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HomeMy WebLinkAbout0326 MAIN STREET (OST.) - Health (2) 316MAINS'�( j A = 165 097 0 i Fee----- --------- No.------------------ BOARD OF HEALTH TOWN OF BARNSTABLE Application furVei[ Congtructionpermit Application is hereby made for a permit to Construct ( Alter ( ) or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address Type of Building Dwelling --- -- - - - - Other - Type of Building------------ - No. of Persons-------------------------------- Type of Well I/ w e. Purpose of Well---- - !____—_------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Sig ------- - - J—(�—J -- ate Application Approved By --------— -— ''F-'= date Application Disapproved for the following reasons:----------------------- - -- --_ date Permit No.-- �_a��-�' ---- Issued--- -��_�J_ --- ------___ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compfiance THIS IS TO CERTIFY, That the Individual W 11 Constructed�; Altered ( ), or Repaired ( ) bY- d -- --— - -- - ------- staller has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------- - -- Inspector-- - ----------------------------- ---- i r �-�-- No.----------------- Fee----- ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Appiicat ion for Well Con5tructionPermit Application is hereby made for a permit to Construct Alter ( or Repair ( )an individual Well at: Location Address Assessors Map and Parcel Owner / Address Installer Driller _ Address j Type of Building Dwelling ----- — -- — ---------- Other - Type of Building— - ------- No. of Persons------------------------------ - Type of Well— — Pv —— — ------- Capacity--- — —------— --— �... i Purpose of Well--- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with,the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. JJ Sig e' .''`� �%� ------------------ --�/ --- date Application Apprcved By — ----- ---—— , -- 4 date Application Disapproved for the following reasons: ----------------------____—__________— __—__—_ date Permit No. ��-' ® ' — — Issued--- -�`—�`�-- ------ date t BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ), Altered ( ), or Repaired ( ) � S' r by---- •9-— /c�l� �cl�� ���✓r_----------- ---------------- —--_--- ---- ()X/staller has been installed in.accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -�—Gated— THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY.. DATE--------- ---——--— - --- Inspector-------- - -- -- —------- I ....�. . _... .� .- ...,�..�.�...�,.. _._.�x..__ ....�_.� __�..— BOARD OF HEALTH TOWN OF BARNSTABLE Well Con5truct ion Permit No. V�J 5 c� Fee_—__---_--- Permission is hereby grantedto Construct (r/., Alter ( ), or Repair�_ ) an Individual We -at: - ------------------------------------------------------ Street as shown' ,on the fFlic ation for a Well Construction Permit \ No.- —� C� � — ------- Dated_—� -- )1—__-- --------------------- Board;of.Health DATE „� t } TOWN OF BARNSTABLE LOCATION �3/6 -Aaobl S SEWAGE # YII.LA( E ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 7 � !' (size) NO.OF BEDROOMS V11 g49 4 q BUILDER OR OWNER �✓� 9 v PERMIT DATE: 'Y 0 COMPLIANCE DATE: d �- 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 CZ - Z71 02 - 336 C3 ®� �---- e /cube 'c._ al No. Fee THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer. —<� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes Z(Ppricatiou for Miopozal bpotem Conotruction Permit Application for a Permit to Construct_( Repair(t�/j Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. 3)6 M A 4- S Owner's Name,Address and Tel.No. ©jtFlZVo ��� '1)� 9) AlV t. 45J 3 /6, MA,N+ S� O�TzP- Assessor's Map/Parcel 1 6'S Installer's Name,Address,and Tel.No. (���D Designer's Name,Address and Tel.No. W Type of Building: G de Dwelling No.of Bedrooms 5 Lot Size / - sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S� 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) Date last inspected: Agreement: The undersigned.agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ue y this oard of H Signed Date �� Application Approved by Date Application Disapproved for the following reasons Permit No. `� 3 Date Issued 3 4? .O ....�....e 4 "�+wi op T l So — No - '.--•. ' — Fee THE CO ° ONWEAL AMJISSACHUSETTS Entered in computer: . .. PUBLIC HEALTH DIMI$ION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes A ricatio,nIorigogaY 6ptein �Congtructionertnit Application for a Permit to Construct( )Repair(&f Upgrade( ,)Abanddn.( ) ❑Complete System O Individual Components Location Address or Lot No. 3 6 m A Ihr S , Owner's Npme;Address and Tel.No. "O$ _IZV+ R) 11N 1. bsJ 3/6 /Y/A,ty S p»SrS_'A , ) Assessor's Map/Parcel 1 6'5 49 8 Installer's Name,Address,and Tel.No. �D� Q "� Designer's Name,Address and Tel.No. calk A(Q ,,60 j QC Mf�/1_ W, Type of Building: Q� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) �' Other Fixtures ,f Design Flow S Sy 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 i .i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this Board of H3 a Signed r 1r) 1 aJ,/-�� te o)C AY Application Approved by \1 Date Application Disapproved for the following reasons Permit No. Date Issued 3 1p O tj - - ————— ————————— --------------------- S�rP ,urwl r,/►1 y lJ hr�I-P r� a THE COMMONWEALTH OF MASSACHUSETTS CAt" BARNSTABLE, MASSACHUSETTS Pod 6'! s rF y(2b14 Certificate of Compliance 'A THIS IS TO CERTIFY, that the On-si a Sevyage Disposal System Constructed( )Repaired(�O Upgraded Abandoned( by - A91 � / ���r�s. at .5)`: f�✓���"!i' Ile—, has been constru ted ip accordance with the provisions ofTide 5 and the for Disposal System Construction Permit No. ;)U a L 3 dated a k Installer Designer The issuance'of this permit shall not be construed as a guarantee that the sys in ill func I n as de ned. Date tt Inspector y No.Q Or) Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligozaf *p.5tem Construction permit Permission is hereby granted to Construct( )Repair( )Up ade( \ Abandon( ) System located at 3) (9 rn Q, S 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 condip,ons. Provided:Cons ction rust be completed within three years of the d a, of thi pe ' Date:_ /d�-� Approved by TOWN OF BARNSTABLE 0 LOCATION ���� �C�/� sf SEWAGE U 'l VILLAGE ��5>�/'U,�� ASSESSOR'S MAP & LOT kS -�L? INSTALLER'S NAME&PHONE NO.�4� /® 0[.� 5�! 7,71 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ( (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: � COMPLIANCE DATE: O �' Separation Distance Between the: Maximum Adjusted GrounaNr Table to the Bottom of Leaching Facility Feet dw i 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 / 2,q :% C2 Z7 ` Dz 3� 6 ,C u5� Town of Barnstable O-1HE 1pk, .�� Regulatory Services * Thomas F. Geiler,Director * BARNSTABLF, MASS. Public Health Division �Fn MAC' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: ._j�Y L� �4 ss� n t� Designer: Installer: Address: -70 W4 y Address: �;­ A �A�Gt1 Yi V,+ 025",T IC Opu-nw3 A&I s On �PoC � +�0 L-6 Cv N was issued a permit to install a (date) (installer) septic system at 314 MA A) ST 05-F6-'.V 1 i.VY based on a design drawn by (address) W)'LL)4 to L" 4� dated O C-rl Z063 (designer) V/ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical.relocation of any component of the septic system)but in accordance with State & Local Regulat' Plan revision or certified as-built by designer to follow. tM Or M tp� +s'S4 WIIIIAM s� VEBERMAN 4NO. 939710 ti (Installer's Signature) �o ": ,sit IV A. aNG��� Wk-An 9--- esigner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form a 01 A M� f m fen rfl J AUGIj r 8 Iggg :> Norge COMMONWEALTH OF MASSACH S �t EXECUTIVE OFFICE OF ENVIRONME AFFAIkS 4,�John Grad DEPARTMENT OF ENVIRONMENTAL PROT1✓TjON 3`EP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500� P.O.Box 2119 a TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 316 MAIN ST. OSTERVILLE MAP 165 PAR 097 L A Name of Owner DR.KATHARINE COTTER Address of Owner: SAME Date of Inspection: 8/6/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evali4ation By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:8/12/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND THEN MAINTAINING EVERY TWO YEARS. I " revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 166 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:8/6199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced z Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 165 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:816199 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 166 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:$16/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nla. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 316 MAIN ST.OSTERVILLE MAP 165 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:8/6/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has.been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 316 MAIN ST.OSTERVILLE MAP 166 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:8/6/99 FLOW CONDITIONS RESIDENTIAL: Design flow:—EU g.p.d./bedroom Number of bedrooms(design): 5 Number of bedrooms(actual):$ Total DESIGN flow: 10 Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry,system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): MO Last date of occupancy: n& COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: nla gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):AQ Industrial Waste Holding Tank present:(yes or no): Xa Non-sanitary waste discharged to the Title 5 system:(yes or no):DLO Water meter readings.if available:n& Last date of occupancy: n/a OTHER: (Describe) nLa Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa_ gallons Reason for pumping: Wa TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1987-PERMIT 87-665 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 165 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:8/6/99 BUILDING SEWER: (Locate on site plan) Depth below grade: L6_' Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nla Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Old If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO nld Dimensions: L 10'6"H 5'7"W 5'8" Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle: L 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: Jr How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: Wa Scum thickness: nla Distance from top of scum to top of outlet tee or baffle:.n/a Distance from bottom of scum to bottom of outlet tee or baffle nla Date of last pumping: nla Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Old revised 9/2/98 Page 7 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 165 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:816/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n1a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) I]La Dimensions: n& Capacity: n& gallons Design Flow: nta gallons/day Alarm present: NO Alarm level:jVz- Alarm in working order:Yes_No_: N_Q Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wit DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nta PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wit revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 166 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:8/6/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: ..n/a leaching galleries,number: _Wa leaching trenches,number,length: nta leaching fields,number,dimensions: n/a overflow cesspool,number: nta Alternative system: Wa Name of Technology: .n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTLIRALL SOUND AND FUNTIONINC PROPERLY THE PIT WAS 1/2 FULL-AND HAD SOME SOLIDS IN IT AT THE TIME OF THE I CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nta Depth of solids layer: Wa Depth of scum layer. Wa Dimensions of cesspool: n& Materials of construction: Wa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n/a Depth of solids: Wit Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address: 316 MAIN ST.OSTERVILLE MAP 165 PAR 097 L A Owner: DR.KATHARINE COTTER Date of Inspection:816/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a AA revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; 116 MAIN ST,OSTERVII_I_E MAP 165 PAR 007 L A Owner: DR.KATHARINE COTTER Date of Inspection:8/6/99 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: nta USGS Date website visited: Wa Observation Wells checked: N—Q Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE I LOCATION SEWAGE # T7 VILLAGE (D,5c+�✓f� t� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO: 'C,t /}�lp SEPTIC TANK CAPACITY® :LEACHING FACILITY:(type) o a (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER -BUILDER OR OWNER DATE PERMIT ISSUED:' DATE COMPLIANCE ISSUED: O e�`- 7 VARIANCE GRANTED: Yes No �O(7!e t v` THE COMMONWEALTH OF MASSACHUSETTS BOAR E HEALTH . ................OF....... �4-5 Appliratiun for Disposal Works Tonutrnrtiun Fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( 4-a4t-Individual Sewage Disposal System at: .. .1.. --._ I .r.!1�.. ..................................... ..........:. ..._...-•-•- cati Ad�1r LotN 1a•U � 1_nlb�• ._. Q..f.1..PY or o ....-•-- .... W / e Owner Address ..................u,1.-. �..- Installer-----------•.............................. ...•..................................-•--•—Address --------............_.._.................. UType of Building Size Lot.................... .....Sq. feet �-, Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Other 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 Lox ( ) Dosing tank ( ) Percolation Test Results Performed by...................................................................•-•••• Date........................................ Test Pit No. l................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........................ 04 ............................................................. --------------------------------------- -------------- ••-•--------------------------------------- 0 Description of Soil........................................................................................................................................................................ x U .......................................................................................................•--•••••••---•----------------•------------------- --------------------•---------•--------: W U Nature of Repairs ox Alterat o snswer when applicable.-tewi ..... ...... -!-�_.______ U �L Agreement./ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been_1SS11eh by the bo rd of health. ? Signe [ ---- 5.......�-.7.. Date Application Approved By•--••... -------------------------------- .......... Date Application Disapproved for the following reasons:--------•-----•----------------------------------------•-----:.._:---•-----------------......................... .......................................................................................................................................................................................................... Date PermitNo....... --..............--.... Issued....................................................... Date No.... " , Fps.............::....... THE COMMONWEALTH OF MASSACHUSETTS .�_ BOARD-•OE HEALTH ..............f :. -.'................OF..... '.t! ...... - g .............. Applirtttiun for Disposal Works Tonstrurtiun umit Application is hereby made for a Permit to Construct ( ) or Repair ( t.)-an"Individual Sewage Disposal System at: t ....... _...a� ...� .�. .... ................ _......_s E/ ✓. ..`.......1_C_'� .. .. .. .. ... '... a.. Location-Ad . s or Lot No. i I. �. d1s r - _ F+ ---••-•--•-•-•--••-•--•-•---••---••-•..............•-•--•-••----_..........--•--- W Owner Address sl s Installer ----•-••....................................Address•-••-•---•-•----------._.........------•-• VType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Oth er fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter----......---... Depth................ � f Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.--..........--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) , Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit---................. Depth to ground water------------------------ r1ro Test Pit No. 2................minutes per inch Depth of Test Pit...---.............. Depth to ground water.---.........--.....--.. w' ----------------------------------------•---------••-------•-....-----.........•.....--••----•-••............................................. .-------------- 0 Description of Soil....................................................................................................................................................................... x V •--•-------------------------------•--•-••-----•---..........-------------•-•----•------.......-----••------------------•--••---------- ----------------•--------•-------------------•------------- W txj --------------- Nature of Repairs or Alterations Answer when applicable r w rz�ram.- :.2 ----..r�'.r r k; `T s fr s' t" ..- �•':J 'ram .... i i Agreement,:;/ The unders_gned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT IE 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 health. Signed -----•----•- '- t •---•• -•�.... .---•..... Date Application Approved By..........641. .... � Date Application Disapproved for the following reasons---------------------------------------------•----------•------•----------------•-----------•--•-••-•-•---•-••-- ----------- --------------------------------------------------- •......... ------------ •------------------ -------------------------------------------------------------------------- :.................... Date Permit N;o...... l'.7'..ta Date THE COMMONWEALTH OF MASSACHUSETTS BOARD-,,OF HEALTH , !, f!? 0F....ir. .................................................... C�rr#if irtt� of f�um�littnrp TH� IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( �- -----•-•--.•....................••••-•---•...._._..•--- at r/ -------- z 9 4 --- has been installed in accordance with the provisions of TI III 5 s f The State Sanitary Code as described in the application for Disposal Works Construction Permit No..-- .2.� l.Cx- ......--. dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ..0 Z. .... - THE COMMONWEALTH OF MASSACHUSETTS BOARD,,9F HEALTH 1 ; .................,OF...... ......f:.:. ............................................ FEE....................... Disposal urku un� rnr#iun rant Permission is hereby granted ....... .........._ xr �fr` • F .�.�., ............................ ........................................... -� to Construct ( ) or. Repair ( an Individual Sewage DisposalSystem ; �' t at No............ ..... ?�+ � �; ` i.. .' r> *. Street QQ as shown on the application for Disposal Works Construction Per it Nol�7_ (. ._ Dated.......................................... _•................. .p.n_. ,5..� .�... w ------------------------------------------ .� Board of Health DATE `� -7-- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS CE13TERVILLE-OSTERVU LE-MAR'ST(WS MILLS FIRE DISTRICT • 1875 ROUTE 28 , CENTERVILLE, MA 02632 (508) 790-23801FAXa(508) 790-2383 OILMAZARDOUS MATERIAL RELEASE FORM F.A.* LOCATION: ADDRESS OF RELEASE: � ,) P_r�r T'' P'1_�i7.1►) i I�,{� Qe��o DATE OF RELEASE: 4-ICI -Q� PRODUCT RELEASED.- ESTIMATED QUANTITY:t )k)✓ CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY"ram►-)►4- ��c��i ?R rr�n.v_i 05�--rrN,C,f I,r N r;—='1(vl D¢r-y r��, s)0-A rri i" fN C NOTIFICATIONS: FIRE DEPARTMENT: YES09 NO( ) DATE. (n TIME- 11 ,01A NATIONAL RESPONSE CENTER YES( ) NO(>() D ATE: T IME: DEPT.OF ENVIRONI-IENTAL PROTECTION YES( ,() NO( ) DATE: TIME: `---3� OE SPILL COOiDQyATOR- YES( NO( ) DATE:44 G.'ice Tt4E: n� TOWN BOARD OF HEALTH: YES(X) NO( ) DATE AA--J5 kTIME. r e.nZ Wl • TOWN HARBORMASTER: YES( ) NO(?() DATE: TIME: OTHER AGENCIES: COMMENT a-" ishL-: �3I.Jo -r"�. r� , nbl -4:;tni kA7„-14 c,<1 - 'i910(n "! "'[ _yf e—' Y LLC'� 1!.AftTl1�. .Gt1!L ^e- t:x+c rGi V,� w1/ _ , Sy 1✓ a,�.)►l r-� +? nOIV\l—VAl" a-r1n 11(Te'yllr a?Ar /F`h'��. NY IT6.. P! `f .1,�.n„-.-:c. _..;.,n., �'tD. ,iGt� n..irs F_.� ►�nl�,..l,f-. t9cn nsr,—oc.on. ('ctii'1"2,A�'tdf~, I2EPORTEi�r1��-� f,�"�..�► ��� MATE' 4-��� WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-O-MM FORM V f ®®q q _ f� y !L.J - Y n Y:. k t7: ?4 .1• 11i,' k - /D X fG Ram -3V6 16' s G tilk �. 30r,�v`rro9� c6v xtz 4 wokg 6t -Too 6 3 30 - � Mao) �. IVY Ar 09 y r t - �fwGl�� t6eL� 94 x e 441 _ - e �yt/b - .. ��-�'ic�r°`� :►� �P��E � - ��. `, , .�i�ts�` �'�• �" r�- cc.r�! }. 4 ,- _ Pf sed , 93 �97 f F 0 N EX/ST `//� G 20 - EX/ST/�G P GARA�'� N ,4ND PL- OO C� W POOL /O N tI� ¢ 20.3 4 0 ;. Pik p11 ,Qt N G E. , ' 96 r N 4f 40 c� 00 Y iiT ...} cn N33589 SURVE i E � � hi6P�f Y CART/FY T/��9 T THE �X�ST//�/G 11 ST�I/CTURES —.-_f cTEI� o� 7,�//s f?�e9/�/ A/�C-` 'S.yOG(f/c/ f�E.�? " �4 s 5/T� PLC/J 0,� L AA/L� i T/-/� 6 6?0 l 0A1 A/�/ A cTv,q SHOGt//�/G T.�1E IV-CAI boa L T 3/G A-IA S Ti�E�T o' Zo ' . 0 M ,38 �J.. - . �' _ sc,�1�.E=/"'=30' ✓vw� 3aJ Boas ✓,.IDYL_E �9�5"�DC. �5D -�5G - 8 3 /994 -. _._ _ _ __ __ _. __ _ /70 CZ-011,6 0 IWY H.4%Ch't//L L 6 FIN, F. nx 4e4. s/, 96 SD/L S TEST RESUG TS t�W�1GE . SYSTEM PROFILE O" EG. 50.8 SY/fs/g SWAIbY A LOAM e F/N/sH ,G,egaE �!/nl. SL 9a 4.r IV, q Ls Di'ASI/vM.DPMAX• 7 S yR sN 3f . BOX Gl MAX. 9 Mhf• 35 Ec. -F7.9 •IN l2" " '•_ .. Jy/N. N�It MEASURE IIVyw .¢4,8$ 3G MAX. . sc:y.,gDf 1 .,. Ff sCH. P.vC c✓ viD L�vEt... s'GH.4 PVc° /vEdi✓/M C 49�88 48•�s ;� $7a0 47.d,3: ;�4 191 3/4'=1%CD C7 2;. ,:; A cRuslyEa Zeb Oka WAs ),3ouG, L-g 4CH CHAMOLNeS W4SHFD Z EFG. ,DEPTHTO �11 C1 o C� Cl 57oN E .e , ••�. ..• ..J•l. EXI.57-1 i&: ISO0 GAL.,PAECAST .S*P7'IC TANK - 4, +016.1 W17H 'I�tdLET�O�/TLET TEES `cONsTQUGTED .. 12A,14�.. *ER 3I0 cMR /5-.227. 08 SOILS AB-l;:wP 1DN SYSTEM /DYR %/ F/n/E CZ fit.. 39.80 soTTDM of 795-r IN T 132 ,:; GRoUN�N/.97�R NOT ErVCOUAITE.E'E� SOILS EVAL41.4TO,P �/OryN 1�oYLE WASHED 51'ONE 4.' PERC. RATE 4 2 A41AI. PER INCII. �93.g�,, 12'/0"' 4.• Fo v.R 5c90 �. coN R�'rE 4� PE,�'G. DEPTH s 37"- 55" t�i4C. H GNr41�9 ERS Sa/GS 7",wV7Ve,4L. CLASS = OAlE •T` _ �_ x �ccE 4,! , WA' 1fE STONE E IYED n.. G8' X rLJQ/Y yl4W F -S A.:5 ...I" "' lop . . x �Q:S.S EsS oR s MAP /G S Pol1 RCEL 9,9 PRopo�Ed RESERVE, Rou • ; =� f1 REA ' TF 2g S°x O ¢2 — _ SEKAce SraTc-M Des✓cn/ c'AZ.c4✓L.lTIoNs � "�--- i .. Jc 47 �s'3• r, !. DES/r N .d A/L EA0W. �' 9 � 2 3' �IT {! Y r 5, AseaKOOMS X 1 fo GPD S'S0 SP b \��+ � G�QE p a� P�toPosE� S� �� 2. REQUIRED .98SoRPT/oN AREA � c � N h 3 GPD -1- 0.74 615FJDAY S•F N W r , a . tg• O 3, USE �4) 500 GAL. PRECA Sr LEAC H CNAM,545P-S N � u v WITH OF .Aovec.E WASHED STONE A)COVAJ A. C kl �4 ( 4•• ADSORPTION A�eEA PROV/SIGN= w� �dh� BOTTOM AP-CA = 12.93 x 4.2 = -6-38 /� •pR!�� — —. ��` 5IDE A)CEA = (Z5.66 + 84) X 2 s ZI9 S.F. TOTAL AAC-A = 7S7 S•F. MAIN a QEX/ST//vG I I NOTE : �a'/S�/NG LEACH/NG PlT SN.4L< ,BE PU/VJPE.1� •4�/d RE/►'IOVED, A�3� .aWEGL/NG I Sa•'� L0C44T/v/-4A ' SCALE- / 3000 • - i � � �L.= S/: 9G i A i yoX� � 5/TE ,Q�t/.:I) SE1�t/AGE' PLA/�! k I l2q-' tH ar PiSEPAReD �v�t I W I Q ��. /BM: To,,- of ,s.R, a. � JONN 9�\� ,p/P1AA1 AND 40.33Vs 5,q0N//NG ?X/E RROPOS -b GARA6EP PODG St1R` AND .s'Eh/AG E SYSTEM URaifADE .— ._ __ / -- ——— _._..._•._ —,l. p'� o p3 3/C. /v1A//V S 7W EE'7' AD" OA PAY MENT ,�3� �bt�� E/ ¢.�2 GtS'TC�VILL45 , A 4 A . �y S4C,44E= 30' 0c71OBER 4, 2003 MAIM 5TREET SLAGE=N FEET p• 3O• Go' ✓.DOyL�' Mod ASs Oc. TEL t'og- seas -/994 ,o O.BoX 595 X/�s7' F.q�Mocrr�/ 02574