HomeMy WebLinkAbout0127 AMELIA WAY - Health 127 AMELIA WAY, MARSTONS MILLS
A = 148 003 va E
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No.----- - ®� Fee------ ------------��
BOARD OF HEALTH
TOWN OF BARNSTABLE
application ArVell Con5truct ion Permit
Application is hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at:
Location'— Address Assessors Map and Parcel
t/,_- t-')f? /14 O
Ownne /� /—,— Addres — p�4
ba e L 1—a(//C rb. (J }C 6 GD /U GeS G� s+6(Ca O Ca 7 C
_ O
Installer.— Driller — �— Address
Type of Building
Dwelling ----- -- ----- --
Other - Type of Building - No. of Persons-----------------------
Type of Well L-- — — Capacity-------------------- --__
Purpose of Well
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certifica 7,A
mpliance has been issued by the Board of Health..Signe — — A &A`_/— -
date
Application Approved By ----- - -- - -`��
ate
Application Disapproved for the following reason : -------------- ------------ ---
.� — -- — — y�— --- date---—
Permit No. ` -�� — Issued
------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( `'), Altered ( ), or Repaired ( )
by------ ------- ------------- -----------
Installer
at4.2 � _-- --—_— _ -- -- -- —_ ——------
has been installed in accordance with the provisions of the Town of Barnstable B a of HealthPrivate Well Protection
Regulation as described in the application for Well Construction Permit No Dated----- ---------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- - Inspector------------- --------
NO. ---- ----- Fee----- --------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
i Z(ppticat ion for Vell Cootructionpe ntit
Application is hereby made for a.•permit to Construct Alter ( ), or Repair ( )an individual Well at: -
i� It r� , ; 6 •s r� is ----kyd - 3 - - ---
Locatio 'Address,,;,----- ,_. - Assessors Map and Parcel
M/._ /10/�2��So.� JJ) • QMe /�i �v >� �.•(4 /uaoJ6 %
f� 1 Owner ' Addre�
t ✓j� "I—_�� JrO /✓oly _ t(i�J�C:/ 14v4
Installer — driller i -- Address
Type of Building `_ 0A.
-
Dwelling
Other - Type of Building-i o. of Persons----------_______—__—_—__
t
Type of Well �J L — -_ ? Capacity - — - --—---- ---
Purpose of Well
Agreement:
The undersigned agrees to install the aforedescribed individual well in acc dance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned furper, agrees not to
place the well-in-operation until a Certificate-�f j'o`mpliance has been-issued-by�Ehe Board of He th.
t
Sign - —� '-- _—
AVA K�' dat 9
Application Approved -----�Z 'j
date
Application Disapproved for the following reason
date
Permit No. 1= = — Issued---C��-- --- - ----- ---- --------------
date
r -
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ('), Altered ( ), or Repaired ( )
by
Installer
at-- /J o wt 4 G .. ------ — -- -- ----_--___--
has been installed in accordance wi�provisions of the Town of Barnstable 4oarcl of Healt rivate Well Protection
gapplicationf x_-
Regulation as described in the for Well Construction Permit wax
_- Dated---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------- - -- Inspector------ - - ___— ---------_----
BOARD OF HEALTH
TOWN--OF BARNSTABLE
Veil Con5truct ion Permit
No.6--- Wiv Fee-------------
Permission is hereby granted 4A
;\c -------------
to Construct (✓r, Alter ( ), or Repair ( ) an Individual Well
Street
as showmnop t applic tion foa a Well Construction Permit
LA) I nil
No.- -- —_—_ Dated- --` -----------------
DATE -
Board of ealth
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COMMONWEALTH OF MASSACHUSETTS
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EXECUTIVE OFFICE OF ENVIRONMENTAL AIRS g l0
DEPARTMENT OF ENVIRONMENTAL P OfI Eg�' 60�4*hp
ONE WINTER STREET. BOSTON, MA 02108 617-292- 00
�/y (91998
WILLIAM F.WELD 063 MY CORE
Governor Secretary
ARGEO PAUL CELLUCCI AVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 127 Amelia Way Marstons M"'Rddress of Owner: Teresa Gieschen
Date of Inspection: —A—"—/ !�, (If different)
Name of Inspector: WM E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Servi _P
Mailing Address: PO BOX 1089 Cent'ervi 1 1 e MA 02632
Telephone Numberry 5 0 8 7 7 5—A7 7 F, r
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
'1 Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: !�IV 0 Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: . Check B, C, or D:
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.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indi to yes, no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved,by the Board of Health.
(revised 04/25/97) Page 1 of 20
DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep
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ej Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,� CERTIFICATION (continued)
Property Address: 127 Amelia Way, Marstons Mills
Owner: Gie,sdhen
Date of Inspectiofj � }g
�jB)�SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
w 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). Describe observations:
broken pipe(s) are 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) FURTH R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic 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.
1
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has.a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has aseptic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OT ER
(reviled 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 127 Amelia Way, Marstons Mills
Owner: Gieschen
Date of Inspection:
A FAILS:
dicate ei; :er "Yes" or "No" as to each of the following:
ave determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
failure.
Backup of sewage into facility or system component due to an 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 cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the 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] LAGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
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)
The o Iner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
require ents,of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART B
CHECKLIST
Property Address: 127 Amelia Way, Marstons Mills
Owner: Gieschen
Date of Inspection: ^ .a"
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
-L[ _ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least 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.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected 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:
LI/ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
Existing information. Ex. Plan at.B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Page 4 of 10
.v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 127 Amelia Way, Marstons Mills
Owner: Gieschen
Date of Inspection: 4^07-3-19 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: C l b .p.d./bedroom for S.A.S.
Number of bedrooms: `/
Number of current residents: 41
Garbage grinder (yes or no):�p
Laundry connected to system (yes or no):,Z-'3
Seasonal use (yes or no):A—O 1996 171 , 0009
Water meter readings, if available.(last two (2) year usage (gpd):
Sump Pump (yes or no): A4- 1997 - 121 , 000g
Last date of occupancy:
COM RCIAUINDUSTRIAL:
Type of stablishment:
Design flew: gallons/day
Grease trap present: (yes or no)_
Industria Waste Holding Tank present: (yes or no)_
Non-san tary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last ate of occupancy:
OTHE : (Describe)
Last d of occupancy:
GENERAL INFORMATION
PUMPING RECORDS a d source of information:
&- �
System p6imped as part of inspection: (yes or no)L O
If yes, volume pumped: ¢allons
Reason for pumping:
TYPE OFF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any).
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) 7tw d.
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM V
PART C
SYSTEM INFORMATION (continued)
Property Address: 127 Amelia Way, Marstons Mills e
G2eschen
Owner:
Date of Inspection:
BUI ING SEWER:
(Loca on
site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other (explain)
Dist nce from private water supply well or suction line
Di eter
Co ents: (condition of joints, venting, evidence ofleakage, etc.)
SEPTIC TANK: t/
(locate on.site plan)
Depth below grader �
Material of construction: tit:oncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:;
Sludge depth: V—!r y ''
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3-4/'_ ,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:1_
How dimensions were determined: 0
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, d pth of liquid level in relation to outlet invert, structural
integrity evidenV of leakage, et
GRE E TRAP:
(locate on site plan)
Depth low grade:
Materi l of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum t&ickness:
Distaril from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Com nts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
*Property Address: 127 Amelia Way, Marstons Mills
Owner: Gieschen
Date of Inspection: �j' �-907
TIGHT HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(Iota a onOR site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Di ensions:
Ca achy: gallons
De ign flow: gallons/day
Alar level: Alarm in working order_Yes; _ No
Date of previous pumping:
Com ents:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:�—/
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence,of solids carryover, evidence of leakage into or out of box, etc.)
' oR /0 c,
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Com nts:
(note ondition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION (continued)
Property Address: 127 Amelia Way, Marstons Mills
Owner: GiesChe�1
Date of Inspection: /
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:-
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.)
C SPOOLS: _
floc to on site plan)
Num r and configuration:
Depth op of liquid to inlet invert:
Depth QQf solids layer:
Depth df scum layer:
Dimen" rs of cesspool:
Material of construction:
Indicatio of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm I
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate n site plan)
Material of construction: Dimensions:
Depth solids:
Comm ts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(zevieed 04/25/97) Page 8 of 10
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
127 Amelia Way, Marstons -Mills _
Property Address: Gieschen
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
L
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
1.27 Amelia Way, Marstons Mills
P Y
Owner: Gieschen
Date of Inspection:
X
Depth to Groundwater 1 Feet
Please indicate all the method's used to determine High Groundwater Elevation:
(/Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
f
(revised 04/25/97) Page 20 of 10
TOWN OF BARNSTAB-E
LOCATION X-74 1144e �/e SEWAGE # ��� ff
VILLAGE, ��t.,�.s. ����.��.�' 1*1ASSESSOR'S MAP&LOT
_003
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) 940, !Ee/o
NO.OF BEDROOMS
BUILDER OR OWNER
PERMPTDATE: 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
r
M� 3�
�`' �� Al
No._-. . Fmc.... ...... ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dijapmml Workri Tom6trurtion remit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
4
........... ........... ....
......................... ................
Loci' it-Addresso."If.0 I------------------ ----------- 'r, Lot---No.
-------------
L .......
.. ......... ... .... ........ ..... .................c. . ...........................
, �ne,�' I,------------------------------ ------------------
--------------- ----------------------------
------------........... .......
.......... .........
... .... ......................... ..................... ............
Installer Address
Type of Building Size Lot---- Sq. feet
U
Dwelling— No. of Bedro
oms'__...._ Expansion Attic Garbage Grinder
I ig -A/ �_ z--------------------------
Other—Type of Building - 04,1LNo. of persons............................ Showers Cafeteria
PL4 .......... ....
Otherfixtures ----------------------------------------------------------------------------------------------------------------.... ..............................
Design Flow...........-5-25......................gallons per person per day. Total daily flow..............Y/- ----_---------gal lons.
WSeptic Tank—Liquid capaot)/ A.gallons Lengthz/4>....... Width_._._._.... Diameter_--..__.__..- DeptlLy----------
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_..___..............sq. f t.
f1:090 -ft-
Seepage Pit No.-_-.-;i�........... Diameter../_Z.__'*..... Depth below inlet..._.`............ Total leaching area,-C - _.._Z9T.
Z Other Distribution box (L-< Dosing tank ( ) -Percolation Test Results Performed by.Ze0_9F 0' -jq7-.f........ Date,��/Z... ... . ................
Test Pit No. I -minutes per inch Depth of Test Depth to ground water/.. ------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._................__..
..................................................................................j----------------------------------------------------------------------
0 Description of Soil----- .....0.9.-;.. ------
W /911-1, ----------------------------------------------------------------------------
U ........................................................................................................................................................................................................
...................................---------------------------------------------------------------------------------------------------------------------------------------------------------.........
U Nature of Repairs or Alterations—Answer when applicable-------- ......................... -------------------------------------------------------------
................................................................................................................................. ......................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been * ed by th board of health.
Signed ------------1� �� 7
................... ------------------------------------- ........................................
12-p Date
Application,Approved By -------lytw ................................................................. --------------------------------- --------j.—.1...?------
Date
Application Disapproved for the following reasons: ........................................................................................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- .................gg .......................
Date
Permit No. .............. ----------------------- Issued --------------3.....4.).......95...............
Date
------------------------------------------------------ -------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertifirate of Complinurr
TJ IS'D I TO CERTL , Th2-t-the Individual sewage Disposal System constructed ( L/ ) or Repaired
by ------je 0UAf___q ----------------------------------------------- -- ------------------------------------------------------- --------
-------- -_ --------
........ ------ ------------------ ...........................
J� ------ ----
Insrdle
aj��.......7........a_AXX-&---:--hw2b, -----------------------------------------------------------------------------------------------
has been installed in accordance with the prbvisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. 9-57 ._el3l...... - -_---- dated , .....9 ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------ --- -- -- --------------------- Inspector --------------------------_-------------- --------------------------------------------------
No...._ �T..._V�3 ... - Fps..... . ............
THE COMMONWEALTH OF MASSACHUSETTS
_BOARD OF HEALTH
TOWN OF BARNSTABLE
. pphratiou for Diraitil M�- Drk �d�Bt �rl�r tliri Prlltt
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
-1 `�it'f�� /• ------------&/-t�n' ...... Z`T-� ��
Local:^on.-\ddress _ fj�or Lot No. 3"
..... ............. f ............................
.ner �I�GU/` � -------r��-� ci�lr-r-5 ---^_.—'.-_.�f l�✓ 1.<1 /
Installer Address �
U Type of Building Size Lot---- e" �Sq. feet
., Dwelling— No. of Bedrooms.__._..__ ...........................Expansion Attic Garbage Grinder( ) ( )
aOther—Te
yp of Building _ -No. of persons____________________________ Showers(( ) — Cafeteria ( )
dOther fixtures --------------- ----------------------------------------------------------------------- --- ---------
W Design Flow____.___.._. ....:................gallons per person per day. Total daily flow-._---.-----_7-_.--_ .__._.___....__gallons.
WSeptic Tank—Liquid capa6ty_�-�-�.galIons Length_ZC)....... Width__- __r._ Diameter---------------- Depth.- /-_--__--.---
x Disposal Trench—No. .................... Width-------------------- Total Length._---_-__-_------ Total leaching area....................sq. ft.
Seepage Pit No --_---_.-- Diameter../Z----_.-- Depth below inlet----. /........... Total leaching area_1<190:ZSq:-fr
Z Other Distribution box Dosing tank
'-' Percolation Test Results Performed by..< ���-� .._ �r ?--- -�
a - --- - � ---- -------- ---�----Y----
.a Test Pit No. 1.-.-:;:,- ._minutes per inch Depth of Test pit,/- y ----- Depth to ground water_ ?_ ..........
(14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
9 ------------------------ -- ......................................... .......-•---......................................................................
0 Description of Soil---- . c�= " 'z' ���' ?-^`� ---------------------------------------------------------••------•-----
l'
U ----
------------------------------------------------------------------------------------------------------------------------------------------------------------------ ..............-....................
U Nature of Repairs or Alterations—Answer when applicable.....................................___.............................._........__...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health. �.
Signed - ----------------------- --------------------------------------
,p Dare
Application,Approved BY .a1w�.. ............................................................... - ..:. ............r..Date
Application Disapproved for the following rearons: . - - . . ..........._.. ....-_............................. .. ........................
----------------------------------------------------------------------------------------------------------- ---------- --- ------------------------------------------------ -------- ..............................
Date
Permit No- -------------- 5.....y_s. ..------ ----- ---- Issued ................ .. ..1-2...'.... -- ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
y
BOARD OF HEALTH
TOWN OF BARNSTABLE �
UErti�� fi>rate of ('VTvrayfianre
THIS IS TO CERTIFfY, Thai-the Individual Sewage Disposal System constructed ( V ) or Repaired ( )
by - ............;y.-
------------------. <--------Gt !'.....C76------------------- ----------------------------------------------------------------------------------------------------------
ncrJlrc
at .. ........... .....- t- .............. / /.. - .� 1.....✓-'�--.... ............F-------------- ---------------------------------- ---------
has been installed in accordance with the pro visions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .�' :..y3-Y----_--------------- dated ---1_-./.7'._p-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................................. ----- -- .........._-------- ------.... Inspector ---------------------------------- --------------------
-
f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH-,
TOWN OF BARNSTABLE
No........g.....�/3 FEE /DU........
RaVviial Workii Tom trz#uart rruti
�— c� ��
Permission is hereby granted..... -----...---------�--------------------/-----=---•--------------------...----•--•----•------...._........
to Construct or Repair ( ) an Individual Sewage Disposal .System
atNo.-�r!- ' �._.._. t�0_!& �t It/lu f °7M `. ----------------------------------------------------------------•-------.-.---
Street 22�� A
as shown on the application for + isposal Works Constructio�n�r rlit No. _�' . _ DateZO�?�....1 7- ...Jr-�
IBoard of HetlthJ
DATE -----------------
I-i
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
TEST HOLE LOG
TEST BY: WELLER&ASSOC.
WITNESS: CzD
PERC RATE:_._
�4 3y S
ej
• ' \ Z'!j• � } c, w .Co.133Ci S � Z:., ,� •o�
Ae to 1
9� 3v.3 ,
�
�y
�\
--� --- - i- DESIGN DATA
DAILY FLOW: Cy)
SEPTIC TANK �:_yYc� .
USE: /Soo
LEACHING FACILITY:
i USE:_L�0_. yX L'G,P 4-- . -off 5T �.
�. CAPACITY:
SIDEWALL:
BOTTOM: 3,/
TOTAL: j'jo,/xc'• `JBo.Z'���
N � t
PIPE TO BE LAID 2"LAYER OF 3/8"PEASTONE
LEVEL FOR 2' OUT OF OVER 3/4"-1 1/2" WASHED
DISTRIBUTION BOX STONE ALL AROUND
TOP OF FOUND.
@EL. y9oo
/ 10" 14"
yY5�; �
ALL PIPE TO BE 4"DIA.SCH 40 PVC 13,"
RAISE ALL APPLICABLE MANHOLB '/Z
COVERS TO WITHIN 6" OF FINISH
GRADE
THIS SYSTEM IS NOT DESIGNED FOR
THE USE OF A GARBAGE DISPOSAL
1
SEWAGE SYSTEM PROFILE
SCALE: 1"=10'
r.., r2n'1iyPl�llel�:9a,
` v1 GENERAL NOTES
" 1. CONTRACTOR TO BE RESPONSIBLE FOR THE
SITE-SEWAGE PLAN, LOCATION OF ALL UTILITIES,ABOVE AND
FOR
UNDER GROUND,PRIOR TO ANY CONSTRUCTION
OR EXCAVATION.
2. INSTALLATION OF SEPTIC SYSTEM TO BE IN
PREPARED FOR COMPLIANCE WITH 310 CMR 15.00: TITLE V.-.
�tH OF y� 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY
T Ps LINE DETERMINATION. i
SCALE::AST o DATE:
No,J: ;
,
WELLER & ASSOCIATES P. O. BOX 119 YARMOUTHPORT, MA. 02675
(508) 362-8131 AP '?gVED BY: