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HomeMy WebLinkAbout0076 BLACKTHORN ROAD - Health 76 Blackthorn Road Marstons Mills P A = 046 070 r � Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills 1/ MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information G3 filling out forms I 03 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. Excavation Company � Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S14595 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 Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 'j 5/1/1 5 Inspector's Signa ure Date -The,System inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)wit-iin 30 days of completing this inspection. If the system is a shared system or has a design flow of ',0,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal S t •Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E/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 meal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits sut:stantial 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): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): 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 t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection 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 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 ❑ ® 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 cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 16,000 gpd. For large systems, ycu 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 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following nave 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? . ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(loca_e on site plan): Depth below grade: 1 1/2"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working with order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order. No sign of back-up. Liquid level equal with outlet invert. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..''- 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town 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 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.): At time of inspection d-box appears to be in working order with no sign of deterioration or carryover. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (2)6x6 ❑ leaching chambers number: ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Water level in pit# 1 4 1/2' below invert. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 76 Blackthorn Lane Property Address George Norris Owner Owners Name information is required for every Marstons Mills MA 02648 5/1/15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately i 2 A � 3 A1} AS - LA ` 0 —B2 - 3Dt _B3 q(a 5 5 5 t t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >20' 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: 1999 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: rear of dwelling drops off over 20' within 150' of septic Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , ' 76 Blackthorn Lane Property Address George Norris Owner Owner's Name information is required for every Marstons Mills MA 02648 5/1/15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCA'IiON 7I� EAcl-1 .: SEWAGE # VILLAGE f l�� cL�� ASSESSOR'S MAP & LOT 0-70 INS7 ALLER'S NAME dt PHONE NO. SEPTIC TANK CAPAC= ( 0 d 0�e j LEACHING FACILrN: (type) (size) I C) � NO.OF BEDROOMS BUILDER OR OWNER PERM)=FDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table �U t Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) W 1 Feet Edge of Wetland and Leaching Facility(If anyi wetlands exist within 300 feet of le hi facility) ~ lr Feet Furnished by _ C�LI� 0-76 , ` L � A3 -3b Aq-5s o B�, SS` o Q y DS- 55, 5 TOWN OF BARNSTABLE LOCATION ]L_ �� SEWAGE # /\3 VILL.AGEA 1� S , ASSESSOR'S MAP & LOTOW —070 INSTALLER'S NAME di PHONE NO.QP( ow � ►a�t�i e 101"0.3117 SEPTIC TANK CAPACITY f B � LEACHING FACILITY:(type) ` �,` (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER' �W� •NS v� ' D?LTE PERMIT ISSUED: Y \3 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No A/ . • 3 �' 1 " � ' ti �f , + � � `. � -- 0 No.. .1.�1.1..... F .. O`..�... THE COMMONWEALTH OF MASSACHUSETTS ll r BOARD OF HEALTH Barnstab+G t.�r:.;�=t grit+ort Ue�,artment TOWN OF BARNSTABLE rgned W1 IffTWt Ui�5pwial Works C outitrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location- Address or Ipt N ..............:�_�._.�-'-� �y„�.��s�L. �'-'-------'��-•-••-- l`� �= rw: �2�-^ -- O�.-ncr dress Installer Address UType of Building IsSize Lot...........................S q. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 04 Other—Type of Building ...............:............ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow..............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench--No. .................... Width-------------------- -rotal Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......._.................................................................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........._............. 04 •---•----•-•...... ...............••---•--••------•----•-•-•-••--------..__.._..._•--------........_......................................................... Descriptionof Soil.. '-----------•--------------------------------------------------------------------------------------•-•---.-__-_--__-------_-- V ...-•--•----•-•-••••----•----------•--....--•---•-------••-•-----------•-------•-----------------•----------•---------•----•---•-----•-••--•........................................................... UW -•--••-----------------------------•-----------•------------------------------------•-----•------------------------------------------- ---------------•---•--•-----••••-••---•------•------_._.. Nature of Repairs or Alterations— sw when applicable.......... _�—``............... �V-!�._..___._.._-_.._.. Q©C9 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 Com -a ce ha been issued by the board of health. c� --- ...................... .. .._..... � 3 r Signed ` ^ .............. Application Approved By ........... c.Yw,J.... ..c...r,^�,� ....q... . .......... .... Due Application Disapproved for the following reasons: . .. . ...................... ............................................................ .r.a/q...... " 1-3 Dw Permit No. ....Gf--3-------/.7/................................... Issued .............'Y.7.;q!T— ^7... . Dare ' 4�._ NO. IIqq�� .g.??-&.... Fps..` ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �rliration for DbjV iul lVnrk.6 Cnnn,strur#inn Ilrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....... ........... �°---��� � �.. .--•-��----•--_.... .----•------•--.....--�-`-�----------- . ------------------------------------ Location--Address p or Lot\ No.h� i!. ..� =S C�-�'.............. --- �• ...-�- ===�1.............a :k Address (- Instalter Address UType of Building -•� Size Lot...........................S q. feet a Dwelling— No. of Bedrooms._-_-_--_-_-J-------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ----------------- ---------------------------------------------------------------------- -------------•-••--•-•••••-•'-............•-•.............•-- W Design Flow............................................gallons per person per day. Total daily flow.........._........._........ ...............gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... .rotal Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I................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..............:......... ........•----••---.-----•................................................................'-'-...............-•-----•-----------•---.......................... 0 =Description of Soil........ _ .._. a.��. -- ............................................................................................................................ V .....•••••-••-•••-•••---•-••-........•••--•---•------...-'-••••----•------•-----•-----••......---•-----•----•--••••••--••---•••••--"--------••-•••------••----•-••-•----•------'.....................••- W --••••• -••-----------•---••-••--------•-••--••••-----------------------------•---•••-•-•-----••--------------•--•••---------•--. --•••----------••-•••••--•--••---•----•---•--•••••-•"----..._..... U Nature of Repairs or Alterations— Iswe when applicable......... �-...`.............. _:e.w..................... ...........................1. 0°•P....... - = --L...........--........................................................................................................ 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 ComphThce has been issued by the board of health. Signed .................. a ce Application Approved B ............................. ....4_.._.....I.). .................. PP PP y ...........�c`> ._.. -"'""" D�e Application Disapproved for the following reasons: ....... .... ............................ ................................ .............._._.-. ��� � 7 � Permit No. .... 3..... /.?/..... .............. Issued ".. ue S.. S............................................. ........Dare... .-- Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Ertifirate of fiv-11'amplianre THIS-IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (v ) at �.a .. --------------................... -- --------- - t._.�. . ....-----ram. Incr.Jlcr _............. "1 ... ._.... ...a c_ ...-- .............. ...............--'------------------------ ._...,.._.1M... �.S- `,..... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _........_....._............................ dated .............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE . .. ._._....... .... ...... .. Inspector ------J,J.-1-.. ..... ............................................................... V 1 T / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ TOWN OF BARNSTABLE FEE. Q,e� 3---•-•'----•------ Diipnoal nrkii Tnntrnrtinn Prrntit ff� , ._._._ .l... _-r._.�.. �- ................. Permission is hereby granted . _��_---.-Y`-s-•-... 5:..--•---............_..----..... to Construct ( ) or Repair y adivirlual Sewage Disposal System at Street as shown on the application for Disposal Works Construction Permit a No._� � . - -........� � �.._ _~a . ............................ -----.........----Board of Health DATE......................................... -------------------------------•---- FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS LOCATION 5EW&r-4E PERMIT UO. V`ILLpGE • �.��-��� .�`��-� - - )lJ R STQLLER•S W&IJAE ADDRESS 5 ILDER S Q &VAF- ADDRESS DtITE PERNA T ISSUED DATE COKAPLI &&ICE ISSUED ; -® �� i`Ro HT L e �.� No ...... Fas..../� ...z''J.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH/ DGJ�cf�.-._...------.OF...................... Appliration -fur Diovv at Workii Tonotrurtiou Prrutit ,Application is hereby made for a Permit to Construct ( kil-0*7 Repair .( ) an Individual Sewage Disposal System a •- � // // == =Eocat,on-Address r 0 o" r Lot No. a ---� 42.----------------- - --------------------------- ------•..... (�J�i?rlr W Ow J�. Address Installer Address d Type of Building Size Lot-C?`�- aG----Sq. feet U oms-.--__---4Dwelling—No. of Bedro .........................Expansion Att'. (YS" Garbage Grinder ( ) Other—Type of Building ____________________________ No. of person s........... .............. Showers ( ) — Cafeteria ( ) dOther fixtures ----- ---------•-----------------------------•--------------•----------------------------------------------------------------------------------.--•--- W Design Flow_______________1-V--__.d------------------gallons per person per day. Total daily flow......... 2-0.._________..........gallons. WSeptic Tank—Liquid capacity/� ..gallons Length................ Width---------------- Diameter.........-...... Depth.--._.--_----.-. x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No-------/--------... Diameter..."4f._X®.__.. Depth below inlet.................... Total leaching area.--_.-..-.---...__sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..-.__---__._-.----_---- G� Test Pit No. 2................minutes per inch Depth of Test 'Pit-_-__-________--_-- Depth to ground water-_-_-._-__-.___-.--_-_- P4 .----- ....................................................................................................... 0 Description of Soil----------- - W ----------•- •------------- -----• •----•-----•-----•-----------............---•---•--------------------------•-----•----•-•---•••------------ ----•------------- --------------------- h"It- 'd, ...... U Nature of Repairs or Alterations—Answer when applicable.----------���Q---_._-�'� __-._.._---�' [L -- ----•-----------------------------------------------•----------------------------•---------------------------------------------------------------------------------------•----------------------------­ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued board of health. C Signed -- ------ o f/ �"_ ApplicationApproved By---�9 % =--------•-•-•--------•-----------------------•-•----•--•----------•-------- ..._....__��t A"<_2� Date Application Disapproved for the f ol,'owing reasons:-----•-------------•---------_....................._............................._........ _-______'--•-- ----•-•---•---------------•-•----------------------------------•--------------•---------••---------------------------•-----------------------------------•--------------------------------------------- Date Permit No. y-4_ -•-•••---'----....................... Issued.------.. -- s- 7'`1................. Date aT N9.......414.5 ...... FRiz .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . ........... ..OF....... '11_� ............ Appliration for 43hiposat lVorkii Tomitrurtion Application is hereby made for a Permit to Construct (k<�or Repair Individual Sewage Disposal Sys�tema . ................................................. --- ----------------------------------------—......................................... ........................................ Loc4ion-Address or Lot No. ..................................................... ----------------_-.................. .................................................. Address 0...................................2 ----------------........................ ...----------------------- ................................................................. Installer Address Type of Building Size Lot .....Sq. feet U Dwelling—No. of Bedrooms.---_-_ e-7—_Expansion Garbage Grinder---------------------------------- aSOther—Type of Building -----------_--------------- No. of person .... ..... ........ Showers Cafeteria PL4Other fixtures ------------------------------------------------------------------------------ ---------------------------------------------------------------------- Design Flow..............�5........._6--------------------gallons per person per day. Total daily flow-------- -----__-_______._.--..__gallons. 9 Septic Tank—Liquid capacit/�9--0 ----gallons Length________________ Width.--_-._-_------ Diameter__.--_..-..-_--- Depth...--------.._.. Disposal Trench—No_-------------------- `Width..........._.....___ Total Length_.__._..._.......... Total leaching area--------_----------sq. ft. Seepage Pit No...../------------ Diameter.4i�_!?------ Depth below inlet.................... Total leaching area------- ----------sq. i.t. Other Distribution box (_� Dosing tank ( ) Percolation Test Results Performed by----------------------------------------------------------............... Date--------------------------------------- a Test Pit No. 1................minutes.per inch Depth of Test Pit-.-________________ Depth to ground water....---.._------_---___. (14 Test Pit No. 2................minutes per inch Depth of Test Pit..___............... Depth to ground water-._--.---_-.-_-.----............................................................................................................................................-------------------- 0 Description of Soil-------------I/---------_------------ ---------- --------------------, ------------------------------------ ---------------------------------------------- -------------------------------------­..........------------------------------------------------------------------ -------------------------------------------------------;�/------------------------ ------------------------------- --------- -----fit-- - 1.-440, to r:--- --------------------------------------U_,Ox/�46jt4t-------------T A.1.4 re o. ------------------------- C U Nature of Repairs or Alterations—Answer when applicable----------Z - ----------------- ------I------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue WjVe 6oard,of hn Ith Signed .•............................ _f..... .ed-------- -------- -------------------- Date Application Approved By ------------ ........................................_- --------------- ................ I — Date Application Disapproved for the following reasons:................................................................................................................ .................................. ----------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- Date Permit No... ...................................... Issued........ --zq ----- . ................... Date A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............0 F..........o6!�#o. A5 r,6Pk4!C V". .................. Trrfifirate of Tlimpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.........If.d-----&A-r--------O..OA-------­----I................... ....................................................................................................... Installer A, at------------ ------------------------------------------------------------------------------------------------- has been installed in accorckmg.with the provisiG.u4,qf Article ;,Kj. of The State Sanitary Code as described in the application for Disposal Works Construction Permit N%R"H_'A& ------------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SMALL-NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ------- ---------------------- spector.................................................................................... ........... In THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF -HEALTH 4 ................. ........OF.... ...................................... 0...... N FEE.At..;IL9........ Permission is hereby granted--------if&,6s le r.......�:....aaA....................................................................................... to Construct ()�) or Repair an Individual Sewage Dispo;U stem atNo. ------------------------------------------------------------------------------------- ----3-3-11------------- ........... Strect as shown on the application for Dispds'al Works Co'n§0 6ftidn`Permit No...-41.4—'r----- Date d -----------;.................. A/ .................I--------------------------------------r'. -------- .......................... Board/�Health DATE-__. FORM 1255 HOBS & WARREN. INC.. PUBLISHERS Z GENF-R RL NOTES �,nis�rec� C_,t�e ISIo_r\+r-�o\e � Co.Aer brov�`-rr vPTe w,T�•.\n \2" o� �,r,\s�, Graff F` � +) Elev��ons cle4'ar To (ems NNerw-%-% r5lmr• e, or. P\crr F'1sr�� Lnca<+ed \ ��b"m�� � 7 � wr-co\oc�\.� Teancs �Sr-4ee-rr,.d ,r, o,coor-ao,r,c. w,,�r, �•�,v ,r�.�,e^r,er� CD 02yl R,\,�rr,,rr• _ 77 •: \n -h,. C'.er.,.TTor,we�r\T� oA masso,e4,,,�r-rs 0. �-,r Pvb\,c P,T c�, z• i b• ;O� i RS •- \iem-.\tom Sto�t+e Ser>htas•v�Code F vcl� o,s cum-wr-)c>Se d. o\fn�T • 3) F-eTwr cm&J Flow G.\\p1s Pet- < � r ' • o o \ lC"�sT-Mre PS : .• + r� i1e Ol �, ."• <o�e�t'1 R4'��r m�rllt�ti6 �(` \rW4'f ( Z lgml � !� U, J \ ` 0.T OlT"!� �,• \ Itf 1 �/ •. .• 5� �C�Or1T� Cti. t�� �\�T'7a 1 ` �j' f �\ 8Tt•. ors 't+o w� + P\���a --_ _ -- ----- - - - \ . ;!s •�: V �� b�. Box �o� �s d 4 QJ fxPer,a�en oa a�+ewc, an SEPTIC TiIN K box LERCN PIT 7� Lawn, Area ?q-.1.\4ed 6�voxr crfiT, O uT\eT9 v (fj i e) F�r,:a� Gr�o,d: -ro �e e1,orTt �., occoT,d..ncs w\•?4+ T•\r+� \vr 1�; /�iF /�T/•� - ,' - / CoPnclTy Ga ons -S1,v.rt Elevet�ec�s '=;�- 9\1 0".T1.r3 To 9)-To \Imft `�� 9 Q _ ��.-- I Pc'ecsaT R.el�n�resa� Ce��reTe' � �•�'a Sarver /�j 10) Pfc\• �\ corierrv`cT\e" a�...\ cr•,�' �\ .r ,r-� �• o T��-e 'C ` +�`u�`ne we cis e4 � cam_ -C om\•,•+cr+.�e,)!�/ O T O.fKCr1 VDT c /�Y's >wpa rvr O4 r'V O\\C !'mLA-rk-, -Oft Colt p\T \ 'R-vvAm � tab oxrwvc" air--A -e*w 'Tewr, -a-(- Soor•c� PROFILE OF SYSTEM sf U - NO SCALE o4 rya . \ ��� R11 �oF,eo►1 � Sv��eei\\ nerd �a1�le-\aue mn.,�.-\�,\ �4 �+Gourstatr�al .?tias� 'oQ •�c"+ tacco"v���1 onJ Y�srr�o\lam !e ka" 1m+\ew '�r�+e bvr4e.ce aG tie c+owc'o (� �� 1 + G j //�/' 'i> trso�r4� � ''Fctie �rern �\r•R>,G�� \ Or c r►'14Tter�a 1�"' `. � \��`\ •<-`�`�� / �w,r\ram e• FyrC-a\�T�.e">• r�aZ1 \ate �Ts ot"\q.flpr� \eG!'�er1 O'4' L� e'r'1�r,\dRs Per c 1 �i'IR�C'• 1 1 Rrr( al-varooners& rrwetr b ojvprovm4A \r, a 15 Se fin o-r—k 5\,..\\ eorr•,P\� w\•�, -Tsr,e vnrwd S�+.•wa Fti��c � ..\el►� o.�rl �` • '� / Rpm Pp. .•e,~• � .:,t ST'o,.� e4 �3S. 4,AC`r{�ct�erlS I-4) Sep) Beo..^\,j s\�.\1\ be 3\00o Lb. �r S� FT. . \5)eer,erar. `.arrr,gr4-, a4+..\\ b m a 3, op L-6. pec- S`. 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Q / -317 \\o\e -TEST HOLE PEF�COLR-T= 0 N —f EST RESULT S T �J 'ter EffccTlv� C7��*��- J PLR1\I OF Op SEW R(SF- D\SPosAL_ S (STEm o� re"moo 4/6., w� -_' LTtrl\\ �rourrd _��4 rrarrmr,.r i N LET +2„ O F O R - 0 I`1�tr F\1\ ro •�- - � SCFIL£: RS NOTED CI FATE '. e2 �orrf _Lrp r1 ,', PLOT F.>L R N F,r..a o�,T place - _ - 00 m 0 OO 0 0 T SCRI_k_ LET RRE» _ BARNSRBLE SURVEY CONSUL-rRNTS , =roc. O /a a 0 0 � O 0 C1�t�Z N STREET W EST YRRtZIOU'TH , C�IgSgRCNI�SETT� 0 00 m O _ 0 0 4 S 0 0 ® 0 `D 0 _ f" BVEAPTT cy� _ r _ HINCKLST SCHEDULE O1 F- E V 1 ! 1 1 D N d _ • A�r�Q�SrE�"\���� REGISTERED PROFESSZONRL EN NEER 0 ly T ® O /ONAL \N� F G above STr�'vre � . '��91•,ocl �rv.c+e S obovo cJT-r-ycTyre �n ITT __ �o'- (o., •TOP OT Fovnda.T'ior•r = _ =nverT o.T �,s�r,c:�;Tlor� Fox — '" __ _ - --- -. - ----- - -- ---- - ---� B o.so.rc\a n! T-:i — -- - Zn w.-r (a.T ) ,STr-,bvT,on L N 0 UT•Qe r = // ry'� Lrws.-r o4 RQe o7r F1o�r,�T�on Lr,Je,-r �F3T,c '��ar,Tt =r,'Itr _ -- - TYPIC RL PRECAST' LE F)CHING PIT 4T ` RPPRG�ED'• p TE R D c�F F � , Nk AL rN RGENT -_-._- E lev�t,o� o� -- . Leoc�,rn �l T- _ NO SCR LE Z"oeer qT 50prr,c Tor,k (a.�T1eT - - - E16voTor, of \aJa_Tar -T7o.b\e �4. m