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HomeMy WebLinkAbout0025 AGAWAM ROAD - Health 25 Agawam Road Marstons Mills P A = 043 007016 J 1 TOWN OF BARNSTABLE s LOCATION o2S 4f AW A /y SEWAGE # VILLAGE ' /j'1 L S ASSESSOR'S MAP & LOT 6yf-do9 /''S"O£c DIS- -ER'S NAME&PHONE NO. �� ��9 k rG .Sa 8• 9 9 s-;�i r— SEPTIC TANK CAPACITY � ��S�£ c T T x— LEACHING FACILITY: (type) (size) NO. OF BEDROOMS .�BUILDER'OR OWNER PERMIT DATE: _-�G@M=WE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Y Private Water Supply Well and Leaching Facility (If any wells exist r 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 `F;Furnished by l N r �6 0 9 o � r COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m + d DEPARTMENT OF ENVIRONMENTAL PROTECTION A f �C MAP 350 MAIN STREET PARCEL , WEST YARMOUTH,MA 508-775-2800 LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 043 PAR 007 Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner's Name: SEARS,CHRISTINE RECEIVED Owner's Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Date of Inspection MARCH 4,2004 MAR 1 5 2004 Name of Inspector: (please print) JAMES D. SEARS TOWN OF BARNSTABLE Company Name: A&B Canco HEALTH DEPT. Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ./ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3 The system inspector shall su mit 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to detennine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SLTSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in leaching is less than 6"below invert or available volume is less than'/z 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have detennined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received nonnal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? J Were as built plans of the system obtained and examined?(If they were not available note as N/A) J Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? J Were all system components,excluding the SAS,located on site? J Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing infonmation. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 5 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002 66,000/2003 36,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 2002 Was system pumped as part of the inspection(yes or no): NO If yes;volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM J Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1999 PERMIT#99-403 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 BUILDING SEWER(locate on site plan): If Depth below grade: 18" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 24" Material of construction: ./ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: F, Distance from top of sludge to the bottom of outlet tee or baffle: 29" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.OUTLET BAFFLE.TANK AND COVERS 24"BELOW GRADE.NO SIGN OF LEAKAGE OR OVERLOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of 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.): Title 5 Inspection Form 6/15/2000 7 i Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 TIGHT or HOLiDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ./ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 3' BELOW GRADE.TWO LINES OUT.BOX IS CLEAN AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2 leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO 500 GALLON DRYWELLS.LEACHING IS 5'BELOW GRADE WITH 8"WATER.NO HIGH STAIN LINE.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 AGAWAM ROAD MARSTONS MILLS,MA 02648 Owner: SEARS,CHRISTINE Date of Inspection: MARCH 4,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i i i f Title 5 Inspection Form 6/15/2000 10 Page 1 1 of I 1 OFFICIAL INSPECTION FORM—1NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 AGAWAM ROAD MARSTONS MILLS.MA 02648 Owner: SEARS,CHR!STiNEL Date of Inspection: MARCH 4,2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 47.2 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation .Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS WELL DATA WELL 47.2 ZONE C 1.9 a i v 7.� 1 i 1 f I Title 5 Inspection Form 6/15/2000 11 f - _ TOWN OF BARNSTABLE LOCATION SEWAGE # 99-S'o3 VILLAGE/��s ran !'lily/lS ASSESSOR'S MAP & LOT 5 -00 INSTALLER'S NAME&PHONE NO. `17-7-O3 Y9 Jo.s G D.c ���✓ S SEPTIC TANK CAPACITY /6ao LEACHING FACILITY: (type) ��size) NO. OF BEDROOMS 3 BUILDER OR OWNER 2c,* ea PERMITDATE: 2 1 7 9 f COMPLIANCE DATE: .7 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 fac_ili�ty) Feet Furnished by . A o� yL._ TOWN OF BARNSTABLE I LOCATION _&J— SEWAGE # .99-S'o3 VILLAGE f Vi4i-s rdh lLr,114 ASSESSOR'S MAPn& LOT 0 5' -00 INSTALLER'S NAME&PHONE NO.-S'77-03 Ye Jos-C�G� d/{ �s�.na�5' SEPTIC TANK CAPACITY /bd o LEACHING FACILITY: (type)2-SDO 6m/ 0~ —W—lil57size) NO.OF BEDROOMS 3 BUILDER OR OWNER 11-m ur;g .(Zr-d pa a PERMTTDATE: 7 - 7 — 9 f COMPLIANCE DATE: 7 — 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 n� Y� 3 3 � rf ys9 c�/,vlli! No. — 3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Digozar *pgtem Construction Permit Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �, ly m ul,44 /2 Owner's Name,Address and Tel.No. Assessor's Map/Map/Parcelopsra/�s ^//S 4 oarI-e Orvgo 0-Y-1 007 016 -e Installer's Name,Address,and Tel.No. Z/`I`�— O 3�9 Designer's Name,Address and Tel.No. So Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when pplicable) ��"1d// 2-rao 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 thi Board 9f Hea h. Signed r, Date 7— 99 Application Approved by A-4 Date�7 Application Disapproved for the following reasons Permit No. / ? Yo3 Date Issued i _ _ pp u •f c y� t //— ! O 3 �'""" ..� Fee �-- No.�T � e — (/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS (pplication for Migonl *pgtem Construction Permit Application for a Permit to Construct((Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �j Ay14 wdgvJ 47 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Iy1 OOSSPO,75 f?'"11.; 4oa/rl-e 49'r,4go 0Y:1 007O/(> Installer's Name,Address,and Tel.No. 4/`7 1— 0 3W f Designer's Name,Address and Tel.No. r^ vlos,e ph 64, CA2eA'0?s ✓oscp4 a" /3,0^,aS Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date ' Title `Size of Septic Tank / Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer wh plicable) - 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 th' Board 9f Hea th. Signed I P Date 7 Application Approved by �..w._ 1`�,c. Date "7_ 7 rI Application Disapproved for the following reasons Permit No. / I'. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( C.)-Repaired( )Upgraded( ) Abandoned( )by J a at 1 1424 UIAO 4 geln has been constructed in accordance with the provisions of itle 5 and the for Disposal System Construction Permit No. 7— YjQ dated Installer Designer .�s..-� The issuance of this p rnutt s-all not be construed as a guarantee that the s st/e ww I function a desigQed. Date t�� t� �� Inspector �/ ---------------------------------------- No. / �3 ©y�j 00-7 016 Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS xi!5pont *patent Construction Permit Permission is hereby granted to'Construct( p'air( )Upgrade( )Abandon( ) System located at S- r' �GJs�r�ra�-is "l, /�s and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. ' Date: -7 - 7 Approved by � � f i 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L ,&,-,P hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 2, meets all of the following criteria: �e failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. e--The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. kThere are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system ere is no increase in flow and/or change in use proposed There are no variances requested or needed. e bottom of the.proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface evauon(using GIS information) f�D B) G.W. Elevation +the MAX. High G.W. Adjustment . = CJ DIFFERENCE BETWEEN A and B SIGNED DATE: 7^S Q F i [Sketch proposed plan of system on back]. q:health folder:cert o �z F err-icy Ord �15-11 ,ggAp '00? � v�e TOWN OF BARNSTABLE Q(�AwaM �d LOCATION SEWAGE # VILLAGE „Marsrpn� M,IJ S ASSESSOR'S MAP & LOT q3-y2. INSTALLER'S NAME & PHONE NO. S: gp- ,c 5 4cA-V?t/q SEPTIC TANK CAPACITY Lp00 C:(Al , LEACHING FACILITY:(type) PA p r s-r Q (size) 600 GAl ' NO. OF BEDROOMS.2PPJ"'"" .L OR PUBLIC WATE �L?,°BUILDER OR OWNER I'�C�C('nr� l ynnr, l�l P S�aY1 DATE PERMIT ISSUED: DATE ..COMPLIANCE ISSUED: S} 1 VARIANCE GRANTED: Yes No ,L/' ai, ,*;" �, ,. as R \:� ..% I J w L _ 411 t assEssoes W 110: 4 ?rq � SYST PARCEL N0: ;� ALLEfar THE COMMONWEALTH OF MASSACHUSETTS WITH TITLE 5 BOAR® OF HEALTH 11 VIRONMENTALCODE �n 7 /mot.. . ..:���C� `(Z)VIN REGIILATION.S ApplirFa#inn for BiupnuFai Works Tonstrurtiun Prrmit Application is here,}ay made f a Permit to Cons u ( ) or Repair ( ) an Individual Sewage Disposal System at: 1 CA LO O- ` ,<0T o20 ...............`._._...... ...-• e - -- - -------•••--- l , ..---............. L ation-Addr ss -------- or o, ...................... "` Ownez Address . a 17h�iV �igC' / -----••------------------•------•-------•- -•----......--...-•------•---•---.......-----.....------•••---•-•-----•----•------•--•-----.•..._. Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms......��...............................Expansion Attic (✓f Garbage Grinder Wo) a Other—Type of Building a YP g -•-------•-------•---------- No. of persons..........:................. Showers ( ) — Cafeteria ( ) Otherfixtures ...................••--••-•••---- • -••------•-.......--•--••... ---------------------------------- W Design Flow_S-.5._-5 ..... .............gallons per person per day. Total daily flow..............??z(n... .............. WSeptic Tank—Liquid capacityZ gallons Lengthof.-`I..... Width..%414...... Diameter________________ Depth....`/...-_.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area______----__ ------sq. ft. Seepage Pit No.4'.5) Diameter.._... ..... Depth below inlet.................:.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by. `7�!?F/............................................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._�0_...._._-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................... 9 -••••-•••--•••-----------------•-••-•••------........-•---••-•------......------.....----•-•---•---•......................................................... x Description of Soil.../Lll �/l/j V .....•-••••••.....-•-------•--•--••••••••----••-••----------••-••--•-•••.----••--•-••------••••--••......------•...-•-••--••--•••----•-•••-•-•-•---•---...--••-•....-•-••-•---•-••-••......._.•---....._ W -•••--------------•-••--•••• -----...•••••--•--••---••.......-----••••.....•-----------••------•••-----••••--•.._....••-•---••---.._..........•---•------......... U Nature of Repairs or Alterations—Answer when applicable-----------------•_________----__-___--_..____-_-_----_-_--_____--....................... ._..;. -•---------•--•-•-----•----......-••---•--------------••----•------•-----•-------------•---------•-•-•-•-----------------........--...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disp sal System in accordance with the provisions of ii i Ll 5 of the State Sanitary Code— The u urther grees not to place the system in operation until a Certificate of Compliance has been is 12 Signe • •...�,. . - 7 ApplicationApproved By........................••-- ...•-•------••••-•--•---•....----•••..........._•.................. .....C.2. .Z ---• Date Application Disapproved for the f ollowi g reasons:--••--------•--•--•-•--••--•-----•----------•-•........................ ..................................... ---•----•--------------••--•--•-•------•--•-••--••----•-----•-------••----••--•-•-------•----••-•--•...--••••••--•--•--------•••-...--------•••--•---•-••••-----•-•-••••------•••---....••••----------•- Date Permit No.----��......�.-�-��'--••--- Issued-........................................................ Date J i No.... .... 10 ----3 Fps.. .5.[............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -----_....�C'.. (�//1 ..--... .�i�a Appliratinn for Disposal Works Tnnstrurtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: l e' T 'o (✓4///lVS/ o W woe i_. ................__.............................................................................. --...-----•----------------•-•-------------------------------------------------------------------- L cation-Address or t No. ... r .... .................... Owner Address . Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P 1 Other fixt1ges ----------------------•-•----.... . Design Flow_�v ..... ...........gallons per person per day. Total daily flow............._ ..` ....................gallons. W . %oO -� Gd Septic Tank—Llquld capacity__.._..:____gallons Length�.....1..... Width._�..6....... Diameter________________ Depth....-/....... Disposal Trench—N'o. ................... 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 ( ) 0 4 Percolation Test Results Performed 1.............................................. Date........................................ ,14a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.._ .......__. (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_______..__-_-_.-.______ a 0 Description of Soil ...... � `��--------�.......y�---•--.......-•--------••-------------------------------- --. . .............................................. - x W ----•------------------------•------------•-------------------.....---------••---------------••--------------------------•----•-••------•-------•-------•---•-------------------•--•----•---------..._. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•--------------------------------------------------•-------------------------•--•-•--......-----•---...------------------------------------------------------------------...................... Agreement: The undersigned agrees to install the aforedescribed Individual S;;Zthe's�- Diosal System in accordance with the provisions of'T'LE t p 5 of the State Sanitary Code—The i grees not to place the system in operation until a Certificate of Compliance ha- een I Signed - - ------------------------------------------------------------------------ --------D------------------ D Application Approved BY = ti .---•---------•---------•-•--......-- •---• r Date Application Disapproved for the f ollowi g reasons-------------•---..._...--------•------------•-•--------•---------------------------------....-•••--•------_...-- ............•-------------------•--------....------------•-•-•••-•--••...---•-•----------------........-------------•••--•••---•--•----------•----------------•---------------------------•-•----------- Date PermitNo----------------------=....................I...---------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c /1 .........OR.,��.;�'��, �.�f�........................... TntifirFatr of Tomplianrr _ w THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( } by .................:.. L DT - �' Tom— ............................................................................ ..... Installer %!l-•----.._.. �w4a ....---.._. . �_ _ l � has been installed in accordance with the provisions of "'fim�r' of The State Sanitary Code as desc in the application for Disposal Works Construction Permit Nb� 3_-- 41.J............... dated....6-----7 _ -___ -------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... ' ............................................. Inspector - _Yr=- f 43- 00-7 -6 -?- THE COMMONWEALTH OF MASSACHUSETTS c BOARD OF HEALTH �I /G )ax /............OF,���� Q- ... ..:._..•............................. N ..................... . FEE2 .---f..!.0 .......... Disposal 10orkii Taanstrurtion Vrrmit Permission is hereby granted..02:'_-)_!,/�?,�..... e '7;,�_.....__�'_.._ w'�__.. ✓� _� � �.C._........._ to Construct k ) or Repair ( ) an Individual Sewage Disposal System at No.- /-4-x---...' .......A/i'u-_<ZZ 4-A--------- �� as shown on the applicati n for Disposal Works Construction Per NN7.___�..1_`!._ Dated;._. .__._.G..-..-.....!�................ .................. ._--P•_ - _ _-_�� ............................... -. .F / Board of Health' DATE --•-----------------�..��,?.!...:-.--_----•-------- / FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ' S 38'36 ` 90 21 � U-1) 2QN J Qj —�° T zi G� 1 d , 1 \, L� ti� 0,Oo JP�COi `�i R-3 � - -ET,,✓ , I,� ZX/ST/NG ~CDN70UR /1 hI�• O PRoPOSFD.._co,vTpUQ ,'G,,.�, Pam` o SCALE : ®ATE•' � AJ It _ SHEET OF Z I _EL.T/4... TOP OF FOUNDATION ENG ?ETE COVER CONCRETE COVERS / •. CQ 40.0 r,A ?0.0 EC. So.o nnmr_,r MAX 4' AS IRON 12"MAX. OR SCHEDULE 40 4''SCHEDULE 40 PV.C.(ONLY), P.V.C. PIPE 1 PIPE - MIN. (EACH P67 PRECAS PITCH I/4"PER.FT PITCH 1/4"PER.FT. � IEACNIt. i < PIT OR o'• �I RT INVERT % • w EOUIV RT INVE •:'• 0 G DI ST. EL 57 :�. SEPTIC TANK ' EL.8.7. �. .. EL. ...ZY.. ' : _ • ' Box .� �� INVERT GAL. I INVERT rrj w w b WASHE( EL$. .. LL• 0 E • `�' •E 1 �•— /o ' DIA A. e' 'PROFILE OF A10 GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE S O L LOG WITNESSED BY :. � BOARD OF HEALTH 8�/tfb 'TIME . . .. . . . . .. . DATE .. �. . . , - R TIJ TEST HOLE 2 S- Ti'tfDr3� ENGINEER TEST HOLE i - - ELEV.y�x�. . . . . ELEV. .. .. . . . . . . /�Vtl. 4 (/r}Tio�/ DESIGN DATA NUMDER OF DEDROOMS . TOTAL ESTIMATED FLOW 33fl. . . . GALLONS/DAY BOTTOM LEACHI tIG AREA 7 D. . . . SO.'FT. /PIT SIDE LEACHING AREA 40.5 SO.FT./ PIT '. GARHAGE DISPOSAL . . !✓�• - •(50% AREA INCREASE) TOTAL LEACHING AREA J �.7 • SOFT 3-�i� llE� ant/ PERCOLATION RATE .��.SS Z• . . . MIN INCH LEACHING AREA PER PERCOLATION RATE . .. SO.FT. !'!..WATER ENCOUNTERED NUMDER OF LEtC ING PITS . . z�R s 7? PD. .�34 � APPROVED . . BOARD OF HEALTH 7,Z7 S. DATE. 7A ' AGENT OR .INSPECTORI 12F ATF- NAL Shy, gel 1A1,0,-A oR io FT Al 19.1L 17,47, ,✓o Tv �N rC No. 814 _ t BOA•,, �C•. t r PETITIONER : w"40h,:i < fl_f9A` h -z t.