Performed by..'.:...................................................................... Date.....................................-- ,-a Test Pit No. ................ per,inch rDepth of Test Pit.- ............ Depth to ground water__________________ ____ (i Test Pit No. 2_____._._.__._._minutes per"inch Depth of Test Pit_________________.: Depth to ground water................................ N , P D Description of Soil............. •-•---------------•---------•--._ ..-----•--•------••-----._...---------------=---------------------------------------------------..................... W -•--•--•-•---------------------•---•-----••-----•----•--------------------•--------•-•-••----••------------------- --•--- ....... U Nature of Repairs or Alterations—Answer when applicable____________________________________ --•--•-•-•--=-------•---••--------••------•-•------•-------••._._...----•..........................•--•---••----------...•--••-------•••-------•----=•-••=-----•------•---------••---•-•---------•--•-•• Agreement: The undersigned agrees to install the aforede"scribed Individual Sewage Disposal System in accordance with - the provisions of TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h th. Me ApplicationApproved By..........--••• ......................................................� ----------------- ----•----.............................. Date Application Disapproved for the following reasons_............'-................................................................................................... -------------------------------------------------------------------•----------------•------•---------------•------•----•--------•••-------------------------------------------------------------------•- Date PermitNo--------------------------------------------------------- Issued_........................................................ Date THEFCOMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... -........OF... a.. ... ........__•_ ... '................. Tntifiratr /o"f Toutplinttrr THIS IS TO CERTIFY, Thatt e u vi �evcrage Disposal System constructed r Repaired ( ) .,, ,. by - .�.. °#-�-- •°--•-- -' -•--•--•---•-•-------------•----•- .................................... Installer has been installed in accordant ,with the provisions of T 5 7� State Sanitary Ce R r,4 in the application for Ni posal!Works'Construction Permit No___________________7____._.__._._______. dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUE® AS A GUARANTEE THAT THE SYSTEM WV LL FUNCTION SATISFACTORY. � - 6- 7 DATE... = •-• •--••-- -....... ....j-------slene�x ... .................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ....-......OF.... G �� ..::..................................... i N ...... •-- FEE...Z...S--_--_•-- Map Permission is eby granted. ." t ...................................... to Constr t ,�`Repair ) a ndivid Sewage isposal Sys em at No l = i2 - -Y..- � ' `' as shown on the application for Disposal Works Construction Pei Board of Health DATE--- r ---------------------------•---- -•--•••- FORM 1255 HOSES & WARREN, INC., PUBLISHERS - �b t�`��tG►�t �QTA. ` O GArrs,�e ��I�JDE�tZ. 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SM�wt.x� . . .. . ... ,. t,br BE- Used To U,t=rceMl�� LOT- ,t_ N�� ;APPL_t . _....�_.._' ;. t� Dig• �eV•. �. �'"