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HomeMy WebLinkAbout0016 THIS WAY - Health 16 'PHIS'WAY, OSTERVILLE COMPLEY CLEANING SERVICE i o i s t i f /4•4 -19� i74 $p t S , 1 Z t ti A� t1 .../-64 $ 'PIT .1000 C TAT @Ot W�1 S TOHB o � s :zst Sr �. �aa S as�.f''' utVVII • /)S.0 � z / t Scale Horiz,/vest. ltt-40f zi M` r PROPOSED PLAN OF LAND IN .BARNSTABLE MASS, ' or k KEMPTON--NICXERsON Bt�ILb��t i Being lot- ire 2 as' shown on a plan Pot George D. Fardyi Jr& � by King & Reekie Assoc, j Surveyors Scituatei Massy Elevations shown are in feet above anr.assumed datums ` 7 i - ------------- ------ ------- Date ----------------- Agent. Barnstable Board of Health t I Certify that the foundation shown on this plan is S located on the ground as shown thoreoti and that it conforms to' the zoning and building laws of the t Town of BARNSTABLE when constructed and to the restrictions on record, Date, 5-29-78 Sub Soil Za t t Medium ' to { Course COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS x DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: Q Date of Inspection: �a Name of Inspector: (please print Company Name: Mailing Address: Il _ G1�fZD� Telephone Number. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa)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: 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system; !/ passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority e Fails p Inspector's Signature: ' ;� Date: (J� ; a The system inspector shall submit a o •of this inspe ion report to the Approving Authority(Board of l le;a�th or DEP)within 30 days of co' t 's inspection, Ifthe system is a shared system or has a design Ilov< of I� OUO gpd or greater, the inspector and th' system owner shall submit thr;report to the appropriate regional office 1 the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the app oving r authority. co 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. I Page 2 of 11,:, OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: /�' ,4 Date of Inspection: — Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst asses: (have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more stem components as described in the"Conditional Pass"section need to be replaced or repaired. The system,u n completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not detennined N,ND) in the for the following statements. If"not detennjaed"please explain. The septic tank is metal and over 20 yea old* or the septic tank(whether i aetall or not) is structurally unsound,exhibits substantial infiltration or exfiltrat or tank failure is immi. t. System will pass inspection if the existing tank is replaced with a complying septic tank as roved by th oard of Health. *A metal septic tank will pass inspection if it is structurally so t 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 br out or high static water level in the dis tion box due to broken or. obstructed pipe(s)or due to a broken,s ed or uneven distribution box. System will pass in ection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The s tem.required pwnping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspec 'on if(with approval of the Board of Ht alth): broken.pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11.,. OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR 1VI PART A CERTIFICATION(continued) Property Address: LtY Owner: �, f Date of Inspection: _ QCf- rt — C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to det is failing to protect public health, safety or the environment. ermine if the system I• S. will pass unless Board of Health determines in accordance system is o da n 'ce wit CMR I5.303 protect .pu i (1)(b) that the sa e y ent: — Cesspool or privy is within 50 feet of a surface er _ Cesspool or privy is within 50 feet of a Bring vegetated wetland or a salt marsh 2• Syste 1 fail un s the Board of Health (and Public Water Supplier,if any)determines that the syste s functioning in a anner that protects the public health,safety and environment: _ The system has a septic nk and soil absorption system (SAS)and the SAS is within 100 feet of'a surface water supply or tributa a surface water supply. The system has aseptic*tank and and the SAS is within a Zone public water supply. The system has a septic tank and SAS and ` SAS '&wit�i'in 50 feet of a private water supply well, The system has a septic tank and ►H nd the SA less than 100 feet but 50 feet or more from a private water supply well** used to determine disc e **This system p if the well water analysis,performed at a DE ----.' bacteria olatile organic compounds indicates that the,well is free fr ified laboratory for coliform the ence of ammonia nitrogen and nitrate nitrogen is equal to or less th pollution from that facility and tlure criteria are triggered.A copy of the analysis must be attached to this fortnpm,provided that no other t 3. Other: Page 4 of l I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4� v' Owner: Date of Inspection: r. D. System Failure Criteria applicable to all systems: 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 �ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �—,-�Static liquid level in the distribution box above outlet invert due to an overloaded ur clogged SAS or esspool , iquid 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. �y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Zater supply. _ / ny portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. nAny 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 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. 1 have determined that one or more of the above failure criteria exist Ls 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 Syste To be considered a la system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or "to each of the followings (The following criteria apply to large sy s in addition criteria above) yes no _ the system is within 4 et of a surface drinks water supply the syste s within 200 feet of a tributary to a surface drin water supply _ e system is located in a nitrogen sensitive area(Interim Wellhead Pr Lion Area.--'IWPA)or a mapped Zane II of a public water supply well z. 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 CN1it I S.304. The system owner should contact the appropriate regional office of the Department. Pag e5ofll ' OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST: t Property Address: �CA Owner: Date of Inspection: ' Check if the following have been done. You must indicate` es"or"no"as to each of the followin IYI— Yes Pumping information was provided b the Y owner,occupant,.or Board of Health — �re any of the system components pumped out in the previous two wee Has the system received normal flows in the previous two week period ? (/Have large volumes of water been introduced to the system y em recent) or as Y part of this inspection? Were as built plans of the system obtained dan �d examined. (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage g back up . Was the site inspected for signs of bre out ? N CL U &+V % Were all system components, .the SAS, located on site ? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank .cted for the of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sl dgenspe and depth of scumndition v,C Was the facility owner(and occupants if different from own ' maintenance of subsurface sewage disposal systems '? owner)provided with information on the proper The size and location of the Soil Absorption System (SAS)on the site has been determined based on: . Yes — Existing information. For example, a plan at the Board of Health. i Determined in the field(if any of the failure criteria related to Part C is at iss is unacceptable)[310 CMR 15.302(3)(b)) ue approximation of distance I I ,Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: � i LUG Owner: Date of Inspection: 0 Y FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): f be_ ! DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x 9 od_rooms): --3a-(a-P Number of current residents: Does residence have a garbage grinder(yes or no):!� Is laundry on a separate sewage system(yes or no)� (if yes separate inspection required] Laundry system inspected(yes or no): 0,4 �} Seasonal use: (yes or no):_0 Water meter readings, if available(last 2 years usage(gpd)): _�✓�} _ Sump pump(yes or no): Last date of occupancy:jf'L a_fAJTL- OC�V p I ( U - k. COMMERCIAL/INDUSTRIAL Type of estab' ent: Design flow(based on MR 15.203): rind Basis of design flow(seats/person tc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no Non-sanitary waste discharged to the T' system(yes or no): Water meter readings, if avai Last date of occupan OTHE escribe): GENERAL INFORMATION Pumping Records Source of information: `," Pv C—.2 G,,tJ fy)4(A;74-1,tleA.)(I► 'Was system pumped as part of the inspection(yes or no): If yes,volume pumped:gallons—How was gyan ' pumped determined? Reason for pumping- TYPE SYSTEM 4-1;eptic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy —Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _ Other(describe): Approximate age Qf all components,date installed(if known)and so ce of informatio Were sewage odors detected when arriving at the site(yes or no):/`w�"''� i Page 7 of 11 4<. OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 T < ,n Owner: Sr°27 Date of Inspection: CjC �. ►� BUILDINGS (locate on site plea) Depth below grade: Materials of construction: _cast ' _40 PVC_othertex.pl�in): Distance from private wat pply well or suction line: _ Comments(on co on of joints,venting,evidence of leakage, etc.): , SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: 'concrete_metal_fiberglass_polyetrrylene 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: Sludge depth: >� Distance from top of stud e to bottom of outlet tee or baffle: Scum thickness: to t� Distance from top of scum to top of outlet tee or battle: d '� Distance from bottom of scum to botto of outlet tee or baffle: How were dimensions determined:-nI/�T d 't—ic�:g.q $,j �o�- Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): GREASE TRAP: locate on site 1 _( plan) Depth below grade: Material of construction: concrete_metal fiberglass__polyethylene_other (explain): . - Dimensions: ��— Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet t a e: Date of last pumping: Comments(on pumping reco ions, in and outlet tee or baffle conditioh,structural integrity, liquid levels as related to outlet invert ence of leakage, etc,): Page 8 of 11 , OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: u t( - Owner: — Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of ins Pectionxlocate on site plan) Depth below grade: " Material of construction: ete metal fiberglass of eth lene—p Y Y other(e,xplain); Dimensions:` Capacity: allons De _sign Flow: alions/day Alarm present(yes or no): Alarm level: Alarm in working ord es or : last ping Date of no) Comments.(con of alarm oat switches, etc.): DISTRIBUTION BOX: (if present must be ope ocate on site plan) Depth of liquid level above outlet inv Comments(note if box is lev distribution to outlets equal, any evidence leakage into or out o etc.): of solids carryover, any evidence of PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump er,condition of pumps and appurte ; i ) L TOWN OF BARNSTABLE LOCATIO?4 /G TLli,; ode/ SEWAGE li VILLAGE (�sr !i /„%_ ASSESSOR'S MAP & LOTZJZ _���/ Oo/ INSTALLER'S NAME&PHONE.NO. ;)Z SEPTIC TANK CAPACITY /D00 �o,a/ LEACHING FACILITY: (type) (size) ( X l 3 NO.OF BEDROOMS BUILDER OR OWNER r p o Y��- 7 PERMTTDATE:_T/-_�� �b COMPLIANCE DATE: V- 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 leachin� facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ost� ✓ � II a .��% _pp 3 �Q• , Page I 1 of I 1 ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART C SYSTE M INF ORMATIONonh c '( nued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 1 Estimated depth to ground water I 1 ( feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-'If checked, date f Observed site(abutting property/observation hole within 150 feet of SAS) p�an reviewed. Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you establishe d ed the '6t round high g water elevation: i - I . I k n . • I r (L E N Tf i L)E. Z Fil LL 2 i 2 j P f ion. 10 Y P 3i CL 00- W, CA 1 TOPAGI-IFY 92.02' �L-E W.TH x Wl D TV IJ -4 ,pf);S iZ GAUDAY -j'4 Gp[).,S Sandy Loarm c.-.. 23 ip-ay = I DY R 3,2 TOTALS: TOTAL NIAMBEER Cf-(JAMBERS 2 LEACHING ARE 4 41 SQF-F Pea; -A T lry GAdJOAY N11--c Gravelly Sgrit? Gravpf 5'/c CobNo-, I r-hv ate r ­0 -,rot Encounterct 144" 80-52' 1 E. sir- HG 2 SEP rIG COVER IN (1) 12.9 35.8' SEPTIC COVER 20.3' -)tjT(2) "AS-BU I LT" D-BOX (3) 28.2' 43.9' AL a CHAMBER COVER(4) si.a* PLA I I :CHAMBER COVER t.5.) 37.7 46.3- No. ♦�7 M 6 /� ' .... Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi5po5af *p!6tem Construction permit Application for a Permit to Construct( )Repair(x Upgrade( )Abandon( ) O Complete System ❑Individual Components Vion Address or Lot No. 1_0 E- �. Owner's Name,Ad ess and Tel.No. �5 ea�A�w 05�v�A(4 • n'la. , ��e..—T +� Ip�:t4 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ,Q Designer's Name,Addraessss_and Tell.No. c p ",—'N � C���+��� VMK 'W,'r �ee�wt4. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow_ gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil VVX"; 4, C— c,-,,, Nature of Repairs or Alterations(Answer when applicable) 'may sk-c. �� N 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 this Board of Health: , Q Signed 1 d - Date Application Approved by Date V_ LI.1 2 Application Disapproved for the following reasons Permit No. Date Issued .1100 11 1 111 L ------ s • , f / ----- Dale Issued _ Permit No. —._-----1 --- -- — — THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance Repaired ( ' "Pgraded ( ) THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) P, Abandoned( )by ""',�"'�'' has been constructed in accordance dated at with the provisigns of Title 5 and the for Dispo 1 System Construction PermitNo. Installer ra1%\C �eaar:c.1�.. Designer.COL ` The issuance of this permit shall not be construed as a guaranteethat te system will function as designed. Date l - Inspector ' Fee n�� No.Nl '� OF MASSACHUSETTS �,�e°�OS THE COMMONWEALTH Ro��f1 �.� wh D� PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Lf° . I ]Bi5po�al 4bp5tem Construction Ve>rmtt Re ( Jpgrade( )Abandon( . ) permission is hereby granted o Construct( ) Pair System located at 1� A lication for Disposal System Construction Permit.The applicant recognizes his/her duty to and as described in the above PP comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b completed within three years of the date of this it. Date: V �, 1 Approved b 'J�1 . `4.CUU-) 4�•Uca•;I DrnC'-{_.i H_•,—t tAJHKLi Vr Ht.HL I H hf1 211 P.1 1 Town of Barnstable ]Board of Health. « RO.Box 534,Hyamais Mk 02601 u�oc: wt+•aaa.aaaa 'd'Jaow.."h,h QUM,is,CM FAX: 505-790.6304 Iri ctra aPP�blio He,ld1 s MAIL TO.TO WLV OFBARNST.4Bra PLMUCMALTH DIVSIOA' I 200-14ADi 5TRWr HYANNIS,MA 02601 FAX 509-790.6304 SRg'IYC S 3T 1�Y SPTCTORREGIMA"1'1G1 Date I C/% S Name of DEP Certified Inspector J /L Ressinresa Address 3 a le<q ,w FAX Nwmber Home Address Rome Telephone dumber --L52. 19 The undersigned agrees to comply with PART VM, SECTION 14.00 of the Board o s Health RB cations. "Tb,-.s tic tcm' � c-- - 4fftciat LWOction Poem.-Not Par Voluntary t f�omface SO applD*X seedon of tha ic.s 5 c� Disposal Sy3t2m F� —� - Mpliad by dw Mesawlwetts Uepartt=t of 8uviromrtenlal ProtectimL to addition,at the bottomi►f ® -- Iast page of this OMPW inspect m tbzm,the septic s7stemiuspectar shall provide a sleet4 diagr=—- Vviug the vertical separation distance bomen dab bat=of the so4 absorption system and dw Sw=dWaii able along with any high 9TOUdwatm elevation 4uatttauts detatttuaed. IU septic Stem Inspector$ - submit a copy of din completed septic system irapectian report along with le,rt quired rocening fez ,-N Public Sealth Division Offao within 34 days of OA j=pecdon date., v q`sY MM: VJ-00 per tepO;t WbmbA W the Publia NwIth DWsi=Office 2, 94RUMber 1,2001. TOWN OF BARNSTABLE LOCATION T Gy SE e, WAGE # %""bl VILLAGE ASSESSOR'S MAP & LOT/;/ 1VZ CV INSTALLER'S NAME&PHONE NO. SEPTIC.TANK CAPACITY LEACHING FACILITY: (type) (size) 5-00 021 NO.OF BEDROOMS BUILDER OR OWNER PERMPTDATE: COMPL CE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by TOWN OF BARNSTABLE LOCATION AG fG15 G/-1-y SEWAGE fl Q 4`, f VI,LAGE 421fF_rfklZlE ASSESSOR'S MAP R LOTf1/-/9/001 INSTALLER'S NAME k PHONE NO. 9Y J J,-Pi ve�arrOS SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) NO.OFBEDROOMS -1 YAP 1 BUI.DEROROWNER 9�r�oJ4 �Po 377� PERMITDATE: a-11- OMPLL NCE DATE: y-7-9� Separation Distance Between the: ' ) Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If my 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 leeching facility) Feet Furnished by I� ~ OSfdrVi//Fi. tUii Af �,rrr»fali' Q . 3 J Y 4/ 1 TOWN OF BARNSTABLE LC►CATION L(D IS WAY SEWAGE # VILLAGE 7T12V( Lt1= ASSESSOR'S MAP & LOT loll- 141-60 INSTALLER'S NAME&PHONE NO. 66U ' 5t etc SEPTIC TANK CAPACITY ISdd (A - - LEACHING FACILITY: (type) (size) _ ,---NO. OF BEDROOMS 3 BUILDER OR OWNER, 13L12r � fx1S�1 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 fee of leaching facility) Feet Furnished by �� ���Gaei ♦ I ,1�rI�Ls. 1 TOWN OF BARNSTABLE LOCATION SEWAGE # ��� VILLAGE ASSESSOR'S MAP & LOT/2/-/5'/ 007 INSTALLER'S NAME&PHONE NO. I JosfRpy De &,ro os SEPTIC TANK CAPACITY /00 - � l 9- S00(�141 Q � C!/iz`�I- (size) Y 1-5 LEACHING FACILITY: (type) C, 140.OF BEDROOMS 3 BUILDER OR OWNER R"/Err 6142OJ 4 COMPLIANCE DATE: t'/~ 7 97 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 3 04, i �y JR . • Q No. �/ Fee���o. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migooal *pztem Construction Permit Application for a Permit to Construct( )Repair(' Upgrade( )Abandon( ) ❑Complete System ❑Individual Components I�¢�tion Address or Lot No. L o ;. I`2 r Owner's Name,Ad ess and Tel.No. �ra.�j Assessor's Map/Parcel Installer's Name,Address,and Tel.No. -i Designer's Name,Address and Tel.No. q-77--283,,� 18:5'rnL;,., SA. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 this Board of Health.. Signed 1 Date N6`1-42,1`7L Application Approved by Date VO U 1 14 5`t. Application Disapproved for the following reasons Permit No. Date Issued 00 f>r arw :� a �{ r.� ,—. .Y.;f .. �Z } .. ,�e� .>T 5..% A,r _ fly .. ,✓v.4• .,y y. — y _ —' No. Fee CT� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: q Yes PUBLIC HEALTH DIVISION- TOWN.OF BARNSTABLE, MASSACHUSETTS ZIpprication for &gogal *pgtem Cottgtructiou Permit. Application for a Permit to Construct( )Repair*( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components 4ion Address or Lot No. L of 1( Owner's Name,Ad ess and Tel.No. ,. �5 WA� OSk�J:114 IV��+. , AfrQ9oSA Assessor's Map/Parcel.:: / . Mom 1, � :`I' 1:, ©/ ' 4 ,�. i;s WAy. . Installer's Name,Address,and\Tel.No. Designer's Name,Address and Te`l.No. �" C C c�w 1 w ��q r: G.1�,� 4"77„1 / ur r-1 Tom' W.F v�'C- L1�7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title' Size of Septic Tank Type of S.A.S. [ Description of Soils�.:�,... C e k-r s- 'Sa-►,a Nature of Repairs or Alterations(Answer when applicable) &Zoo j a 1\ ca Al � . 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 k3yhis Board of Health. Signed L,-, j, Date N AV )a, 119 b Application Approved by Date 1Ao�l g 4 L Application Disapproved for the following reasons Permit No. °" A0<11e Date Issued` b 04 . 1 i`1*1 L --------------------------------—---=----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired(Lo;01 Tpgraded( ) Abandoned( )by 0 a r_\ N.► � �� �I�.c. at {. - _; w C 44 T%, has been constructed in accordance with the provisi ns of Title 5 and the for Dispo 1 System Construction Permit'No.� �+ / ' dated AICV IX 11 Installerea r ►v Designer_e.,\�... The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date_ r - Inspector No.< � R ---------------------------Fee hre�05�' THE COMMONWEALTH OF MASSACHUSETTS R �44- o `,;t l YJAI d�PUBLIC HEALTH DIVISION -.BARNSTABLE., MASSACHUSETTS Mi!6po5ar *pgtem Construction Permit Permission is hereby granted o Construct( )Repair(/)`Upgrade( )Abandon System located, �t) - l o� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to F + comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this it. Date: V 1 ( `� Approved b}�:. _ l a LOCAT ON / TOWN OF BARNSTABLE .S 1 VILLAGE _ / SEWAGE # INSTALLER'S NAME 4:PHONE NO :2t6 ASSESSOR'S MAp a LOT SEPTIC TANK CAPACTIy �p o 6.*l LEACHIIVG FACIL TIy: (type) /�/i l/NO.OF BEDROOMS .3 _ ' (size) BUILDER OR OWNER-. 9¢1 - PERMTTDATE: h w ° c, COMPL IANCE Separation Distance Between the: DAB' Mum Adjusted Groundwater Table and Bottom hivate Water Supply Well and Of Leaching Facility . on site or within 200 feet of leaching Facility (If any wells exist Feet Edge of Wetland and Leaching 8 facility) within 300 feet of leaching f caLry�(If any wetlands exist Feet Furnished by Feet .h h sz; a 0 i io CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) eteb certi that the a lication for disposal works h y fy pp p construction permit signed by me dated NQ,4• a""� I- t(a , concerning the e located at L of- *02 --its La ®s Lv 6 1�.14"- meets all of the prop rty� `' : , following criteria: * There are no wetlands within 300 feet of the proposed septic system R There are no private wells within 159 feet of the proposed septic system The observed groundwater table is 1.4 feet or greater below the bottom of the leaching facility There is no increase in flow and/or change in use proposed There are no variances requested or needed• s , SIGNED. CL� DATE: 019V •.22 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. { i BEAng lot fi 2 as shown oh a plan for George D Fardy) Jr: = -by "King & Reekie Assoc ) Surveyors Scituate] Mass Elevations shown are in feet above ain`.assumed datum4 I -------------------------=- ------------------------- Date Agent! Barnstable Board of Health ! i .-N r I Certify that the foundation shown on this plan• is located on the ground as shown thereon and that it conforms to the zoning and building laws of the Town of BARNSTABLE when constructed and to the restrictions on record: t Date, 5-29-78 Sub Soil r 24 ! Medium to Course 1 Sand ,,• " '`�, �► Gravel M9s e , n , Thomas A. N It Thomas A. JACV SO 144- Sup,14 `'►;,:`",�< <� Test made No water endountere l 0 ., j perd4test more than 20 drop pet one minutes • Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: gam[�P, BUSINESS LOCATION: 1,6 hi& "A/A,n S-fxy� 1q_-) MAILING ADDRESS: �Q As (b4 & Mail To: Board of Health TELEPHONE NUMBER: (569) 4q,�- !1"1;; Town of Barnstable CONTACT PERSON: 9,aiB` l�X Z F-QAIY66 4 P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPE OF BUSINESS: �`e-, �r��^ ;c , Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes _ Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) _;l Other cleaning solvents (HoL4teWA �I and Wy Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS �LO•CA . 10 SEWA GE PERMIT- NO. � s VILLAGE DsT�it'✓r/% INSTALLER'S NAME 4 ADDRESS .�llrJ1LS ���//.,�a✓� .� B._U I l D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED. _�� _� r ,. � , ,, ���✓-:e � _ i � ,� .. - 6 :ti �� `-06 - , •'_ Irt tom•. No...........a:..2 FEB.....z................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O FjHE�A�TTH....---..__.._�tf'Lt✓'1---------.OF.....--. ... ... ..................................... ApphrFativit for Bhipoii al Worhi C omarurtinn Vantit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: .. o�.. .t ..........................................................i ✓i�L,�.. .................•••--•••-•-- •--••••--•••••••....__................----/ Locat'o Addre or Lot No. . ._. _ ... `. .... ........................................... ..........--...........---._......---..._. .................--•--....._.._._.._....-- Address ............. .............•-•----------...... ..._..._.. --.._...----_..._..........---•............._. •--sue""' ....- -•--- � Installer 7 Address d Type of Building ?f�y� .� Size Lot.... �:./-7.�...Sq. feet U Dwelling—No. of Bedrooms........K3______________________________Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons.........1_............... Showers — Cafeteria Other fixtures --------•----•-•---------- ----- - W� P .........................qsY ..........g r person per day. Total daily flow......... Q_____....................gallons. 104 Design Tank-4 Liquid*ca acity.t'_OV').gallons lions P Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No_ ____________________ Width_.___...__.__.____._ Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No________ __________ Diameter.......... _..__ Depth below inlet......... tal lea-c 'n area____2_l1_/....sq. ft. Z Other Distribution box ( � Dosing to ( ) /'�� �(� �;_ '-' Percolation Test Results Performed b 1 Y Date---- -= 7 .'.............. Nest Pit No. 1_____7.......minutes per inch Depth of Test P ____________________ Depth to ground water........................ 0,")<Test Pit No. 2.......1--.....minutes per inch Depth of Test Pit____________________ Depth to ground water......_................. R; --------------------:---•--•-•----------••----......................................................._ ......- Description of Soil_...---�v.-�'....` �--!----- J�:_�`: .. ®......m-'P=_4---rv.---tp._L—.c3 A'��-•psi f�l, -...------ W ------------------------------------- --------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...-------••------------------------------------•-•-----------------------------------...........--------------------------------------•------•--------•------.-----------------------...-•••...._•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT 5 of the State.Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss by t thbo c 1 e- - - --•--•------------------ ............Dat.e.............. Application Approved BY r { Dae�Y1 7-� Application Disapproved for the following reasons---------------••---------------------------------_..---------------------------• .......................... ......................................................-................................................................................................................................................. Date PermitNo........................................................ Issued....................................................... Date No.........:2. ........ Fxs....0 ........... THE COMMONWEALTH OF MA< ACHUSETTS BOAR® O� H A T i-1 ,r _0 i!41. . OF, Allp ration for Binpniiaal Workii Towitrurtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -----------------------------•---•---....---•---••-•------.............--•--•--:_.-.:....._...... f ;.cation-Address r, or Lot No. ..... � 1._..Xl.t.. ..[..Vr..!?vl -•............................. Address `� •-••----....-•-•.................•---•--.....--•-••-•-•--•--._.................-----•...•-•----•-- Install r Address Type of Building 31,1 Size Lot../.(?,/---/_7-_____..Sq. feet � Dwelling—No. of Bedrooms••-___-----------�•--_--•-__--•--____-___Expansion Attic ( ) Garbage Grinder ( ) Other Type of Building ........... p ( ) ( )_________________ No. of ersons....____�___...__....._: Showers f — Cafeteria Otherfixtures ------- =-....................................-................................................................................................ WDesign Flow........... ------------------------gallons per person perFday. Total daily flow.............._qS5. .................gallons. WSeptic Tank—Liquid capacity/011).gallons Length________________ Width................ Diameter................ Depth_________....._. x Disposal Trench—No..................... Width.................... Total`Length.................... Total leaching area.___-_•__-_--______sq. ft. Seepage Pit No.......1._.--------.. Diameter........sf.'....... Depth below inlet........G _p._. T�tal leac -n area_.,�:Q/.....sq. ft. Z Other Distribution box (e) Dosing tank ( ) ,P!?.t '—' Percolation Test Results Performed by..- ... �_. . Date--- ............... -) W022 Test Pit No. I.....2-____._minutes per inch Depth of Test Dep�i to ground water-__________-•-.:---•___. (Tq thc4, Test Pit No. 2......�.....minutes per inch'"bepth of Test Pit....................'Depth to ground water.-:__.................. 04 ---------------..................;---------------- -- - --•-___ __,--.. _.....--•---..... ___ '_______--- ------ 0 Description of Soil........SLr6....�L?_e....... ;.-_. y ..... Yl r@ . S _-S,...NQ------ .w W -•--------------------------------------------•------------------------------.... --------------................. ......-----------------------...----------------,=------------------...-•--------- UNature of Repairs or Alterations—Answer when applicable.............................................................................................. d --•--------------•-•--•----•---......------•--------------------•-•---•-•---------•---••----•---------------•-=---••----••-----------•••-------....................................... Agree4nt: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1is p S of the State Sanitary Code— The undersigried4urtl.er agrees notto place the system in operation until a Certificate of Compliance has been isssu by the boare o h lth. nedg �' "-•--- `' -••--•---•-•-•------•-• ..........................».... Date Application Approved By..... / �y h�c.ey _ „- ,. ` ate Application Disapproved for the following reasons-------------------------------------•---...--------•----------------------------------------------._..........._ •--•-------------------------•-•-------------•----•-------------------.....-----•------•--•--•----------------•••-----••-•-------------•-•----------------•--•--------------------------------•-------- Date PermitNo......................................................... Issued.----•---•---•----•------== Date Pr' THE COMMONWEALTH OF MASSACHUSETTS w. BOARD OF HEALTH # ....,t......O F...... ..L�14 .....e........................... Trrfifi.rFat of Tontpfiana T IS IS TO CE F17 , hat the Individual Sewage Disposal System constructed, �) or Repaired ( ) b ---•-- Y I taller A has been installed in accordance rth the provisions of >of The St e San Lary Cn�de.� 'described in the application-for Disposal Works Construction Permit N Z .............: dated,5j'."=__.? An.74..__._._._........ THE ISSUANCE=OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM''WILL.F CTION SATISFACTORY. DATE........................ _. ..... f _.".�..--•--...--•-_••---- Inspector--_•_... ••--• ................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7— .......... .......OF.. ................................... ve � 4 No......................... FEE-•_.. ............. t aa1 fork n trudwWn Vamit Permission is hereby granted_ . '� '__ � f` w - -- to Co r�t or Repair { n ndivl i V.wage DI os A- ..i. at No , <a:. '- Street as shown on the application for Disposal Works Construction Omit o.. _____'.:._..___ Dated..$_P _t. ......... Board of ' r i t DATE'!' = { .,---•-----------------------------•-•-•--•------ FORM 1255- HOBBS & 'WARREN, INC.. PUBLISHERS _4 - r 1 ' 1 }} ' f 'llli 1 1 19•4 1 C)_r 4 i 19�.174 SF A_ e 1 p -PIT.. ON + T v VV 3 O C d F579 < ���� l �' , tEOT PIT 23 + AO i LU co li. of p Q �! moo. i Scale Horiz. vert. lit_4O I ,T'9b ' �� z + ! PROPOSED FLAN OF LAND IN BARNSTABLE,MASS. gfor KEMPTON NICKERSON, BUILDER - Being lot m 2 as shown on a plan for George D. Fardy, Jr. ` by King & Reekie Assoc. , Surveyors Scituate, Mass. ; y Elevations shown are in feet above an�.assumed datum. r ---------------------------------------------------- Date Agent:, Barnstable Board of Health i , S F C I i. 1 1 Sub Soil i 24 ; e Medium 1 to S Course Sand & d Gravel •r;' E s10 o s � < Thomas A. s S DhA1No.8937 > '\k'V cI a , 0 �o suF��y,� `'►r`,,J ,� t�. Test made 5-4-7 �--- No water encountered Perc.test more than 2" drop per one minute. xr�ZIN X/51lN� 74 'c-xl5T11vG Dd6''w/1 --- - ---- 1411 o% ' 4�� tl r-