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HomeMy WebLinkAbout0215 TOWER HILL ROAD - Health 215 TOWer,Hill Read, A = 142 01.1 a Oft t- v l Commonwealth of Massachusetts Pf a Title 5 Official Inspection Form lii; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 215 Tower Hill Rd Property Address Bassett -o Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling A. Inspector Information c51�# /338,3 ngoutout forms on the computer, use only the tab Darren Michaelis key to move your Name of Inspector cursor-do not Foresight Engineering Inc. use the return Company Name key. 518 County Road � Company Address West Wareham MA 02576 City/Town State Zip Code ietmo 508-245-2148 3595 Telephone Number \ License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10/15/18 Inspector's Signature Date The syste i spector shall submit a copy of thi inspection report to the Approving Authority (Board of H or DEP)within 30 days of completing t is inspection. If the system has a design flow of 10,0 0 gpd or greater, the inspector and the syste owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please ril 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd V Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. i 1) 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: System consists of 2 sets of components. New components, 1500 gallon septic tank, pump tank and distrubtion box have and existing coc on record and are functioning properly. The existing components installed in 2004, 1500 gallon septic tank, 12"x12" dbox and 13'x34 bed of concrete galleys with stone. All components were located and are functioning properly. All covers are to within 6" of finished grade. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - g p Y 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is Osterville Ma 02655 10/15/18 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form I s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd u Property Address Bassett Owner Owner's Name information is required for every Cisterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc'•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts A. Title 5 Official Inspection Form t I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 215 Tower Hill Rd u- Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 460 gpd . Description: Single family dwelling . Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Town Water Sump pump? ❑ Yes ® No Last date of occupancy: 2018 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner-every year Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 4/7/04 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >10 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,'etc.): no evidence of leakage or blockage, proper venting provided t5insp.doc•rev.7/26/2018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd V Property Address Bassett Owner Owner's Name information is required for every Osteryille Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 1/4 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid levels, no evidence of leakage or backup, pvc tees in place, effluent filter added to outlet, outlet cover to grade with plastic cover, recommend pumping tank every 2 years, the effluent filter REQUIRES ANNUAL CLEANING to prevent backup and carryover t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade. Material of construction: ❑ concrete- ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts =. Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l' u- 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 12"x12" box 24 below grade, level distribution, no evidence of leakage or backup, no carryover, ads riser installed with 20"concrete cover 3" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ��- Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd L� Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. Cityrrown State . Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Cast iron cover at grade, safe access, pump system enclosed * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: (3)13'x34' bed ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd u— Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): . (3) 500 gallon concrete galleys with 4' of stone, system is vented, no evidence of ponding or breakout, dry soils around dbox, dry stone probed 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I- 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd u Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 9 p Y ry 215 Tower Hill Rd v� Property Address Bassett Owner Owner's Name information is required for every Osterville Ma 02655 10/15/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >10 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/14/03 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: System was designed and installed with proper separation to groundwater determined by a soil evaluator and board of health witness under current regulations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i TE e-F 1 ICLE I oa i A 71 ��� �� o TEST GY: PE.RO RATE: -� � ��•✓.�N� �2/, a f STABLE �- I TOWN OF B 60y- 01 SEWAGE #c2 oe,LOCATION _ (( ASSESSOR'S MAP & LOT VILLAGE INSTALLER'S NA-NE PHONE NO. ISEPTIC TANK CAPAcmr LEACHING`FACILITY: (type) CH� /��cei r3 (size) Lf NO. OF BEDROOMS �--� BUILDER OR OAR 'A"� I a �J S-��( COMPLIANCE DATE: PERMITDATE: Separation Distance Betwern the: Feet Maximum Adjusted Groundwater Table & to the )ttom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells east. Feet on site or within 2W feet of leaching facility) I Edge of Wetland and Leaching Facility (If any wetlanljs exist Feet within 3{)d feet of leaching facility) Furnished by w � V i . T Entered in compu(er. THE COMMONWEALTH OF MASSACHUSETTS Yes P'��L�C HE LTH !)!VISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Dioanl eisP-5teni ttCon5truction 'Permit Re air )Upgrade( )Abandon( ) O Complete System O Individual Components Application for a Permit to construct( ) p ( p8t" e) ( ) Location Address or Lot No. ' Owner's Name, ddress and Tel.No. Os��iLut. Assessor's MapTareel )y Installer's Name,Address,and Tel.No. 3 / Designer's Name,Address and Tel.No. `f '-7 SSA! 1� , Type of Building: Dwelling No.of Bedrooms Lot Size L' sq.ft. Garbage Grinder(PC) Other Type of Building !,,x l i 018r"- No.of Persons Showers( ) Cafeteria( ) Other Fixtures �S j. ; gallons per day. Calculated daily flow z/�/� gallons. Design Flow Plan Date i 7 l al Number of sheets Revision Date Title�^ � -. Size of Septic Tankv Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) . rrv, 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 sy tem in operation until a Certifi- cate of Compliance has been issued by thi Board of Health Signed Date i t 3 D Application Approved by Date Application Disapproved for the following reasons Permit No. 2(00 Y —d t "S Date Issued 11,3 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by at ) +`> i 'r r �,h 11 i) ' r' ` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.G'��i�/' f�r dated i + `� Installer Designer The issuance of this permit shall not he ronst ited as ague-rantee that the systcri, v.tll.unction as designed, s Inspector ' Date — ��r -- --- ------ ,._._— ------ --Iec V\/A C--�7L FLAN PREPARED FOR: ,t='t�'� ,��5 7""T'� •{ PRAM �5y JOF5 NLM �F-R: PAT-E: I Il�5 (`ALMQ�JT"h RD f� 4G GENTERVIL.LE MA 1 ► 02� � TEL.: ('505) 775--07-:55 FAX: (505) 7 5--075,4 I! PRO=E551ONAL ENC�INF.��Z� & LANP `�JRVE 5 { -- YOB �� R L 1 Ni A 7 S " A PA 1 Y FLOW ��} �PEPFZOOVS x I b epp 7AW: Yo x20 ' 0 CAP L6E:/5':)o -GALLON PRF-6AS7 SEP76 TAW ILEA6HItO FA61L(+Y: ..._._. 6APA 17-y .3'0ff'r T ALL• ;F3 .+ \ c 1' � t1 { NOT 70 SGAIZ rU' raiv.,i+GN ro wrrrIM �'Q57 Pik �F. i OVFP 15/b"- VZ"pojN b" G�" rIN��7 6p.�s ro C� 'fir I LV�L wAltfEDsrOW 21 yU . A" r v(' .� VY.85 Dorrc+� ;�Z, ?1157. box' /Sow &ALi-GN '-;U't4RAT-Oq s�r� rurc E" sr04-m DLs51&N PAT A pAl Y FLOW: (�) t5EDROOMS x I b ePD = y o� i eel cEs oc_ 6or"rp,,�: o, i 0� TO N I. B"; 1ZtiSIAI1 L1' c' i] 1 1t t)F i;�l'� 1"�I?( 11, .l:-1;N CAP- LFACIlltit; FACfl_M'�tty e) L ;' __ (size} NCI (A BEDROOMS PLR'MI I`D;\TI_ — tv COMPLIANCE DATE: t'.1i3G't'itSt!)ia3l:ie flemcen the- Ai:r:;ir.;:m;Adlustcd Groundwater fable to the Bottom of Leaching Facilityt Feel 116vate Water Supply Well and Leaching Facility I,If any wells exist on site or within 200 feet of leaching facilitV Feet Edge e of Weiland and Leaching Facility t if anN+%ctlands exist a iihm t 3011 fee,of leachine facility) 4L Fect FURNISHED B)' o r- L �` (, 5gl2!intranGl t:;ntrrcu in computer. THE COMMONWEALTH OF MASSACHUSETTS Y� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicatloll for 't I£t1o5a1 C13115trllcticn Vern"t Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑individual Components Application for a Permit to Construct( ) 1 � ' er's Name Atddress, ind 11-1.No.J"'S S r 7 Z } Location Address or Lot No.:L/'.S Lli �� /L n � S$r�) d Cc !ir ^ Assessor's iVtap/I'arcel / ' lnsta is Name,Address,and Tel4No. Designer's Name,Address,and Tel.No. 'I.ype of Banding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures ',t ,C- Design Flow(min.required) / gpd Design flow provided / i" gPd Plan Date Number of sheets Revision Date Title 'a'j Size of Septic Tank/ ^ti Type of S.A.S.'3 Description of Soil i Nature of Repairs or Alterations(Answer when appiicable)j2 arh /I — — Date last inspected: -- Agreement: The undersigned agrees to ensure the construction and maintenance of the afire 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 Certificate of Compliance has been issued by this Board of Healt� ,.. a�' ..�, / - Date f °" — Application Approved by Date_ Application Disapproved by Date for the following reasons Permit No. )0 Date Issued --- ------------- ✓ -f' THE COMMONWEALTH OF MASSACHUSETTS BA.RNSTABLE,MASSACHUSETTS i / j��� t�Ertificate Of C�Omfl�tanLP THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( } Repaired Upgraded( } Abandoned( )by 2U;2 /sum mac ': ✓/K` �'I f/``�" at % / f _2 6WE 1-C �f % 7 /t L has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No-., :)/77- ri, I dated_`1 Designer Installer ,+ I #bedrooms r Approved design-flow /y _—_ The issuance of this pertnit.S1611 not�e construed as a guarantee that the syster will functt n as designed. Bate Inspector ' ------------- _ _--`_-i---- ------ 1 Fec �N ,Ba i i J- , �fjlnity 2 NCI I'fovn, � �s -r4w �• U Q � V I o - � Commonwealth of Massachusetts Title 5 Official Inspection Form r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 215 Tower Hill Rd Property Address Bassett Owner Owner's Name information is required for every Osteryille Ma 02655 10/15/18 . page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed'& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank- Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 10/15/2018 Print Page P(mt.this page • Owner Information-MapBlock/Lot: 142/011/- Use Code: 1010 Owner Map/Block/Lot 1,S MAPS 142/011/ BASSETT, BRIAN C Property Address Owner Name as of 1/1/17 2800 RIDGE ROAD 215 TOWER HILL ROAD CHARLOTTESVILLE, VA. 22901 Co-Owner Name Village: Osterville Town Sewer At Address: No GIS Zoning Value: RC • Assessed Values 2018 -Map/Block/Lot: 142 /011/-Use Code: 1010 2018 Appraised Value 2018 Assessed Value Past Comparisons Building Value: $ 164,100 $ 164,100 Year Assessed Value $ 41,900 $ 41,900 2017 - $ 446,400 Extra Features: 2016 $ 448,500 2015 - $ 464,300 $ 3,600 $ 3,600 2014 - $ 459,300 Outbuildings 2013 - $ 459,400 2012 - $ 467,000 $ 250,900 $ 250,900 2011 - $ 458;700 Land Value: 2010 - $ 463,700 $ 460,500 2009 - $ 464,200 2018 Totals $ 460,500 2008 - $ 508,700 2007 - $ 533,000 • Tax Information 2018 -Map/Block/Lot: 142 /011/-Use Code: 1010 Taxes C.O.M.M. FD Tax (Commercial) $ 0 C.O.M.M. FD Tax (Residential) $ 741.41 .Fiscal Year 2018 TAX RATES HERE Community Preservation Act Tax $ 132.76 Town Tax (Commercial) $ 0 http://vmw.tovmofbarnstable.us/Assessing/printl8.asp?ap=0&searchparcel=142011 1/3 10/15/2018 Print Page Town Tax (Residential) $ 4,425.41 $ 5,299.58 • Sales History-Map/Block/Lot: 142 /011/-Use Code: 1010 History: Owner: Sale Date Book/Page: Sale Price: BASSETT, BRIAN C 2004-04-14 18451/314 $100 BASSETT, BRIAN C &COLLEEN M 2004-02-23 18241/77 $500000 HOSTETTER, DANIEL C &PRISCILLA M 2003-09-08 17602/86 $405000 HOPKINS, LEROY C JR&CLAIRE B 1949-07-06 724/113 $0 • Photos 142/011/-Use Code: 1010 • Sketches -Map/Block/Lot: 142 /011/-Use Code: 1010 x C ck. 3 w c As Built Cards:Click card#to view: Card #1 Card #2 � • Constructions Details -Map/Block/Lot: 142 /011/-Use Code: 1010 Building Details Land Building value $ 164,100 Bedrooms 4 Bedrooms USE CODE 1010 hftp:/Aw,w.tov,nofbarnstable.us/Assessing/printl8.asp?ap=O&searchparcel=142011 2/3 10/15/2018 Print Page Replacement Cost $237,858 Bathrooms 2 Full-0 Half Lot Size (Acres) 0.4 Model Residential Total Rooms 8 Roorns Appraised Value $ 250,900 Style Cape Cod Heat Fuel Gas Assessed Value $ 250,900 Grade Average Plus Heat Type Hot Water Year Built 1948 AC Type None Effective depreciation 31 Interior Floors CarpetHardwood Stories 2 Stories Interior Walls - Drywall Living Area sq/ft 2,086 Exterior Walls Wood Shingle Gross Area sq/ft 4,718 Roof Structure Gable/Hip a Roof Cover Asph/F GIs/Cmp • Outbuildings & Extra Features -Map/Block/Lot: 142/011/-Use Code: 1010 Code Description Units/SQ ft Appraised Value Assessed Value BMT Basement-Unfinished 1264 $ 21,500 $ 21,500 FPL2 Fireplace 1.5 stories 1 $ 3,900 $ 3,900 GAR Attached Garage 300 $ 8,500 $ 8,500 Enclosed porch- FEP 160 $ 8,000 $ 8,000 roodceiling PAT2 Patio-Good 466 $ 3,600 $ 3,600 • Sketch Legend Property Sketch Legend 62N Barn-any2nd storyarea FPC Open Porch Concrete Floor REF Reference Only BAS First Floor,Living Area FTS Third Story Living Area (Finished) SOL Solarium BMT Basement Area(Unfinished) FUS Second Story Living Area (Finished) SPE Pool Enclosure BRN Barn GAR Garage TQS Three Quarters Story(Finished) CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished) CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished) FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished) FCP Carport KEN Kennel UTQ Three Quarters Story (Unfinished) FEP Enclosed Porch MZ1 Mezzanine, Unfinished UUA Unfinished UtilityAttic FHS Half Story(Finished) PRG Pergola UUS Full Upper2nd Story(Unfinished) FOP Open or Screened in Porch PRT Portico WDK Wood Deck PTO Patio http://mwv.to\&nofbarnstable.us/Assessing/printl8.asp?ap=0&searthparcel=142011 3/3 Legend L •�� ih �% a. bL• Parcels 44 R y Town Boundary s � '� IJ Railroad Tracks ' Buildings :: 243 s r • �.. 142�04400 �� �Approx.Building k., :i Buildings Painted Lines r� s a i861 ` i, R Parking Lots K z <», � � t •ems,` Paved 'a v s ::.. Unpaved $� Driveways MOW Paved a € Unpaved .. °, 142044681: Roads 20 N Paved Road y #.x V y 142161 Unpaved Road - a a '� 40 Bridge 41, ,; 1> Paved Median Streams qff 11888 � ME Marsh Water Bodies J #45 1461 �2 24 s 21 -; � 1:1it S142010 f 142013 y3 .. 2 4 @ u 142�1 z •,_ Q32 1#1 #1944 #oi� 7 A "1411834 q { 00� ✓' 1420151f05 �# 142003 142 x $ ,. . #188.#86 �,,.. #48 #181 Map printed on: 10/15/2018 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA o26oi 0 83 167 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: l.inch= 83 feet cartographic errors or omissions. gis@town.barnstable.ma.us TOWN OF BARNSTABLE CATION MU),6 r// Of-SEWAGE# SDI � I VILLAGE ©S 1�ejg(Z W-1 A ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY js[ LEACHING FACILITY.(type) a (size) NO.OF BEDROOMS OWNER J3a SAS-.e-:M B0;!P V) PERMIT DATE: 'q?1 / 9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility I r IL4 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 Al: oq POT TQ-z Rq G No. ' Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS YeS 2ppliCation for ]Disposal *pstrm C onstCUttion 3permlt Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon O ❑Complete System ❑Individual Components Location Address or Lot No. . / O r's N �ddsreSss.� 1.No.� sye 67Y 72 / Assessor's Map/Parcel ®/ /® ' & Ins is Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. tS 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(min.required) Al gpd Design flow provided gpd Plan" Date Number of sheets Revision Date Title Size of Septic Tank/, 1_0 Type of S.A.S. _5r /�.�f mac! Description of Soil 44 7- Nature of Repairs or Alterations(Answer when applicable)` / -GE y3G. [y - 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 Certificate of Compliance has been issued by this Board of Heal Date Z), Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 0 Date Issued v },:j-..,�r,.4 r �<.. ,. .a.- .,�,.,� ..(rt,,• ,„ ,��r�``ri,.. r f.., i _ 'i a , .. cr"s ,_ .. � { _ l y i' No l;Z 'b '� [Ju � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:j/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS- —Yes . ftpfication for Misposal 6pstent Construction i9ermit Application for a Permit to Construct( ) Repair(Vj_*`Upgrade„O Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.a/5' 7-( F y2/4/Z4 X,> Owner's Name,Address, d 1.No.�7$ e B 7 7 7 Assessor's Map/Parcel f Q/ l l blZ 6,6 A r/ f.,i FS?/L t, i Installer's Name,Address,and Tel.No. "� Designer's Name,,Address,and Tel.No. Type of Building: / Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other- Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / A / r Design Flow,(min.required) / gpd Design flow provided A' / gpd Plan Date Number of sheets Revision Date 0 Title J / - Size of Septic Tank/_ Type of S.A.S. 6�1 I-I-Ay c/aAw P-e,;�GI Description of Soil All-A X ° t Nature of Repairs or Alterations(Answer when applicable)_,/4t/PQ nAl/ s/IlJ6-G r"FSS F064_ rZ 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 Certificate of Compliance has been issued by this Board o�Health Signed � � Date Application Approved by l( /) Date Y. Application Disapproved by ( / Date for the following reasons Y Permit No. ®. I Date Issued Ll _1 t I ------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS f (Certificate of Compfiante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�� Upgraded( ) Abandoned( )by at /T �l(Jfil1 c' f /� L -Fj/a has been constructed in accordance _ with the provisions of Title 5 and the for Disposal System Construction Permit N00-9 .()r/dated Installer () lc C,r y a i/,r1t ---" Designer .4 #bedrooms Approved design flow A , gpd The issuance of this permipsh/ ll not be construed as a guarantee that de the syste will function as signed. 5,/'Date n�� Inspect r%_ ' ----------------------------------------=----------- - - - - - - - - ---------=-------------------------------------------- No. �d - C� 7 Fee THE COMMONWEALTH OF MASSACHUSETTS - '� PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal Opstent Construction 3permit s Permission is hereby granted to Construct( ) Repair(ti)'f Upgrade( ) Abandon( ) System located at 5) /:5—, 2 v and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. /1 Provided:Construction must be completed within three years of the date of this permit. / Date / �/ Approved by TOWN OF BAJRNSTABLE . p c✓e/L f/ + SEWAGE #c260y- LOCATION � l ( VILLAGE AS l�a / ®�1 ert' t�`e S/ESSOR'S MAP &LOT I &PHONE NO. `LJrCtG18 0-�/%�s/cr ZfoSo1� INSTALLERS NAME SEPTIC TANK CAPACITY. ��506 /9l` �(3 nisi/- ffA�vl ter ize)(s r� �3 LEACHING'FACILITY: (type) a C �3 � NO. OF BEDROOMS. L/ BUILDER OR PERMIT DATE % ^�-O COMPLIANC$ DATE: d Separation Distance Betw e: usted Groundwer able to the Bottom of Leaching Facility Feet Maximum Adj Private Water Supply Well and Leaching Facility,,(If any wells exist, Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by � W VD w v - Tb*N OF BARNSTABL,E . POO SEWAGE # O/S' V L1. ls C�c5 l e('ir t AG �l� ASSESSOR'S MAP & LOT Xd /I rN.-TALLER'S NAME&PHONE NO. --Q, OLC-0-/k /cr— LFo18, SEP-11C TANK CAPACITY 1606 -(S 9 LEACH NG FACILITY: (type) 6O69/. C`HArY►bt� 3 (size) 33 NO. OF BEDROOMS BUILDER OR OWNER A�c PEKhiTTDATE` COMPLIANCE DATE: d Separation Distance Between the: N/laxinntm Adjusted Gf ourdwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching FaciLty ,(If any wells exist on site or within 2W,feet of leaching factltty)' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of-leaching facility) Feet Furnished by 4 Z S � 7 1 ... 8 G S . � u No. Fe l - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Migpooal bpztem Construction Vertnit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.o?1S lOtv EK ,(Gt[, Owner's Name,Address Tel.No. l� �►�;� 1�I ps�`e7T� Assessor's Map/Parcel A o 1 Installer's Name,Address,,and Tel.No. Designer's Name,Address and Tel.No. ®af• �� e 14A• 775= 07'3,r Type of Building: Dwelling No.of Bedrooms _ Lot Size 11C, sq.ft. Garbage Grinder(u� Other Type of Building k.00 ) ftyvli' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ys9e gallons per day. Calculated daily flow 1jyb gallons. Plan Date Number of sheets Revision Date Title . b S + 'LA11 )U. 05 f. Size of Septic Tank %SOD 0 J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)/ FAm %T 4 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 sy tem in operation until a Certifi- cate of Compliance has been issued by this Board of Health Signed � Date-11 f e Application Approved by Date Application Disapproved for the following reasons Permit No. 2 cW L( —d 15 Date Issued i No. Fee �n ` " `* THE COMMONWEALTH OF MASSACHUSETTS Entered in compute�rw�// V PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(pplication for Zigpogar *pzterri Con!5truction Permit Application for a Permit to Construct( . )Repair( )Upgrade(.,.)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �l s TorverC �G(L ITI Alas t tte�.; Assessor's Map/Parcel Q��PIG�G lye 0/J 770 WA) S . Af"ede P'J,U• y��Ody� Installer's Name,Address,and Tel.No. Designer`s Name,Address and Tel.No. rT'" soc B2tK Ni[Allist�a �tl P,c t 9Sf0� l6 qX ,f 0st• (2 e 0A- *775: 0737 Type of Building: Dwelling No.of Bedrooms _ Lot Size C• sq.ft. Garbage Grinder( N9 Other Type of Building hV69 rtlAwE No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �59. 9 gallons per day. Calculated daily flow yy0 gallons. Plan Date �Z�/ / Number of sheets / Revision Date Title Sift )/i/YAQl. — ZJs / "d, L1j1/ /�• 05/ , Size of Septic Tank /500 0 Type of S.A.S. Description of Soil, F'hirG: P14 �,O dl Nature of R pairs 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 by this Board of He91, Signed / C, �/ .1 L// Date / e f 7 Application Approved by Date f '�� Application Disapproved for the following reasons Permit No. 7 Y --c)l -'S Date Issued I , 1s 4 --------------------------------------- + THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif hate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by Kr,)tP at a 'vif r 611 01f 1) -"s".,J", has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. /. dated 11 If 3 Installer Designer / The issuance of this permit shall not be rorstmed aE a rwntee that the syst�m. W�iil- ailciion as designed Date ` l --rl�1 Inspector !—_ ✓• .. �lr� No. ��cJ� [� � � ---------------------Fee ) L� '.THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Zisspoal *p! tem Con5tructiou Permit Permission is hereby granted to Constru t( ,)Repair( )Upgrade( )Abandon System located at_ D (� i �� ' l ' 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:Construc r'n ust be gpleted within three yeazs of the date of this-;D`t J -Approved i Date: pp by 2 N9 �roorc, c2 ,s T6Wm t1.tl �- Li PIP Noog V o( ' M TOWN OF BA.RNSTABLE . LOCATION`4I,5- /O It . SEWAGE #,260-'1- O/$' VILLAGE O c�(e{ t e ASSESSOR'S MAP & LOT d "II ll�STALLER'S NAME&PHONE NO. SEPTIC TANK-CAPACITY. �cS�06 �gl LEACHING FACILITY: (type) - -0 0 6si/e'EIAM�re�(�3 (size) NO..OF BEDROOMS. BUILDER OR OWNER A PERMITDATE. COMPLIANC$ DATE: OV. Sel aration Distance Betw o: Maximum Adjusted Groundwater. able 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 PROff?!E: NOr TO 50ALE 2"LAYER OF'�/V'PEASTONE EL � '� rRST PIPE LEN�T?l i� TOP rCU ,fG ION G(TJEh' r0 W�TtitN ro m '5ET LULL wn�tiF�5TON PA i t-,: •'�✓''�< • I� �c>0'3 �` E].• y2, F 6" Or rNi917P 6RAm rOR MIN. 2' TESr DY: .1-/, O J rnvIsri , ERG RATE: a } ` �� p SGf1 AO �^^4 // G�. S ylo.a 1 ! yS.Sa y ,yo �jr• :� DOTTOM 0 a-Y2,rb IN Ovrur r M cd 'Soo &AJ-ON sFJ'AIL1T�aN /�yf� s B Q Z,Sy � /Z4>` DES I CAN PATH PAT Y FLOW: (j�f5_ ROOMS x1 b&PP= SEPTG TANK: C�PD x2o01388a C�PD USE:/SooOALLON PREGASr SEPTG TANK 72F/V C C. _ 'r� LEAGN I NCB FAG lL(TY: �r GAF AC.frY: ,3 " s' � ' OENERAL NOTS POTTGM:- /3 X 3 3, x o. - ,3Z2. ;5 y I U l GONTRAGI-OR TO M RESPON`j15LE FOR THE LOGATONOF ALL Url_fFE5 --- ApOVE AND UNPEROROUNP,PR OR TO ANY EX(AVATON OR GONSTRUGTON-191 ,. 2. SEPT6 SYSTEM TO 13E NSTALLED NGOMPLIANGE.Wfrh 3b(.4MR CDO:TfrLE V 7` T*,'Ir PLA000 N A. ALL PrT•URMP AREAS 7015E LOAMEP ANP SEEPEP S. GONTRAGTOR TO PROVDE 2A MOUR NOTGE FOR ANY REQUREP N5I'E6TON!5 1-41 1 6f iq to V 51 TE SEWAGE FLAN LOCATION:- Z/S 7wE2 Illu- lco, ©s PREPARED FOR: DRAWN pY: 2a ' S� 7�3 cF n� � ',a 4�IA OF Mq u- G'GS ' 4*e-t) VEN JOD NLMf5ER: DATE: .oe�,is Zc.-3 5flEET: V\/FLLEFZ si & A66001AT�� (o-45 FALMOUTM RD - SUITE 46 GENTERVILLE, MA 07/,on TEL: (505) 775-0735 Mli FAX: (503) ?75-0754 PROFESSIONAL ENGINEERS & LAND SURVEYORS