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HomeMy WebLinkAbout0022 VAN GOGH DRIVE - Health -= 22 Van;Gogh-Drive Osterville P A.= 146 106 i n TOWN OF BARNSTABLE LOCATION \J CV-, Cj)S Or 09MA SEWAGE# © i 7 0 O i VILLAGE _ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY C—y j 3-k O o`0 LEACHING FACILITY:(type) (size) O n\ �f NO.OF BEDROOMS OWNER PERMIT DATE: ( 1 f3 `\`� COMPLIANCE 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 Ilk 3 1 .3 h r° No D` 7 Fee 76 v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZipplicatIon for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. ' 1 a P<; (�w Name,Address,and Tel.No. Assessor's Map/Parcel i fl b 10 I s e ddressand 1.No. Designer's,Name,Address,and Tel.No. �c r 3 b c.r•Muu�, � Type of Building: Sow 4-914 Dwelling No.of Bedrooms Il A Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) ()`6w RY S�c, k3()y— �'�.. l-1 _fit s��:� cY� �0 —San 1 « n G E,Z �.�� ��- ��.n kC.J\V-- k-y RaW 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 Health. Signe Date q Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2-0 t 7 6(0 Date Issued 1 '!ry. ..'r`• +. ri...f.. r "�„ln1r.-...-yy... ..,r id M1Tr-, ..A.. § ..., .r°.�� 6� p No. d b f Fee. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:L11/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for MispoBal *pstem Construction Permit Application for a Permit to Construct( ) Repair V),Upgrade( ) Abandon( ) ❑Complete System 2 Individual Components Location Address or Lot No. "�„ v ®�h �(; OZ} s Name,Address,and Tel.No. Assessor's Map/Parcel I tale 's me ddress,and Tel.No. Designer's Name,Address,and Tel.No. Ou Yrvr­qu�, Q,( I �f TypeofBuilding: �4yc '\OS S'bX f. Dwelling No.of Bedrooms A)l}.6 Lot Size sq..ft. Garbage Grinder( ) Other Type of Building * No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title - Size of Sept c Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9 D�G�� �_�1 N G c s�<< scan Q O mac, n c c� n��.� ; ..c �'�-•�,.n �k C"�, ku 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 Health. < , Signed--, _ Date l r ��� !�` Application Approved by j Date ; -? Application Disapproved by Date for the following reasons Permit No. !7 ' to Date Issued r f , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaire (c� Upgraded( ) Abandoned( )by �>c O t't ( �'f-t,•���}'( at - 1 1 rl rN -('��, (,� ( y j has-been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o /-7' �U dat_d I/h j Installer , c r". C=r r_,�1/C - Designer #bedrooms Approved design flow Al gpd The issuance of this permit shall not be construed as a guarantee that the system wil `unction s designed. Date Inspector r 1t t ! p , ----- ----------------------------------- O1 )— Url6' Fe _2� No. THE COMMONWEALTH OF MASSACHUSETTS PtiBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBal *pstem Construction Permit Permission is hereby granted to Construct( ) Repaire Upgrade( ) Abandon( ) System located at -PA M C f' CFO r.L' '6! C"At 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. Provided:Construction must be completed within three years of the date of this permit. Date ( f l �f '� Approved by�� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ulp RECEIVED JUS 0 6 2003 TO VN{O_3AR DEPT.gLE TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 44 D Property Address: I/U rl arm {� c1 ��b (� (�v,1 Os 4 e,, L Owner's Name: Owner's Address: /9� j o��,. /5��// Ali (p Date of Inspection: 5 /G MAP PARCEL ; 0 Name of Inspector: Wease print) Company Name: /1/!%o LOT Mailing Address: Telephone Number: (Sea ) S ,Iy CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.3-40 of Title 5 (310 CINIR 15.000). The system: � Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �&,�2 /�V14, Date: /C112 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. if the system is a shared system,or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �d 114 exiC4 s h Owner: Ji?e 75 r Date of Inspection: , Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. SysS Passes: C� I have .not found any information which indicates that any of the failure criteria described in 310 CNiR 15.303 or in 310 CN1R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System m 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. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please 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«ill pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank gill pass inspection if it is structurally sound not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced . obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 4 Page 3 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSINIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 l CERTIFICATION (continued) Property Address: 0 ` 1�k9 ,/�� \ T�- Owner• �pP✓l �c� Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health. safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CINIR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water ' _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 4 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety ind 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: eV'vi Ile, 4�/1 Gam)- Owner / fw-OT- D.Date of Inspection:System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each of the following for all inspections: Yes No _D(/ ,-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 �ogged SAS or cesspool — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool V Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number >�A` f times pumped . — _ ny portion of the SAS,cesspool or pray is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface%titer supply or tributary to a surface water supply. 3� Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Anv 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, Ncrformc-' DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates m... one 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.] /O(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large s%.stem the system must serve a facility with a design flow of MUM gpd to 15,000 gPd• You must indicate either"yes' or''no" to each of the following: (The following criteria apply to large s,-sterrs in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat.or answered "yes"in Section D above the 1LI-- a system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ) CHECKLIST Property Address: "'4) 0 n L 1/� OS w Owner: ee v► r Date of Inspection: r Check if the following have been done. You must indicate"yes" or"no"as to each of the following: �"es No /Pumping information was provided by the owner, occupant, or Board of Health V Were any of the system components pumped out in the previous two weeks y 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 V P� Were as built plans of the system obtained and examined?(1f they.were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected pec ed 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 condi i of the es or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum [ton _ _ 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: Ye no Existing information. For example,a plan at the Board of Health_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CNIR 15.302(3)(b)l Page 6 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION . ON FORM PART C SYSTENI INFORMATION Property Address: ' r'Vi eel Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-2— Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: d Does residence have a garbage grinder(yes or no): /P� Is laundry on a separate sewage system(yes or no)'. �1 [if yes separate inspection required] Laundry system inspected(yes or no):/C�-0 Seasonal use: (yes or no): ;0 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):ZV Last date of occupancy: COhIMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 13.203): god Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER bc): Pumping Records GENERAL LNFORINUTION Source of information: p� ha- Was system pumped as part of the inspection(yes or n If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: T YPCO F SYSTEM 1/ Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspobl _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 of all components, date installed(if known)and source of information�-"'v Were sewage odors detected when arriving at the site(yes or no): �� I'M _ f - Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ll SYSTEM INFORMATION (continued) Property Address: c� -, a � Prv,l Owner: Fcc'0S r Date of Inspection= BUILDING SEWER(locate site plan) Depth below grade: Materials of constructiocti n: t/cast iron ( PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) // Depth below grade:�_ Material of construction:—concrete—metal—fiberglass—polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: O Distance from top of sludge to bottom of outlet tee or baffle: Q0 e Scum thickness: p IiV Sc I 1-7 Distance from top of scum to top of outlet tee or baffle: D Distance from bottom of scum to botto�0 outlet tee or�7e: �_ How were dimensions determined: /C le /<ti s 4�LA Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels Llated to outlet inve evidence ofrl ge,etc.) / r+ 7,n o /Cat'N !� �17i1 f `"1 fl yeti 1v GREASE TRAP:Z(Iocate on site plan) Depth below grade:— Material of constriction:—concrete—metal_fiberglass_polyethylene other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, Liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYYSTEM INFORMATION(continued) Property Address: V Owner- /—C�C'h� va 6 '�� Date of Inspection: 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(eeplain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): D15TRLB L i 0%'1 ILI,O`C: resent_ if must be o n.... . P pe ed)(locate on site plan). Depth of liquid level abov.: invert: V70170ct Comments (note if box is Ic•.cl acd distribution to outlets equal,any evidence of solids carryover,any evidence of nninto or out of c,etc.is ���. AVSo li cj 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 chamber,condition of pumps and appurtenances.etc.): c , " F f R 4 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: IL—eek J S Date of Inspection• C, SOEL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tvp� f� l `S�o l/ leaching pits,number: J10� UY �O vi C/r L 4c leaching chambers, number: h- f %/ �r �r n y , leaching galleries,number: } S 9I leaching trenches, number, length: "'�� �o ✓I J-e°-T / leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of po ding,damp soil,condition of vegetation, etc.): �+ �O SG✓lS pT CESSPOOLS: (cesspool must be pumped as part of i on ovate i)� on site plan) Number and configuration: Depth—top of liquid to inlet invert: L)eptit of solids layer: Depth of scum layer: Dimensions of cesspool: , Materials of construction:. Indication of groundwater inflow(yes or no): Continents(note condition of soil, sign of hydraulic failure, level of ponding,condition of vegetation. etc.): PRIVY:A—/(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: k2� -7 ,, 'GJ S crv, _a.c Owner: C n Date of Inspection: / SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Gr / r Page II of II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l p� Q j e l Owner. Lek Date of Inspection: / 0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water C;6 j feet Please indicate(check)a]I methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) hocked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: , You must describe how you establish d the high ground water e�ev�tioo: r c., Lei 4, Gt S l v� /O TO o P o r � 0 00 " -� i Oo � b ',�+ 0 eo 0 O O Cis f 0 ,� _ - -- — 9,1 9; � ' d � BORTOLOTTI CONSTRUCTION,.IINC. tJf 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM IN SPECT�ON FORM PART A. CERTIFICATION Property Address:od Date of Inspection: Inspector's Name; er's Name d Ad ess: CERTIFICATION STATEM *iT� I certify that I''have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed b on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further Ev don By the ocal Aproving Authority Fails Inspector's Signature: Date: ��l The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty,(30)days.of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd-or greater, the inspector and the system owner shall submit the report to the alpropriate regional office of the,Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority: INSPECTION MMARY• A);;YC M PASSES: , I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated ` below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. , Indicate yes,nor,,or not determined(Y,N,OR ND). Describe basis of determinaticn'in all instances. If "not determined",explain,why not. t The septic tank is metal,cracked,structurally unsound,shows substantihFinfiltration or exfiltration,outank failure is imminent.'The system will pass inspection if the existing sep- "tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water,level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The ;system will pass inspection if(with approval of The Board of Health): is \IQ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water —T Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND,PUBLICWATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a.surface water supply. The system has a septic tank and soil absorption system and is with a;Lone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. N The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less } than 5 ppm D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as de fled in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool: Discharge or ponding of efluent 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 or clog- ged 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 -2- —�, Ad r i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface'water supply. Any portion of a cesspool or privy is within-a Zone I of.a public well. Any 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. If the well has been analyzed to.be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAR S: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant. tlireat to public health and safety and the environment because one or more of the following k conditions exist: 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. .The owner or operator of any such system shall bring the system and facility into fiill compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B t CHECKLIST Check if tie following have been done: 1 Umping information was requested of the owner,occupant,and Board of Health. jG1Qone of the system components have been pumped for atieast two weeks and the system has .,been receiving normal flow rates during that period. Large volumes of water have not been 1 introduced into the system recently or as part of this inspection. _.�/As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. e septic tank.manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- >.0 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) jZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM: PART C SYSTEM INFORMATION / FLOW CONDITIONS RESID FNTIAL: Design Flow:43jo_gallons Number of Bedrooms: v3 Number of Current Residents:Zk4a2LI Garbage Grinder:a_ Laundry Connected To System Seasonal Use: AJ d Water Meter Readings,if ay 'Iable: Last Date;of Occupancy: - ^ ... ;COMNI '1R AL11ND ISTRIAL•" Type of Establishment• Design Flow: gallonstday Grease Trap Present: (yes or no) lndus;UW�Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION DUMPING RECORDS and source of information-, + s �/ System Pumped as part of inspection: If ye ,volume pumped: gallons Reason for pumping: TYPE SYSTEM: t/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APP 0XIMATE AGE of all components,date installed(if known) id source of-information: Sewage odors detectO when arriving at the ite:_A O -4- a i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) . SEPTIC TANK: v Depth below grade:2_ Material of Construction: ✓concrete metal FRP Other (explain) Dimisions:; Sludge Depth: � Scum Thickness:�/� Distance from top of sludge to bottom of outlet tee_ or baffle: Distance from Bottom of scum fo bottom of outlet tee or biftle: 7 Y1 Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid t 1 mr9laflon to Outlet invert,structural integrity, evi ence of leakage, etc. 01 ii G IeA&M V.: �. r� Depth Below Grade: Material of Construction` concrete metal - FRP Other (explain) I — — — Dimensions: Scum Thickness: k Distance from top of scum to top of outlet tee or baffle: "".comments::(recommendation for pumping,condition of inlet and outlet tees or baffles, liquid'de th of P level in relation to outlet invert,structural integrity,evidence of leakage, etc.)' i TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete—metal FRP—Other(explain) 'Dimensions- Capacity: gallons Design Plow: gallons/day Alarm Level: Cgmments:.(condition of inlet tee, condition of alarm and float switches. etc.) DISTRIBUiTION BOX: V _ Depth of-liquid level above outlet invert: Comments:;(note if 1 el and distributiot is equal,e ' en solids ca over evidence of leakag into or out of box,etc.) PUMP CHAMBER: �.;_ .• Pump Is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) 5...:�'."$ �,"n.. •,Y:ref + .F..;�,.awFe,yF.4 f i e. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) i If not determined to be present,explain: Type: / Leaching pits,number:1caching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Commen : (note condition of soil,signs of hydraulic failure level of pon ing,condition of v etatio etc. �r ^ CESSPOOLS:, t �, 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) r PRIVY:, Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)'` i -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. r "'�• �., _ � .I_I r�s�r�/�- _i���� �. ``�:E-+,} 3j`� ?�S F' ^,G,C�t+`',.:r r a S y��a�, 3 , } � •+ DEPTH TO GROUNDWATER: Depth to groundwater: Feet Met.WofDetbrnu 'on or Approximation: ��7�T � �'I 7• 4' Iq A 15 <!a 7 -7- r jN It BORTOLOTTI.CONSTRUCTION, INC. MPS �� 765 WAKEBY ROAD,MARSTONS MILLS, MA 1I2G48 ` " 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C PART A CERTIFICATION OqA) Property Address: c-- Date of Inspection: //-C3'Co Inspec or's ame: Owner's Name and Address: v i3MIL, ze CERTIFICATION STATEMENT, I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further aluation By the Local Aproving Authority Fails Inspector's Signature: Date: -711-7196 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. ]'he original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION MMARY;. A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of"The Board of Health): Broken.pipe(s)are replaced Obstruction-is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SY EM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 C 15.303. The basis for this determination is identified below. The Board of Health shoul contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 or clog- ged 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen: E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into'full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: _L, Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _jGThe site was inspected for signs of breakout. .�All system components,excluding the Soil Absorption System, have been located on site. one septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- �t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ��The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTLAI.:l/ Design Flow: gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: 1P3 Seasonal Use: Water Meter Readings, if ailable: Last Date of Occupancy: COMMERCLAL/iNDUSTRIIAL! 0 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION / PUMPING RECORDS and source of informa ' n: /�J ' �� - 6(S of System Pumped as part of inspection: =If yes,volume pumped: gallons Reason for pumping: TYPE F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System 4 Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): A'70 TE AG of all mponen ,date installed(if known)and source of information: t Sew ge odors detected when arriving at the site: -4- a ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction:-Zconcrete metal FRP Other (explain) Dimisions:&!57yt,lo l )� s ' Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: .13 ' Comments: (recommendation for pumping,condition of`inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage etc.) i�_ /p(j 01 ol- GREASE TRAP: . Depth Below Grade: Material of Construction:_concrete metal FRP Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK:/ 0 Depth Below Grade: Material of Construction:_concrete metal FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: `Depth of liquid level above outlet invert:4-br /?q I i�2W Comments: (note,jfkvel and distribution ' equal,evince of solids carryover,evidence of leakage into ut of box,et j.S'7i ';6; 0'-V e< /- -)01*22j4 / �'-'Q,00-,- er PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlinued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: I Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure level f ponding,condition of vegetation, _�+ Ge / a Ce. CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:/V Q Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) t -G- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . SKETCH OF SEWAGE DISPOSAL SYSTEM: . Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 0 3a DEPTH TO GROUNDWATER- Depth to groundwater: 7 Feet Meth ,of Determination or Approximation; /"�X/v�/q l'�O��l lit. ✓, m -7 1 TOWN OF BARNSTABLE LOCATION JO ( aa n 111-JA SEWAGE# VILLAGE�� � ASSESSOR'S MA,P/& LOT -i�vSpg �AME&PHONE NOI`J�OfOD�i SEPTIC TANK CAPACITY /000 QQ1 \\p6L?4 � �'�G 2D�lo�7 ZY LEACHING FACIL=: (type) �� ��J (size) , 6606QIS' NO.OF BEDROOMS 3 / BUILDER O OWNER ' 149 2e_/'',� 61e,) c Q PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: O Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 4 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 facili ) Feet Furnished b /ot60el /��r �� � � � �a� 9► 1 a� 0 �� TOWN OF BARNSTABLE LOCATION ( Qn 00,71.a SEWAGE # 9Co VILLAGE k 0y'Ae ASSEWR'S MAP //&LOT —/D INSTALLER'S NAME&PHONE NOTIl� � SEPTIC TANK CAPACITY LEACHING FACEL=: (type) (size) N<d f NO.OF BEDROOMS BUILDER OR OWNER1--------------- y o �• C���a �h �� d` Ge - PERMITDATE: . ���lo,�l� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility") Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by �� yq' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprtcatton for Mfigpaal *pgtem Congtruction Verna Application is hereby made for a Permit to Construct( )or Repair( I--<an On-site Sewage Disposal System at: Location Address or Lot N . Owner's Name,Addres§and Tel.No. 1�r/ e G i z L."rl ki Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(441 Other Type of Building 4e_5 e-Y7-Ce_ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ® gallons. Plan Date Number of sheets 'L Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) 11t� -J®®©�o� ` �G�.�•�� 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 t ' Bo He > /� Signe Date Application Approved by Application Disapproved or the following reaso s Permit No. Date Issued ——————————————————————————————————————— No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS' 0(ppYication-for Miopooal *p5teiu Cougtructiou Permit Application is hereby made for a Permit to Construct( )or Repair( 1­#�an On-site Sewage Disposal System at: y~ Location Address or Lot N Owner's Name,Address and Tel.No. �.7-"t/fh 6,©,��r 0-ae Lam/ 05�C/'d�i'/lr 2 Z. liciH la��rod Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. dole felo//iGe#sra ` Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(A- Other Type of Building /e�6e_ No. of Persons Showers( ) Cafeteria( ) j Other Fixtures Design Flow /D gallons per day. Calculated daily flow 33'0 gallons. Plan Date if 3 Number of sheets Revision Date Title ' Description of Soil Ste'6011.0le i Nature of Repairs or Alterations(Answer when applicable) 1N� 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 t ' Bo Signe r Date - �Z6�Y� 'E Application Approved by / ^ 1 Application Disapproved for the following reaso s lei i s Permit No. Date Issued ` ——————————————— THE COMMONWEALTH OF MASSACHUSETTS 4 O b f PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of QCompriance THIS IS TO CE TIFY,that the On-site Sewage Disposal System installed( )or r�epaired/replaced((, )on ) by O�Tl1GD�/ l'ew • for ,l�, as 2 Z v4h / has b en constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated "' - i Use of this system is conditioned on compliance with the provisions set fort below: *� j No. ! Fee � THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Zigool *pttem Cootruction Permit Permission is hereby granted to to construct r �,�an O -site Sewage System located at !l Da r i ,b_ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his er duty to comply with Title 5 and the following local provisions or special conditions. O All constructipY must a completed within two years of the date below. 0 Date: ( Approved by AG'l_._ ' 1' CElrFIFICATION OF SKETCH AMU APPLICATION FOR A DISPOSAL 1V0I110 CONSTRUCTION I'ER1191 I'(�VI'I'I(UU I'llCSICNEU PLANS) thereby certify that the application for disposal works construction permit signed b me dated �Z� l concerning the constty p g y • property located at 2 2 Z-, �lf meets all of the following criteria: here are no wetlands within 300 rector the proposed septic system T acre are no private wells within 15o rest or the proposed septic system T e observed groundwater table is 14 feet or greater below the bottom or the leaching facility There is no increase in(low and/or change in use proposed • There are no variances requested or needed. SIGNED:A&NE� DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAttach a sketch plan of the proposed system. Also irthe licensed installer posesses a certified plot plan, this plan should be submitted]. '166 At . 4J t VT1/ 16, ' o ,^ y 0 Pt T / 1_O 7^ 3 ,� , ,ape ,..�• 6 G •S` 7 3 °2-3'3P �. � � w / 6, og OF A f ? AL �r2T � - V , A 'MORSE cn V. 9 No.10951 O h. DOS�CsIST 'q�'?4' •` , F'rSl�Al.�a LEGEND EXISTING SPOT ELEVATION- OxO �;µ OF �j�SJ` CERTIFIED PLOT PLAN EXISTING CONTOUR — 0 — FINISHED SPOT ELEVATION c� RMERT,. GN LET .�! 5 1/AA• FINISHED CONTOUR ---- 0 ® BRuCE. ELDRE y APPROVED BOARD OF HEALTH I 'PATE ,- AGENT.., � � .= . BCALE� �:� DATE 9 REDGE ENGONEER/NG,�Ca Jail CI.1!'NT � � ��' _� P, - -------+ I CEI T FV THAT ''THE""PROP EGIS �� RE®tSTEREO J09 'N0 5 -22 v: BVII ® � CIVIL a LAND s �•�-�*+—=� 0 �I HOWN ON TF t'B$4 VAN 8 ONFOA�IS x ENaINf R 3 DA '�Y� / !Msw x ti O THE ZONING LAW9 ' ° ay_ a ate- OF r1iE' A9 E3 MA S ez az z f" tik r i5i!' `CS . syafxft t Sti ° 'bps• ✓;,,, : 'r ,` vn� �. i k. 9• a ]' .SyFu z` >SREET CH. r tZ; /3rE., ,A �.� .- .r / ! -.. f ; �' . .. .;.. t � J . . /f EITNLR :tl�. Sc t '.:OC<yIlvG P/T A,tE MORE T,'�A.•/ /2"3EL0 A "� «a a , /�1J/N• '1 SEA ; 24�0/A<N E T�R CONC•t ETB. CC vt ` h f ,000GNT TO G�AOE. •Y E.��?e SJNALL 9E 9 C�VE� 3NAt 3c ��� P/PL l+iEr4Vy CA ST ..20N M/N. ,•/TCM VE i�/A Y . ,4 E�Ev Su' Z COYE�S %j�PEP/� C•O,ti�zE'"— _ eoo s: '• _ �# hLAYER so W�'v: S�PN. 'r/C" TANI+C QOX 8 • . • • ' •' 3 s�- �2 �Kisti ,' - :.i•. -�.��r;`_2+•- :Y ` _ •� ., • ��fECf/:L •• • •` _ _ W SJtED STJ.YE i a+' - • • • • • • • • • • • •' o p • p)rEc.A5 T SEf�AG E 718 s pl-r. CAoff- +� o UVYt �lEY�tTl aW - <<r: vim• �,t r Cn. ( s T/IdL/IAWON.) �3 G:. MLLr` PTJ�C."J1f/C. GROt/ND jYATERT air ' x Qom' z` ltW�6 '�a�? f! T��r! 7 atlL ate_ iA P+!i �' 4 6 z_ .t ` `L�JI� +I PIT iM W t,< —�� a,r ._ .�-� ,- IX�►.r �I p ENJ/O/1[ ar _ - t•`T:'r`r�AL� : s d _ AIMAW SIOA1. 4 fT r�✓, ;fd/6J�t�CRlT�AriA' -Ni, AWN = N� &R oP awPwqdo,vs r 3 Solt- LOG S01A 7"F1TT �GEp/SPO•S.4L l�Yt7r.lY---G,�s. �y SOIL TEST,�I SO/t TFST�� �Z h/�-3 • rC� 7 > �g} TOTAL E?T//►f�TED �LOi�O �fL�'Y. A4'-ff OIL h 'ems. �r�✓MBE,P a�LrACNIAW Firs ASS PV1riv e &Ss.Eo Y ` ,,. _,s�Gt rT 1 f � � :SIDE L1AGHlN6 PER O/T p — I z PfRCCLAT/OH MATE / /"11 WI N[ � ::jOTTOM LiaAG'JI/N4 0/Fat P/T -30• fT. Lo.. r-r B� AE.tCOtI�T/DA/R.r►TE 1�2 T rrV 1�'1/N.�/NC ZVU or xARA PT_ Ml =FSERYELE1tCI!/N6AREA V `xOF bl\ i -ItICFM4,; n % T R ✓/LL...E ,i ROBERT BPUCE rr �ry�( p4ElOREOGE '^ c ORSE E;OREDGy ST,y�!� !?s!•rO,J. No. 10951 O CAS+-EQ` p� o9�`�GiSTEP� t`��I r:. . 3 .Z ` x X `Gtio Stf ty °FF� gab. ,.�.arEM JrNCOWV74rC=oDATE 9 // ® HSATER AT BL=V. .. .. t SHEL'T�ON .. [Q GltO uwo JOD.NO. �` V o�NO. CT 4-r,� VAIo! .�O�a1 1 LOCATION VILLAGE OS7E VILt_ DATE 071T SS • FEE APPLICANT_C_QMAl&g0L=9_ 1$�1�4�a�I �T C4�.�. . ELEPHONE .NO. "871-361 (Non-refundable T _., Si ADDRESS EDIGINEER ELd12.alaDGE f=- th I a 121Nb TELEPHONE NO. '135-w DATE SCHEDULED' JVL`/ ICI IS APPlicant'ls signature SOIL LOG.. SUB-DIVISION NAME QEE t OSTE 1 l " •`PATE O 2 • V10. 03 TIME 9 3e. EXPANSION AREA: YES ✓ NO JS H Lt a. . C L L' 1 S ENGINEER '?v TOWN WATER✓ PRIVATE WELL ja t4 N J R GO b 1 BOARD OF HEALTH . - �. wl� w.w.wwow...w..w.wwr w�.w rww ■w J 1 M D Q t SCOWL w1.w_ EXCAVATOR SKETCH: (Street"name,etc, ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES. \4�' 9, o LET 44 4co n 4d 1 i�=S�.So �/�N !�®mot•-� PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 0�= 8" Lo A7" t T 3 3 4 4 6 /r7 6 I S�� 8 8 9 9 10 10 11 11 ' 12 12 13 try tr�+ }L-•-�-- 13 14 14 15 15 16 16 SUITABLE FOR SUB—SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE.'. REASONS: . y ' NOTE: ENGINEERING PLANS MUST SHOW NUMBERASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED N T RETURNED 0 BOARD OF tIEALTH COPY- RETAINED BY APPLICANT j No........9_3 _40 FEs.._.. ...../_.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --- 'D.�L...-.....-.OF.................. ..... �1��.._.-..-...--•--...-..---- 1 .� rlirtttiuYt for Uiipuuttl Workii Tun rurtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at --------------- a" 7. .._......` ...-----�..�......`..... .� .......................................... _ .. Location_Ad ss r Lo No. ......................_... - --------...... - ...................................................... Owner / Address Installer Address Size Lot.... Type of Building _ 0--?.Sq. feet U Dwelling—No. of Bedrooms...................:..._._____..__._Expansion Attic ( -� Garba e Grinder (/Q -D Other—Type of Building No. of persons____________________________ Showers — Cafeteria POther fixtures -----------•------------•---------•-------------•-----......._...------------•----------------------------•-----•------=--....--------._....---_-•-•-- W Design Flow............................................gallons per person per day. Total daily flow.....__..___._..____.____________...........gallons. W4 Septic Tank—Liquid capacity` s Ugallons Length................ Width................ Diameter______________._ Depth................ Disposal Trench—No. ___'........:...... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) / Percolation Test Results Performed by........................... ! . ___ Date..........._ Test Pit No. 1_._ minutes per inch Depth of Test Pit.............:..... Depth to ground water........................ 44 Test Pit No. 2___-tminutes per inch Depth of Test Pit____________________ Depth to ground water........................ O Description of So 0 ........................ ... ..........-- _--- �.r �lr!__�r. ........... x ••.•------------•-----------••-•-......---••---•---•---------------•----•---•-•--••----------------••--•••--••---••----------------------•---------...-•--•---------------------...................... 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 provision. of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue y the board4ofhealth.Signed------------- 4 ___�_�... ....---•----------•- ---••--•-----...........-------- Application Approved By_ .. .._.... Lj.............. Date Application Disapproved for the following reasons_______________________________________________________________•-------------••••---•------ ••-------••---•---. ...................................... --••-•------•-------._....----•-----•-------._........._...._...-----•----.._.__..._._._....--------•----------------------------•------------.._-•••---......--- Date PermitNo......................................................... Issued....................................................... Date --------- -- -- - ------------ ----------------------- No........9_3=6'53 FEs..........:.._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j.!>. --..........oF................. I '€.. ................................... Appliratiun for Diupuiittl Works Tonstrnrtiun rumit Application is hereby made for a Permit to Construct ,K'�) or Repair ( ) an Individual Sewage Disposal System at: � C� � - `Y �.-•---�~ 6, ��" •...................•-•-------•--•-•---..............--------......-•--••--.._....••-•••••••--.... ............--------•---...--------- = .f�................ Location Ad ess r Lot No. a .'" .............................................................. Owner �p � / Address a .............•--------..............•------•----..................... /.:L.c'`` ...... ........ S_.... 6 { .......................................................... Installer Address v YP g ...f d Sq. feet Type of Building Size Lot__.....5... .� Dwelling—No. of Bedrooms.................:.........................Expansion Attic (44-& Garbage Grinder (,A..y0 Other—Type e of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Q, Other fixtures ............................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/p o Ugallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 2i~' XIrl Percolation Test. Results Performed by........................... l .. __ Date............_..._y .F. _....... . Test Pit No. 1___-4'`-"—`-minutes per inch Depth of Test Pit.................... Depth to ground water........................ tz, Test Pit No. 2....li/ _minutes per inch Depth of Test Pit.................... Depth to ground water........................ •----•-•-------------------------------•--••--•---•--------•--. ....... .............. .. . O Description of Soil---------------•••---•-_.---.- -......._..... 1. ----------------------------------------- - - w .............................................................. •------•-••---•-••------.......------... =------- ... . - .......-- .. ..... ........................................................................................................................................................................................................ UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. -----------------------------------•-----------------------------•--------------------..........-•--•-•--•-••--•--------------•------••--•-•--•-•••-•--•-•---..._........•-••-•-•••-••-•.._....•-•-..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions cf TITI.% 5 of the State Sanitary Code—The undersigned further agr es not to place the system in operation until a Certificate of Compliance has been issued y the board of health. Signed-----------------%�-i- �.--• ---•------- o, - -•----------------- g--------------------•-•----... Application Approved BY-------•-.._�- _c_ , _..... ........................................... ...... Date Application Disapproved for the following reasons:.............................................................................................................. . ......................................................................................---•-•------•--•-•••-•-......_..........---•••---•••-•-•••---•---------•---•-•-•-......-----...--••••--•••------ Date PermitNo......................................................... Issue(L_...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrfif iratr of Tuntpliatta THIS IS TO CERTIFY, That the Individual ewage Disposal' ystem constructed �) or Repaired ( ) bY-••----•-•--•........................ : °�. -•-• ......... r c !_ .--- .... ......... Installer at ..----•----••-------..-- _........ ✓�----------------•------------------ -----=`----• ...... --- ........................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... 2n.(f-i ......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... ✓' No...g.3............ FEE.... l ..- Uifipustt1 Turku .�• aanurnrti�an �ernti� Permission is ereby granted....................................1— .:'`�'".. ''� f, � to Construct or Repair ( ) an Individual Sewage Disposal System at No............................... .'' ----�- �.� a .. : 1_.. (j f / Street as shown on th application for Disposal Works Construction Permit No............... J... Dated.......................................... .�.... ?f--. ------------------------------------------------------ Board of Health DATE-- .-/-.... .. ---- ...................................................... FORM 1255 A. M. SULKIN, INC., BOSTON - r- - - 41. 166 no,N : c✓r 7Yn( , 0 c, 03 r 1 -� L o r 4 /S, v-2,.2-� si. ; XpR �r`NP 1 6 )e c0H f j �041> 0 . P S' 7 3 °Z 3 3 k''' 11V � 6, 0� jN OF M NNi r� �s w C} 1\A. s 14 I HORSE v, U No. 10951 n �oFFstiONA LEGEND EXISTING SPOT ELEVATION Ox0 . `rw OF � �,r CERTIFIED PLOT PLAN EXISTING CONTOUR ——— FINISHED SPOT ELEVATION r. ROBERr FINISHED CONTOUR 0 -'*--�' BRUCEr ELDRED y IN APPROVED , BOARD OF HEALTH .. - _ No suc� OAT E AGENT SCALE � `�' DATE / tt_LO_AREDGE ENGINEERING Ca IN aec1'TA : --- CI.I NT,.,.,r.,:,I ;.,,.,,- I CERTIFY THAT THE PROPOSED EGISTERE REGISTERS ... Jp® No.. BUILDING SHOWN ON THIS PLAN CIVIL LAND DR�B.Y� . V , CONFORMS TO THE ZONING -LAWS ENGINEER , OF BAR14STABLE � MASS. . 712 MAIN STREET CH, 8Y, % .�'—f—.-�. - iJ l r`' N YA tJ N I S, MASS. SHEET OF OF ..,.�. DATE E0. LAND SURVEYOR I.OTE /F E/THLR :NE Sc�T/C TA.V�f DR ,._. � 20 �T_ Pm//1! .� . �f'E.4CN/NG PtT ArtE MORE TN�9:'/ /2��BELOfV •. � �: A//N. . wc Piet 5NA4L BE BaOuaY7' TO GRAZ>F_`.�,v ELt=✓ S t� Z GONCR/.'7rQ All". P1TCN h�EAVy Cif ST .RDA' C�YE.4 SHALL 3c— sE� ;:.. COYER.S •p�r,4 FT 4 ,. /F/.Y DR/VE rvA y a- SVJ MIN.PVTCR,�- t DtST • * • E kVA5, .=O 57Cry'E ` . 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