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HomeMy WebLinkAbout0526 BAXTERS NECK ROAD - Health 526 -Baxter deck Road:: Marstons Mills A= 075-- 007- 0.11 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owners Name informrequired tion is Marstons Mills MA 02648 11-27-12 required for every page. City/Town state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Irnportant:When A. General Information �.���++'�t�trn�lurp�i�i filling out forms ��� �Zla OF• S on the computer. ��•- 9�,��� use only the tab ?• •S''� key to move your 1. Inspector c��;' JAMEScursor-do R, useth return not James D.Sears SEARS :f use the return Name of Inspector % ,k•. key. Capewide LLC Company Name snn SAP 153 Commercial St. Company Address ..Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 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 Trifle 5(310 CMR 15.000).The system: ER Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority LQ.sL 11-28-12 j�lftpector's Date The system inspector shall submit a copy of this inspection report to the Approvih,g Authorr (Boad of Health or DEP) within 30 days of completing this inspection. If the system is ashared sys em oro has a design flow of 10,000 gpd or greater,the inspector and the system owner "shall submit thew 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. ""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. t5ins•11lf 0 dle 5 o seat Ins ort omt:subsurface sewage Dispcsol system•Pegs 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owner's Name information is Marstons Mills MA 02648 11-27-12 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E l always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or`not determined" (Y, N,ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic.tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5tns•11/10 Titin 6 OftM Inspeftri Fomc Sdmfface sewage DIspoW system•Page 2 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owner's Name Information is Marston Mills MA 02W 11-27-12 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑*N ❑ ND(Explain below): I i 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 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 a salt marsh i5itro 11110 Title 5 OfficM Inspection Foam:Subsurface Sewage Disposal System-Papa 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner owner's Name information is Marstons Mills MA 02648 11-27-12 required for every page_ Citylrown State Zip Code Date of lnspediOn B. Certification (cont.) 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 t of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less.than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in awl is less than 6° below invert or available volume is less than %day flow �M Cfl i AiC Wiin9.11110 Tile 5 Oftkial Inspection Farm:Subsurface Sewage DPI System r Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner owner's Name information is' Marstons Mills MA 02648 11 27-12 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal collform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. © ® 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 system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either'yes'or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 fleet of a tributary to a surface drinking water supply El El Area 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 large system has failed.The owner or operator.of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-11M O Tithe 5 Official Inspection Form:Subsurface Sewage deposal System•Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owners Name information is required for every Marstons Mills MA 02648 11-27-12 page Cityfrown state Mp Code Date of InspecHon C. Checklist 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 normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ® this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as WA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? . ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field ('if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)1 D. System Information . Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 islris•11110 Title 5 Official hspadfon Form subsurface sewage Disposal syarem•Page 6 ar 17 IVuv LU 14 Vu...J-rl.J Y• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner owner's Name information is Marstons Mills MA 02648 11-27-12 required for every State lap Cade Date of Inspection page. Cityrrown D. System Information Description: The system is a 2000 Gal H-20 Tank, H-20 D Box and 10-flows__ 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] D Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): 2010-229,000Gal 2011 299.000Gal Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date CommerclaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t51ns 11f10 Title 5 Official InBpection Farts,Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lyn Bernard Owner Owner's Name information is Marstons Mills MA 02648 11-27-12 required for every g� Zip Code Date of Inspection page. City/Town D. System Information (cunt.) Last date of occupancyluse: Date Other(describe below)' General Information Pumping Records: NA Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy, ❑ Shared system (yes or no) (if yes, attach previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the IIA system by.system operator under contract [] Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): i$IrtS•11130 Title 5 OM84 Inspection Form:Subsurrem Sewage cisposm System-Page 8 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Ownees Name information is Marstons Mills MA 02646 11-27-12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1993 Permit # 91 - 108 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 15" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑polyethylene' ❑other(explain) If tank is metal,.list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 2000 Gal Precast H-20 Dimensions: W Sludge depth: t5ins-1Inc 11%5 officW InspemionForm:Subsurface Sewage Disposal System Page 9.ef 17 i•vv cv i�vv.vvN r - Commonwealth of Massachusetts Title 5 Official Inspection Form Imw Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bemard Owner owner's Name information is Marstons Mills MA 02648 11 27-12 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) _Distance from top of sludge to bottom of outlet tee or baffle 3'-1" Scum thickness 2' Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 22° How were dimensions determined? Asbuilt-Plain -Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc_): Tank at 15' below grade w/both covers at 1', Tank is H-20 w/inlet and outlet tee's, No sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle. Date of last pumping: Date t5ins-t t/t0 Title 5 offtwi inspection foci.subsurface sewage otspossi system-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owners Name information is required for very Marstons Mills MA 02648 11-27-12 e page. City/Town. state Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection}(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: ganons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Dace Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No [Sins•11110 Title 5 Dr&iel Inspection Form:Subsurface sewage Disposal System•Page 11 of 17 i vvv �v i�vv.vvN r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owner's Name information is required for every Marstons Mills MA 02648 11-27-'12 page. CityRown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): D Box is 20"x24"-19"below grade, Box is H-20 wl two lines out, Box is dean and solid, No sign of over loading or solid carry over Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order.. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5iM•11110 Trde 5 OWN Inspection Form.SWwalaoe Sewage Disposal Systen-Page 12 of 17 tvvv �v i c.vv.vvr — r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owner's Name information is Marstons Mills MA 02648 11-27-12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number. 1 iJ � ❑ leaching galleries number ❑ leaching trenches number, length: [] leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative 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 ten flows w/4' stone on sides-2'stone on ends, Flows are 30"below grade, Flows are dry and clean, No sign of overloading or solid carry over Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater Inflow ❑ Yes ❑ No Write, �p�D TM 3 ORlcW UfspeWon Form:Subsurface Sewage D13POSO System-Page 13 of t7 i vvv cv i�—.—F, r• • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner. owner's Name information is Marstons Mills MA 02648 11-27-12 required for every page. CRylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Sns•11HO Tlpa 501TWIN Inspection Form:Subagace Sewage Disposer System•Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bemard Owner owners Name information is Marstons Mills MA 02M 11-27-12 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cant.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. M hand-sketch in the area below drawing attached separately 4 1 15ins•11r1D Tn%5 Offidel Inspeaion Form:Subv few Seerage Disposel System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner flwneds Name information is Marstons Mills MA 02648 11-27-12 required for every Me., Cityfrown State Zip Code Date of inspection U. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells V 0 8 Estimated depth tomi h round water: + 9 9 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5-19-88 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. Per design plan 5-1"8 Leaching at 6.8'above G.W.. 4'above ADJ high G.W. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•1 U10 TO 5 ORldal Inspectlon Form:Submtem Sewage Disposal System•Page 16 of 1 T Commonwealth of Massachusetts Title 5 Official Inspection Form MW Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 526 Baxter Neck Rd Property Address Lynn Bernard Owner Owners Name information required for every Marstons Mills MA 02648 11-27-12 page. City/rown State Zip Code Date of Inspection E. Report Completeness Checklist M Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins-11lto Trite 5 01W31 Inspee ion Form:Subsurfeoe Smape DISPMl System-Page 17 of 17 S�rF P Nx 217 _3y4 17 Box ........... �; s� �• nil /-S ASKSMRSW No. ----------- Fee---- -- - - -- ioy BOARD OF HEALTH TOWN OF BARNSTABLE Application jorlVell Congtruction3permit V A lication is he b ma a for a ermit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: P Y P P ------------------ ---------------------- --------------------------------- --- --------------------------- - -------------------------------------------- ,-ation — Address Assessors Map an Parcel Owner Address - -- ------------------------ - o �vx In _staller Driller ss Type of B Iding Dwelling------------------------------------------------------------------ Other - Type of Building --------- No. of Persons----------------------------------------------------- Type of Well -- ---------- - - Capacity----1--1---`' ` ---------------------------- ----- Purpose of Well 01 ----------------------- - 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 Certificate f liance has been issued by the Board of Health. Signed - - - - - -- - ---- -- - �' 9 ---- - ------------ datebr Application Approved By- date Application Disapproved for the following reasons:---------------------------------------------------------------------------------------- - —-- - -—------___----- - ----------------------------------- date -- v Permit No. --- -� ---- _�:L� - - � ------------ Issued------------------------�----�-~-�-�------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS 1.0 �_C,ERT�;, That the Individual Well Constructed (k), Altered ( ), or Repaired ( ) bY------- 1`e-'-L=F-� �_�d -------------------------------------------------------------------------------- —- - —------------------- Installer e ----------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit 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 OF HEALTH TOWN OF BARNSTABLE • Y . A.pplicat ion-for Veil Construct ion Permit b Applic lion is he by ma a for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: jLocation — Address Assessors Map and Parcel Owner Address -------------------------- ---------------- - Installer — Driller ress Type of B ilding Dwelling------------------------------------------------------------- Other - Type of Building ------ No. of Persons------------------------------------------------------- / Q�------------------------------------ Purpose of Well Type of Well--C- o�H/ ---------------------------------- Capacity----f--l'-'-----`�--1---- �' ------------------------ - -- 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 Certificate . f liance has been issued by the Board of Health. --- ---- ----- --- Signed --- --- --- --- ---�'��--�_�___------- date Application Approved By-- - -- - date .:-a Application Disapproved for the following reasons:---`-------------------------------------------------------------------- -- ------------------------------------------------------------------------------------------------------- /�/� date Permit No. -__�'�"�-- "� ''_ ------------ Issued - --- �� r- - ---------- date MqZ*W-M= NCO ' ;3t3Artkc _ _. BOARD OF HEALTH TOWN OF BARNSTABLE -, , � �ertifitate ®f �om�liance fi THIS IS TO CERTY, That the Individual Well Constructed (JC), Altered ( ), or Repaired JJ ' b /leC�_ _�_„�'. sl ---- Y------ ----- - - - - -- -- - - -- - - - - --- Installer at-----Z-0-- 13 A—Y - Ale ee--fie- --i -- -��'�` ��'---------------------------------------- t has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No/r �"- rated -` - -' 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 Vell Con5truct ion Permit Fee-- -- --=--- -- ���/ Ct!, � — ------- ------------------------------------- Permission is hereby granted-�-------- --- -- ------------------------- to Construct (,,�), Alter ( ), or Repair ( ) an Individual Well at: No. -- --- °"7�1 X_f2_ C��! -----12 d--- - Q~ 2. a,6G --------------------------- � Street as show�n�o,ne the application for a Well Construction Permit 9�1- ' If No. —-- - Dated - - Board of Health DATE-- ----'�— -�- -- , i . J- ER �'�ECK r f7�ir�i 1 S 45 L_ E 140f I $ r• r i ' 1 -------- ��s� oc - N 4y •Uo -414 _ --- / f fl Vo � -TO THE BEST OF MY iCNCrlL EDGE taf_ �. PL0T PL .A ur LAND i 1"041404TIGN SHOXtd 0,', THIS PLAN IS AS XT ACTUALLY EXISTS ANO Ct?,y `yy S TO 1 f�7`;,Y(s �� � ti ,� . T,Nt; ZONING REGUL A 7 1'ONS ��� �t7�r1Y OF `A,PNS TAEL E, REGARDING PREPARE,? FGOAVU 04 E. APH. 15. 1996 { H kRL Eb ; I� SA1,41 . + DO, /tst. �{S ,'v j� I,�Jtii _ �►. �f��"7..i lr i` ' � � DATE APR. 15, :yy� SCALi 1 '-`�G FT. r�E�'1. S�i -•-� T � ^ T C r FLC7O0 ZONE NON—HAZARD fit :+yC' t CAPE f' jSL ANDS E,Y, /v Eq NG ©-6. 116C A!A, ,AYPE E MASS y �� �6 TOWN OF BARNSTABLE F— / LOCATION Lo-T' tN }_,� t4E•tc at—A, SEWAGE VILLAGE jpA,c,2S5b til\c— ASSESSOR'S MAP Cz LOT 4A-,M 7-c�(I INSTALLER'S NAME Et PHONE NO. SEPTIC TANK CAPACITY O D O LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WEL OR PUBLIC WATER BUILDER OR OWNER O'er DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No. �/ 63 -ter ,o I All 0 0 ' 1 - P THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H-�E�AQLTH 1.6�I�L f`11..................O F......30&m .`. -e----------------------------------- Appliratiun for Disposal Works Tunitrnrtiun Vamit Application is hereby made for a Permit to Construct (Y,) or Repair ( ) an Individual Sewage Disposal systemat k __ � rztAc--�cs..M� S l_C ti 5Z( .... L ion-Addres ��......M 0-219 n 6A1 IA�LL„ LT �YLIs�"�' •��LU I�R SI�b ............................................................. Owner Address a •...........................� �...5.•• ............•.........._ ............•........................... .............._.._........ -•-•--_....._.....................��y� �er Address d Type of Building Size Lot..—3 ml...Sq. feet U Dwelling—No. of Bedrooms.......... ..............................Expansion Attic (ko Garbage Grinder NO-5 Other—Type of Building No. of persons............................ Showers — Cafeteria a Other fixtures .................................. W Design Flow.......... 5�.rt.� ` .......gallons per person per day. Total daily flow.......... .....................gallons. WSeptic Tank—Liquid capacity.21D00gallons LengthA1_-11'... Width..(a.�-G". Diameter......... Depth_._ _.L_. x Disposal Trench—No. .....V.............. Width....__.4,14....... Total Length---L!(p.......... Total leaching area..52:A----sq. ft. Seepage Pit No--------------------- Diameter.................... De th below inlet..............._.... Total leaching area..................sq. ft. ` Z Other Distribution box (��S Dosing-tank ( Percolation Test Results Performed by.. -�. -l`�y --� ................. Date. '&—IA,9. aTest Pit No. 1...4Z.----minutes per inch Depth of Test Pit__-___�0........ Depth to ground water-----ts_15•-----_- (T, Test Pit No. 2...Z--...minutes per inch Depth of Test Pit......t.0....... Depth to ground water-----7.2........ Description of Soil -� x '. K 4' l 1 L � �..1�`. ...._. 6 U 1 :2=..0`� zf.._. Q2GT--1-4Ayet __1�" �r---��----IL.jY�1s,1�--9'_.�_�?�� ►`� ----------------------------------------------------------------------------------------------------------------------------------------------------•----------........................................ 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 Compl4nce has been issued by the board of health. Signed ........ .......... . ....................��`_ - --------------------------------- .-:---...------.............-- Dac Application Approved BY -----------------------'---i------------ ---- .. D�re- a- �/ Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------- ....... . . . ....................... - --------------------------------------- --------------------------------------- Dace Permit No. ......9- ----- t.o .... - Issued ----- >`.Z©...19--1------------------- ------ \ Dare -_I �'/tk 71 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH vj.1 ..................OF...... ................................... Appliratiun for Dhipasal Works Toustrur#iun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System-at- AXTM....................•-- --------- Lo ion-Ad essr t No �tNCE C.,C 9AL is �n....v�'4" �e ue�zsty� L-' ��! sN Q --------- -----------...................................................... .--•-- ----- ....-----••_... •-•---_.. .- � -. .._._. _........... --....-- ... ----- -- Owner Address W Installer Address — ' Q Type of Building Size Lot..��? _ ...Sq. feet Dwelling—No. of Bedrooms........... .............................Expansion Attic (A() Garbage Grinder (�f Other—Type T e of Building ............... No. of ersons....................._____ Showers — Cafeteria a YP g ------------- P -- ( ) ( ) A4 Other fixtures ............................ . W Design Flow------.... - .----- P ,. y y ,t <.a....................gallons. 'g "t` ....._ gallons per person per day. Total daily flow.............. w � E fF W Septic Tank—Liquid capacity. - allons Length. l.." �..._._ Width. .... ?__. Diameter. ---------- Disposal Depth.5. . .. x Trench—No. .._...I.............. Width......4.4....... Total Length---I.C.(...._...... Total leaching area.. __.__ q._s . ft. Seepage Pit No--------------- --- Diameter.................... Depth below inlet.................... Total leaching area.................. sq. ft. Other Distribution box qe)s Dosin tank (t O _ a aPercolation Test Results Performed by...g� 9 .:-_ ^............................ Date..(--? _.# Test Pit No. I...j(-Z....minutes per inch Depth of Test Pit_____Q.._.__._ Depth to ground water----- -- --------- 44 Test Pit No. 2---Z ....minutes per inch Depth of Test Pit...... .�!...... Depth to ground water...... ...'........ P O Description of Soil--. I `- "F �r..► oe_et T"'Lt !t� / �> 1 t _ a y� g+��j 1 .. �^� $ }l}� V .................................... ��._....�er�.A....�.C��e..4,a1_...... °t�...C+wr/"" I. �.... t�'•!� �__.� ..,� � '. �f 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 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 ................................................ .......................... . .. ...... .. .... ....----------------------------------- Date Application Approved B Date Application Disapproved for the following reasons: ........................................................... ...... ............................................................ ....... ... . . ..............................................................---------...........------------....------.......-----................ ------------------------ -- -- -- . ---------------------------------------- 9 t .... 10 e) e ZO I Date PermitNo. ------- .................................................... Issued .......-- ---. ---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tej......... of ..-' C,............................... k6ex#ifi.ctt#.e of 01-1amplinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X ) or Repaired ( ) Instnlle at ............................��...'K� .. , l^ '�••.... .............A '5M N��.3.. i-°l--t -t S � �.��. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as de cribed in the application for Disposal Works Construction Permit No. mod....`.............. dated ..3.'-Z -.:- .-------.-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. p -------- Inspector ----------------------- ................................................DATE....... ..... ^ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEY........................ ems=# �i��ru��l Turku �un��riun rrnti# Permissionis hereby granted............................•----•-•---•-••--.------..._.....---------.......-----------------.-------------------•--.................---..... to Construct + ,o a air an Individual Sewage Dis; `al stem --------------------...-------------•--- ---••--- ----•--- Street t as shown on the application for Disposal Works Construction Permit No 9I.-{ob... Dated._ 2v.._�................ ---...-•---------------------•-•-----•-------•----------------------------...------------•-----•---.--•-- Board of Health DATE................................................................................ 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