HomeMy WebLinkAbout0191 PARKER ROAD - HealthFrl91 PARKER ROAD, OSTERVILLE
A= 116-083
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= TOWN OF BARNSTABLE
LOCATION �/ ®alcr r� SEWAGE# 1729
VILL•AGE ` 63
'ASSESSOR'S MAP& LOT•&d—d g3
INSTALLER'S NAME&PHONE NO. -AW1274vy)/ Co sy` q7-I r 'g�
SEPTIC TANK,CAPACITY
LEACtIING'FACIL:TTY: (type) (size) b sx Z
NO.OF BEDROOMS:
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Permit
Parcel #
Division
Date Issued
Health D
Conservation Division Fee
SEPTIC SYS$EIli91�9�tT ? �
r � � 1N CC6.,�'
Tax Collecto I; INSTALLED
1' Treasurer � �Z` 'A
Planning Dept. V"
D o
v
Date Definitive Plan Approved by Planning Board/`
a � PP
Historic-OKH Preservation/Hnnis
1
i PA,
' Project Street Address
Village
as-
own '?OM Addres
T ep n ' N Lj
Perm e�u t
�t C. �a
Square feet: 1st floor:existing proposed 2nd floor:existing proposed Tota ew
Valuation ZoninaM&ict Flood Plain Groun water Oggrlay
C)
Construction Typed C
c�XA, sue•
,Lot Size • Grandfathered: ❑Yes ❑Nb If yes, attach supportincument�tfon.
cn w
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes /No On Old King's Hi way: �(es No
co
Basement Type: ❑Full Crawl ❑Walkout ❑Other
.Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing ( new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing
new First Floor Room Count
Heat Type and Fuel: Gas ❑Oil El Electric El Other
Yp �
Central Air: ❑Yes vl o Fireplaces: Existing �_ New Existing wood/coal stove: ❑Yes o
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:Zexisting ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded O
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name Telephone Number
Address' License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONST UCT N RIS REJING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATU E
DATE
I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT..OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION TO®�
Property Address:.
Owner's Name: �NO�ePP��N
Owner's Address:
01-77
Date of Inspection: ( �
Name of Inspector: lease print) @Orr )bV-�3-.I,,,,ss
Company 1NameA66_7
Mailing Address: •%
.
Telephone Number: -5Lok- -5-? c)
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 t Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes .
�gpds. urther Evaluation by the Local Approving Authority
s
Inspector's Signature: Date:, b 6
The system inspector shall submit a copy of this inspection report.to the.Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system,is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the.buyer, if applicable,and the approving
authority.
Notes and Comments
****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 page I
Page 2 of 11
OFFICIAL INSPECTION.FORM—N(.iT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAT A
CERTIFICA+ION(continued)
Property Address: /
Owner:
Date of Inspection:—eaP 4p is, /6,z
Inspection Summary: Cbeck A,B,C,D or E/ALWA S complete all of Section D
A Systein,Passes:
l have not found any information which indicates:1 hat any of the failure criteria described in 310 CMR
5.303.or.in 310 CMR 15.304 exist.Any failure criteria n hevaluated 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 replacemen or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the or the following statements. If"not determined"please
explain: .
The septic tank is metal and over 20 years old* or:he 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 structural y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is availab e.
ND explain:
Observation of sewage backup or break out or hig static`watei level in the distri' iion box due to broken or
obstructed pipe(s)or due to a broken;settled or uneveh disltribiution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are red laced
obstruction is•removId
distribution box is le�eled 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 remove
ND explain:
i
Page 3 of 1'l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address:
2 b
Owner:
Date of Inspection:.
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 add the enviro;nment:`
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
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 watersupply well.
_ The system,has a septic tank and SAS and the.SAS is less than 100,feet but.5.0:.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:
3
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Page 4 of 11
OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owners d-�� L�2Z,(�rZ� 5 rk
Date of Inspection: a
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the4ollowing for all inspections:
Yes No
Backup of sewage into facility or sy stem component due to over-loaded;of 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 ovaloaded.or:clogged SAS or
cesspool
Liquid depth in cesspool 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 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.greaterthan 50 feet from a private water
supply well-with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds
indicates that the.well is free from pollution from that facility and'the.presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis must be attached'to this form.]
- (Yes/No)The system fails: I have determined that one or more of the above failure criteria exist as
described in 310 CMR.15.303,therefore the system fails.The system owner`should contact-the Board of
'Health-to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a.large.�systemahe system must serve'a facility with a-designi 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 systemis..within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT:FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT..ION*FORM
PART B
QIECKLIST
Property Address: vGeG�
Owner:
Date of Inspection: /�' 42 /'0 ;9
Check if the following have been done.You must indicate"yes"or."no"as to.each of the following;
Ye
s No
_S/_... 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?
IP Has the system received normal flows in the previous two week period?
- V/ 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 backup?
_ 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,.open ed,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.di.fferent from owner).provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location.of the Soil Absurption System(SAS)on the site 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)]
i 5 • .
Page.6 of 11
-
OFFICIAL INSPECTIONrOR'MI NOT TOR VOLUNTARY ASSESSMENTS
SUBSURFACII SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. .PART C '
'SYSTEM'INFORMATION
Property Address: lql Pa 6
7/2
Owner: Ce
Date of ns ection: �-
C�
P Co /� s/� ✓
/ FLOW CONDITIONS
RESIDENTIAL
V
Number of bedrooms(design)::. Number of bedrooms(actual);. J
DESIGN flow based on 310 CMR 15.203 (for example: 11:0 gpd x.#of bedrooms):
Number of current residents:
Does residenco'have.a garbage grinder(yes or no): �
Is laundry on a separate sewage`system (yes or noEif yes separate inspection required]
Laundry system,inspected(yes or no
Seasonal use: (yes or no) 4uy-
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no
Last date of occupancy: -
COM MER CIAL/IND,USTRIA L/X�-
Type of establishment:..
Design flow(based on 310 CMR.15.203):. gpd '.
Basis of design.flow(§eats✓persons/sgft,etc..):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Now9an.itary 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:.
Was system pumped as part of the nspection.(yes or no —
If yes, volume pumped: gallons--How was quantity pumped determined? ...
Reasoh"for pumping: .
TYPP OF SYSTEM
_ ptic tank,distribution box,soil,-absorption system
_.Single cesspool,.
_Overflow cesspool
_Privy
Shared system.(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)-
_Tight tank _Attach a copy'of the DER approval
_Other'(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors-detected when arriving.at the site(yes or no
. _ 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: L__ ltf�L t
Owner: w
Date of Inspection: 0/i 0/Od
BUILDING SEWER(locate on site plan)
4 '
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 on site plan)
below Depth grade:
p. �
Material of construction:�oncrete_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:j0 5'XCm' x S
Sludge depth: �3 ft
Distance from top of sludge to bottom of outlet tee,or baffle: .
Scutn thickness: lit
Distance from top of scum to top of outlet tee or baffle: _ i
Distance from bottom of scum to bottom.of outlet tee or ba fle:
How were dimensions determined-
Comments(on pumping recommen ations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leak e, etc.):
GREASE TRAP a e oniite p an).
Depth below grade:_
Material of construction:_concrete metal_fiberglass___polyethylene_other-
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,.etc.):
7
Page 8 of 71
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
:SYSTEM INFORMATION(continued)
Property Address:
Owner:.
Date of Ifispection: /2.9/6
TIGHT or,HOLDING TANK: J&EtAnk 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/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:—Z(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
akage into or out of box,etc .
QAOL I
PUMP:.CHAMBER: Cate 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:):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: &.etia
Owner:
Date of Inspection:, ��/,�.�/�?
SOIL ABSORPTION SYSTEM (SAS): 10 (locate on site plan,excavation,not required)
If SAS not located explain why:
Type
leaching.pits,number:_
1 thing chambers,number:
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), '
D
CESSPOOLLS:/Jjt—(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 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.):
9
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I
Page 10 of 19 i
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPgSAL SYSTEM INSPECTION FORM
PART� C
SYSTEM INFOKMATION'(continued)
l
Property Address: I
Owner:.
Date of Inspection: 9 D/
SKETCH OF�SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system includi g 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
ZIZA
o�
Wo
10
Page 11 of I I F
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: all zla� kv
Owner: / r
Date of Inspection: 17
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to,ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
hecked with local excavators, installers-(attach documentation)
l✓ Accessed USGS database-explain:
You must describe how you established-the high ground water elevation,
P <�
11
V
TOWN OF BARNSTABLE
LOCATION I P O Ertl ter li9l' SEWAGE# l�rl 1729
r�
VH AGE S�ew� � ASSESSOR'S MAP&LOT_
INSTALLER'S NAME&PHONE NO. ®����/� C.l%�IJ/ • �l Z .�QZ�
SEPTIC TANK,CAPACrrY
LEACHING FACILITY: (type) � � i/��¢���y (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: —���`�� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted.Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 'Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No.
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for lDigool *potem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(04.)an On-site Sewage Disposal System at:
Locati dres r Lot No. Owner's Name,A ess and e.No.
Instt s ame Address and Tel.No. Designer's Name,Address and Tel.No.
7.
Type of Building:
Dwelling No.of Bedrooms v -- Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow S gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Rep rs or Alterations(Answer when applicable) IN-337ik� A- t,<_W'-VV -S <--—12W l
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction of the afore described on-site sewage disposal system
in accordance with the provisions of Title of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by i Bo d of He
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. �,'�'/ Date Issued
———————————————————————————————————————
^ ."^wr�« ..,,�,..s-.,+,.kr„vw�. o+Y,,;�,.r• .. ..s�..t f..,*n.�q..:,�� yr"4.;.,.a-• ,.,w - ... ,.. �- n.. -:o... y{)`_ //J{ry��y. '. .. ♦ .r;'. 4: . "*,:
No. ! I�o�
_. Fee
THE COMMONWEALTH OF MASSACHUSETTS
i
PUBLIC HEALTH DIVISION TON OF-BARNSTABLE, MASSACHUSETTS
applicatiou.for M.5pogat *pgtem Congtruct on Vermit
Application is.hereby made fora Permit to Construct( )or Repair(D<)an On-site Sewage Disposal System at:
Locati ddress r Lot No: Owner's Name,'A,d ess and Tel.No.
Inst s e,Address,and Tel.No. Designer's Name,Address and Tel.No.
<f {'KJ4
Type of Building:
Dwelling No.of Bedrooms - .l r Garbage Grinder(r—) lJ 4
Other Type of Building No. of Persons Showers{ ) Cafeteria( )
Other Fixtures
Design Flow gallons pr day. Calculated daily flow S gallons.
i r .
Plan Date Number of sheets Revision Date
Title
Description of Soil
` Nature f Rep rs or Alterations(Answer when applicable) 1 A�1 �'►ti ,4 (SZIU` 5�1�T'?L "TJJ{��
A r 37 ( C t� c.TlL4-,Zr/4l wf i� ziav€ 5WU4UIJD/N6. 14
----,Date last inspected:
Agreement: 'The undersigmA agrees to ensure the constructionM�9L of the afore described on-site sewage g disposal
p al system
in accordance with.the provisions of Title'5 of.the Environmental Code and not to place the system in operation until a CertiWi
Cate of.Compliance has been issued by thr Bo d,of He
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
(Certiticate of Co'mP Lance
THIS IS TOA CERTIFY,that the On-site Sewage Disposal System installed )or repaired%replaced on
by f�'3G/M-DL-y� CQk1C—/ `CuC77G Q AV` /�/ Z/46 / m C
X_ 1`�. GM 4&42 r4--: has been constructed 'n acco dance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
i
Use of this system is conditioned on compliance with the provisions set forth below:
----'No. . —Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
wigogaf *paem Congtructton Vermtt
Permission is hereby granted to -�—e U,i7 c r7c.^1
to construct( )repair(x}an On-site Sewage System located at ' Z 9/ /�.2_:11Zr4£L A"11
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or.special conditions.
All construction must h comply ed within two years of the date below.
Date: Approved by G
i
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C construction permit signed N
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There are no wetlands mthin 300 feet of the proposed septic system
There ar
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o pnvate wells within 150 feet of the proposed septic system
( ,4 The observed groundwater table is 14 feet or greater below the bottom of the leaching
Y facility
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There is no increase in flow and/or change in use proposed
i There are no vanances requested or needed.
SIGNE.
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LICENSED SEPTIC SYS INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
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[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted]
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