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HomeMy WebLinkAbout0201 OST.-W.BARN. RD - Health 201 Osti._, W/Barn. Roa Osterville P A = 120 004 y. ° o a 4 M r , ° ° , o —d ,/iAP PARCEL. COMMONWEALTH OF MASSACHUSET�' W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION O,�M SV9 •� RECEIVED 350 MAIN STREET WEST YARMOUTH,MA APR 2 7 2004 �O 508-775-2800 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 120 PAR 004 Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner's Name: ORTH,CHRISTINE Owner's Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Date of Inspection MARCH 18,2004 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: J Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3- .2 ° The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared systern or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 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: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 C. Further Evaluation is Required by the Board of Health: N/A 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Staiic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in leaching is less than 6"below invert or available volume is less than%2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the 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 I of a public well ✓ Any onion of a cesspool or privy is within 50 feet of a private water supply well P P P �'Y P pp Y ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (YesJNo)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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? I ✓ 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal,use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002 76,000/2003 60,000 Sump pump(yes or no) NO Last date of occupancy_ PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy!use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: TO BE PUMPED AFTER INSPECTION,MAINTENANCE. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumpe& gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ./ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe):: Approximate age of all components,date installed(if known)and source of information: 2000 PERMIT#00-612 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 16" Material of construction: ✓ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: F, Distance from top of scrum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.INLET TEE,OUTLET TEE.TANK AND COVERS 16"BELOW GRADE. NO SIGN OF LEAKAGE OR OVERLOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scrum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) S Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ./ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if boa:is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 20"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ./ leaching chambers,number: 2 leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: - Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO 500 GALLON DRYWELLS.TOP OF LEACHING IS 3'6"BELOW GRADE WITH COVER AT 1'6".4"WATER IN LEACHING.HIGH WATER LINE AT 8".NO SIGN OF OVERLOADING OR SOLID CARRYOVER. CESSPOOLS: N/A (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) t Title 5 Inspection Form 6/15/2000 9 i Page 10 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA.:02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 " SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference'landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. _ l JIG, 1 . Title 5 Inspection Form 6/15/2000 10 Page I I of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 201 OSTERVILLE/WEST BARNSTABLE ROAD OSTERVILLE,MA 02655 Owner: ORTH,CHRISTINE Date of Inspection: MARCH 18,2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater .12'6" Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-]f checked,date of design plan reviewed: J Observation 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:' HAND DUG TEST HOLE 12'6"NO WATER. TEST HOLE 6'BELOW BOTTOM OF LEACHING. Al -------------------- JI , Title 5 Inspection Form 6/15/2000 11 No. Fee V v U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ` ZippYicatton for Mtz=pgrade pztem Com6truction Vermit Application for a Permit to Constrict( )Repair( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.a p/ 0514s tu>'ilt— Owner's Name,Address and Tf 1.No. CJ. (�,rn��ihr� R� ���t•(i� JVC US Assessor's Map/Parcel /a 0 00 s Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &A B CANCO A 350 Main Street W. Yarmauth, MA 02679 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 316 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /j Op ---Type of S.A.S. .S'6p�5 Description of Soil `Z*� Nature of Repairs or Alterations(Answer when applicable) S. 4e-�, / r 1 215 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 issued by this Board of H th. Signed Date Application Approved by Date � ..� � Application Disapproved for the following reasons Permit No. Date Issued Fxr ti / No. _ 'V&y, �� .��/ f �.. Fee F MASSACHUSETTS Entered in computer: :i THE COMMONWEALTH O S Yes �r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS U 2pplication for Miopoiar 6potem Construction Vermit Application for a Permit to Construct( )Repair( pgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.,,;)p 6, 4e t,%/l e Owner's Name,Address and Tgg1.No. Assessor's Map/Parcel OOL n Installer's Name,AddreA R&W-GANCO Designer's Name,Address and Tel.No. 350 Main Street W.Yarmouth, MA 02673 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 3 U gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank Type of S.A.S. GCSeo Description of Soil /Yly Nature of Repairs or Alterations(Answer when applicable) 05 �� �— /�Do r A 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 issued by this Board of H th( Signed Date Application Approved by Date Application Disapproved for the following reasons • __ ,{ f Permit No. f�11�'' Date Issued 'r ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS x ­,Ce of irate of�conmprtance IS TO,CERkIF ;'thatYthe Onsrte Sewage^Disposal System Constructed( )Repaired Graded( ) f Abatidoned.(r' )by K iU< 3 Ot at / 6�- `yi/le (. � r�r /01 S744 ASP f) -12 ©J thas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N7 4"� .4-1` dated Installer r�Designer x `' ` / r� n' A The issuance of thispermit shall not be construed as a guarantee that the sys em ill function as designedf Date Inspector --------------------------------------- NO Q1,11-4 Q -4 , ® Fee •� C J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH-DIVISION - BARNSTABLE, MASSACHUSETTS IDiopozar Op$tem Conotruction Vermit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at ��s% s,�or,�;//o �i r�S4 Leg ra4 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 thi -ermit. Date: �� r // .Wv �2z� Approved b - i TOWN OF BARNSTABLE LOCATION c7<O/ 'S 1t) g SEWAGE #00-��®Z VILLAGE ASSESSOR'S MAP Cz LOT �DD INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY — -Pss�C r,y? _ UJ l'A/, G, .�,•?�SC�'c Y G. LEACHING FACILITY: e(typ , , (size) i NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNE I' l� e y S DATE PERMIT ISSUED: i � C {. DATE COMPLIANCE I SUED: VARIANCE GRANTED: es No. D� . I. I i I , z� - 4 i t i TOWN OF BARNSTABLE ,I LOCATION A 0/ ®-57 IF9) SEWAGE # i VILLAGE d S T ASSESSOR'S MAP & LOT IA® - �R'S NAME&PHONE NO. SEPTIC TANK CAPACITY —�£ ��5�£C 1'71 0 n' LEACHING FACILITY: (type) (size) NO.OF BEDROOMS `/ J ,-,,--BUILDER OR OWNER' ®I?a C hI4015 /1�g �` /�SP£c Toic- } PERMITDATE: CGMPHANCE DATE: Separation Distance Between the: Maximu '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 Furnish Id by i Y 33 O op TOWN OF BARNSTABLE --- LOCATION RA SEWAGE #00-6/oZ VILLAGE ` � � ��, ASSESSOR'S MAP & LOT -®0 ;INSTALLER'S NAME Cz PHONE NO. A & B CANCO 775-6264 .SEPTIC TANK CAPACITY - . .; m e v � LEACHING FACILITY:(type) 5Zv (size) 4;75-X 1,3 .I . NO..OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNE ' t., /e 1/s DATE PERMIT ISSUE 00 DATE COMPLIANCE I SUED: /0 VARIANCE GRANTED: es No C V w 1/6199 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) I �') � � y certify hereby rt fy that the application for disposal works construction permit signed by me dated /o 11 DD concerning the r property located at JOl OS> - 4), &,J, meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5•minutes,per inch. R There are no wetlands within 100 feet of the proposed septic system-X/ • 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 r / There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) .Top of Ground Surface Elevation(using GIS information) C B) G.W.Elevation � +the MAX.High G.W. Adjustment. DIFFERENCE BETWEEN A and B 0 SIGNED : V DATE: D f /&r) [Sketch proposed plan of system on back]. q:health folder.cert � r 1 bct Y \ � V l\ ro