HomeMy WebLinkAbout0119 BRIGANTINE AVENUE - Health L119 Brigantine Avenue, Marstons Mills
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�r r Town of Barnstable
Department of Health, Safety, and Environmental Services
Public Health Division
v� MAM ��� 367 Main Street, Hyannis MA 02601
QED MA'S�
Office: 508-790-6265 Thomas A. McKean, RS, CHO
FAX: 508-790-6304 Director of Public Health
January 6, 1998
Mr.Peter Goldman&David Stagman
119 Brigantine Ave.
Osterville,MA 02655
ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 119 Brigantine Ave.,Osterville was inspected on November 4,
1997,by James Orphanos a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00)due to the following:
• Back up of sewage into facility of system component due to an overloaded or clogged soil
absorption system.
• The static level in the distribution box was above the out let invert due to an overloaded or
clogged soil absorption system.
• The distribution box cover was submerged at the time of the inspection.
• The septic tank was"backed-up at the time of the inspection and the liquid level was eleven
inches(11")above the outlet invert"
• The leaching "pit cover was submerged"at the time of the inspection.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram
of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street,
Hyannis)that will bring the septic system into compliance with 310 CMR 15.00,The State Environmental
Code,Title 5 within(14)fourteen days of receipt of this notice.
You are also directed to bring the septic system into compliance within thirty(30)days of receipt of this
order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground, or in
to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court of
competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE OARD OF HEALTH
homas A.McKean,R.S., C.H.O.
Agent of the Board of Health
q\health\dbfiles\title5i.doc
[Installer letter] mv" 6 0 J ma r�
TO: <. �^ (Date)
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE; TITLE 5. -{—�
The septic system owned by you located at Y 19 � a' I - C�
fie. �5 v
inspected on )Vov. 190/7 by :�Em,S ;p'�f?Aus a Massachusetts licensed septic
inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following:
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ou\-Ue — jnwer+ are '10 a, cave'10G?acQ '1� ' C f"55e4 !�:Dl closes-�s� S�S
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
box COver- sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance
u with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty (30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
z the surface of the ground,or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
LeVe( any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
jncI"_S
Thomas A. McKean, R.S., C.H.O.
,A^ Agent of the Board of Health
Town of Barnstable
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL A RSA t A"
�) DEPARTMENT OF ENVIRONMENTAL P CTON
? ONE WINTER STREET. BOSTON. NIA 02108 617-29 -' 0
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WILLIAM F.WELD 'T�-R,
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Governor A On ®J � Ej4B4t Seadatn
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ARGEO PAUL CELLUCCI d9 DAB 1D B.STRLT- E
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissis=
PART A
CERTIFICATION
Property Address: 119 BRIGANTINE AVENUE,OSTERVILLE Address of Owner:
Date of Inspection: NOVEMBER 4.1997 (if different)
Name of Inspector: JAMES A.ORPHANOS
I am a DEP approved inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000)
Company Name: CERTIFIED INSPECTION ASSOCIATES
Mailing Address: 47 CAMERON ROAD,NORTH FALMOUTH,MA. 02556
Telephone Number: (508)564-5653
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete
as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site
sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
X Fails
Inspector's Signature, Date: NOVEMBER 7.1997
The system Inspect r shall su mit a copy of this inspection report to the Approving Authority within(30)days of completing this inspection. If the system is a
shared system or h a desi n 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 o nvir mental 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 A, 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 repaired or replaced. The system,upon
completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate 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 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 4/25/97) Page 1 of 10
DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep
> Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
C N
CERTIFICATION(continued)
Property Address:1119 BRIGANTINE AVENUE
Owner: PETER GOLDMAN&DAVID STAGMAN
Date of Inspection: NOVEMBER 4.1997
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup,o breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a
broken,settled or uneven distribution box. The system will pass inspection with approval of the Board of Health).
P ( PP )
Describe observations.
broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection(with the approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed I . . ` " 1- . _. - _ - _ . .___ .__ _
c] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH
WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE
SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT 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 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50'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) OTHER
(revised 4/25/97) Page 2 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDMAN&DAVID STAGMAN
Date of Inspection: NOVEMBER 4.1"T
D]SYSTEM FAILS:
You must indicate either"yes"or"no"as to each of the following:
X_ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this
determination is outlined below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
x _ Backup of sewage into the facility or system component due to an overioaded or dogged SAS or cesspool.
X_ Discharge or pond'ing of effluent to the surface of the ground or the surface waters due to an overloaded or dogged SAS or cesspool.
_ Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow.
_2L Required pumping more than 4 times in the last year NQTT 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.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform
bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
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
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.' r
The system is located in a nitrogen sensitive area [Interim Wellhead Protection Area-(IWPA)or a mapped Zone 11 of a
public water supply well.]
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of
314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 4125197) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDMAN&DAVID STAGMAN
Date of Inspection: NOVEMBER 4,1997
Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was requested of the owner,occupant,and Board of Health.
X _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
ys P P 9
Flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_ NIA As built plans have been obtained and examined. Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X _ 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.
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface
Disposal System.
The size and location of the Soil Absorption System on the site has been determined based on:
X _ Existing information. Ex.Plan at B.O.H.
X_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[I 5.302(3)(b)]
(revised 4/26/97 Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDMAN&DIf RO STAGMAN
Date of Inspection: NOVEMBER 4.1997
FLOW CONDITIONS
RESIDENTIAL:
Design flow. 110 g.p.d./bedroom for S.A.S.
Number of bedroomsL
Number of current residents:_
Garbage grinder(yes or no): NO
Laundry connected to system (yes or no): Y�,g
Seasonal use(yes or no): NO
Water meter readings,if available(last(2)year usage(gpd): CONSUMPTION FROM 1995-1996 IS 161,000 GALLONS
Sump Pump(yes or no)_ NO
Last date of occupancy: THE HOME IS CURRENTLY OCCUPIED.
COMMERCIAUNDUSTRIAL: N/A
Type of establishment:
Design flow:_ allor►s/day
Grease trap present (yes or no)
Industrial Waste Holding Tank present:(yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings,if available:
Last date of occupancy
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SEPTIC TANK HAS NEVER BEEN PUMPED,ACCORDING TO THE OWNER.
System pumped as part of inspection: (yes or no)_NO
If yes,volume pumped:_ allons
Reason for pumping:
TYPE OF SYSTEM
X 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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM WAS INSTALLED ON 10115/82.ACCORDING TO PERMIT#82-618 ON FILE AT THE BOARD OF HEALTH.
Sewage odors detected when arriving at the site: (yes or no) NO
(revised 4/26197) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDBERG&DAVID STAGMAN
Date of Inspection: NOVEMBER 4.1997
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction: cast iron _ 40 PVC _ other (explain)
Distance:from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK; _
Qocate on site plan)
Depth below grade: 26"
Material of construction: ZC concrete metal Fiberglass Polyethylene other(explain)
if tank is metal,list age confirmed by certificate of Compliance (Yes/No)
Dimensions: 4'WIDE X 8'LONG X 4'DEEP
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: NIA
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle: lh/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How dimensions were determined: JAPE MEASURE.
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
THE TANK WAS BACKED-UP AT THE TIME OF THE INSPECTION AND THE LIQUID LEVEL WAS 11"ABOVE THE OUTLET INVERT THUS
MAKING DISTANCE OBSERVATIONS BETWEEN THE TEES IMPOSSIBLE A CONCRETE OUTLET BAFFLE IS PRESENT AND IN
SATISFACTORY CONDITION. I RECOMMEND THAT THE SEPTIC TANK BE PUMPED FREE OF SLUDGE AND SCUM PRIOR TO REPAIR OF THE
SAS.
GREASE TRAP: N1(A
(locate on site plan)
Depth below grade:
Material of construction: concrete metal Fiberglass Polyethylene other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
(revised 4/26197 Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 BRIGANTINE AVENUE
Owner. PETER GOLDMAN&DAVID STAGMAN
Date of Inspection: NOVEMBER 4.1997
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design How: gallons/day
Alarm level: Alarm in working order Yes: _NO
Date of previous pumping: '
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: LIQUID LEVEL IS 6"ABOVE THE D43OX COVER
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE D-BOX COVER WAS
SUBMERGED AT THE TIME OF THE INSPECTION INDICATING A BACK-UP OF EFFLUENT.
PUMP CHAMBER: WA
(locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order:(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 4/26M7) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDBERG&DAVID STAGMAN
Date of Inspection: NOVEMBER 4,1997
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non—intrusive methods)
mined be resent
If not deter to p explain:
Type:
X leaching pits,number: ONE• V DIAM X 6'DEEP(EFFECTIVE)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Altemative system:
Name of Technology:
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PIT COVER WAS SUBMERGED AT THE TIME OF THE INSPECTION INDICATING CLOGGED SOIL AND DIMINISHED PERCOLATION
CESSPOOLS: NIA
(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(cesspool must be pumped as part of inspection)
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.)
(revised 4/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDBERG&DAVID STAGMAN
Date of Inspection: NOVEMBER 4.1997
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)
119 BRIGANTINE AVENUE
F
27.3'
47.6'
51.0' - 33.0'
26.5'
73.0'
NOT TO SCALE
(revised 4125/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 BRIGANTINE AVENUE
Owner: PETER GOLDMAN&DAVID STAGMAN
Date of Inspection: NOVEMBER 4.1"7
Depth to Groundwater >12 feet
Please indicate all methods 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. ( be completed)
OBTAINED FROM DESIGN PLAN ON FILE AT THE BOARD OF HEALTH
,ky�.. ..•^era. rr.r.:!.r..c4 ,+rep--w. : "..'.�,...M1 .�-• - rr r..�„4
(revised 4126M7) Page 10 of 10
r
TOWN OF BARNSTABLE jvv�,
LOCATION "I 19 f3 JU(PA#0 t KX 40� SEWAGE #
VILLAGE C�STLS2U1 L,1..0 ASSESSOR'S MAP & LOTOQ 10,3Z.111
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /SO"U A4A XJ yV
LEACHING FACILITY: (type) 7 tT (size) tk
NO.OF BEDROOMS 2-
BUILDER OR OWNER
PERMITDATE: 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 3.01ZPVk A 0tp S t t(4 t019 .1 r-WOM` 64 0
a
.a
ri
L i7..�.��q
2
47N
O '
TOWN OF BARNSTA sLE (�
LOC,k.T 3N.i t 9 SEWAGE # '-
VT.LAGE t`^ ASSESSOR'S MAP& LOT 4'9Wr 0 3 Z
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Ce,,U�M wbp= i S AO
\ o��
LEACHING FACILITY: (type) �i �.� �D Cu G'i (size) vrM �_
NO.OF.BEDROOMS
BUILDER OR OWNER cc�� 0VAli
PERMITDATE: /l/0"/��COMPLLANCE 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
DO, 11
4
No. �L. Fee Q d(7
4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �-
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for 30igpopt *pgtem Cougtruction 3permcit
Abandon ❑Complete System ❑Individual Components
Application for a Permit to Construct Repair ,/U rade b
PP ( ) P ("1 Pg ( ) ( ) P Y P
Location Address or Lot No. l��j�a G "'6\iN� Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel C7 /77.4Re ��6�Ar lv/
01
g
C�32 ce-s
Installer's Name,Address,and Tel.No. —779—66 eY Designer's Name,Address and Tel.No.
2-0. 6 A el
� rra 2 ris et�
N j S A,
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow " 0 gallons per day. Calculated daily flow 3 LAC( gallons.
Plan Date 1 Number of sheets Revision Date
Title 'T A ,-IY\,&tj
Size of Septic Tank 57-4 5`>"�a--�61�7 S A��� Type of S.A.S. + �C. ta`t�
Description of Soil wo
Nature of Repairs or Alterations Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental de and not to place the system in operation until a Certifi-
cate of Compliance has been' i � ard
t�Iuk
tine " Date
Application Approved by Date //-/®-17
Application Disapproved for the following reasons
Permit No. Date Issued ll_lp_7 7
No. 7_CG SZ - Fee dv
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓``
Yes
PUBLIC HEALTH DIVISION -TOWdOF BARNSTABLE, MASSACHUSETTS
ZIpplication for nigoml *p$tem Congtruction permit
Application for a Permit to Construct( )Repair( Xupgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. lC�' �.� rtiq N—���I L � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel �C7r�� �+R5 �(� ��'"/
JJ c LS
Installer's Name,Address,and Tel.No. �78-06 Designer's Name,Address and Tel.No.
dtj 1S hA
Type of Building:
Dwelling No.of Bedrooms �:s Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow O gallons per day. Calculated daily flow `�c( gallons.
Plan Date I Number of sheets Revision Date
Title S:j A r,tY1 aArJ
Size of Septic Tank ' i 5-r-t�l, .�.7 y,AAktw Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations( nswer when applicable)
,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
"^ cate of Compliance has been i red is' ard f
iST ed Date
Application Approved by :!5 Date f/-1 o- 17
Application Disapproved for the following reasons c
/"- Permit No. / Z 41 Date Issued x'-/l—/G' 7 7
r-
THE COMMONWEALTH OF MASSACHUSETTS
-- BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(`)
Abandoned( )by W 1 b - C P1 1'G S T I C ,-)
at 1101 is 0_. I\l-T 1 N C Ayt,_ (�S'i'r-_ij�y 1 trL. has been constructed in accordance
with the provis ns of Title 5 and the f r Disposal System Construction Permit No. 77-4r dated-a'�//4 l0 - 9 7
Installer 1 fj - r /� /J ' Designer
The issuance o this permi(shall not dconstrued as a guarantee that the syst 11€tt'ctio desigg)be'dI
Date Inspector -'Z � L iA
1%�>
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--Q----------------------------------A--
No. / ` �9 S 2- Fee J 0a
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
xigpogar *pgtem (Congtruction 3dermit
Permission is hereby granted to Construct( )Repair( worUpgrade( )Abandon( )
System located at I I t l C�--A� -T 113 G 1:�y L) S Y L iq.y 1 L
and as described in the above Application for Disposal System Constructiot Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. �)
Provided:Construction must be completed within three years of the date of this ermit.
Date: /1/U- 9 7 Approved by C- ���t,., `.
.- r
f
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed '
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A t
DISPOSAL WORKS CONSTRUCTION PERMIT_(WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated to -9 7 ,concerning the
meets all of the
property located at ��01 i 'va.c.r` k �-e. 4V !'!
• US`t�v i�Ir-2 i
oflowing criteria: !
• i
• There are no wetlands located within t00 feet of the proposed leaching facility i
/0 There are no private wells within 150 feet of the proposed septic system
C/• The is no increase in flow and/or change in use proposed
(/• There are no variances requested or needed.
v d leaching facility will be located within 250 feet of any wetlands,the bottom of the }
• [f the propose g tY }
proposed leaching facility will W be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following: i
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) L
B)Observed Groundwater Table Elevation(according to Health Division well map)
S
i
SIGNED: DATE:
LICENSED SEPTI SYSTEM MSTALLE IN THE TOWN OF�BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder.cen
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TOWN OF BARNSTABLE �L
...LOCATION n 111-:1 SEWAGE# .97
.''�:LAGEnble—fi�y ASSE OR'S MAP& LOT. !qr
f >:INS.TALLER S NAME&PHONE N0. r
SEPTIC TANK CAPACITY Ce4
LEACHING FACILITY: (type) ;J L,QG'►T (size) r
NO OF BEDROOMS
iMDER OR OWNER q WY�N
P)rRMITDATE: ll ( � COMPLIANCE DATE: — 69,9 7
Separation Distance Between the:
.:Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Privi}te 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
AS L24 '
^ o 0 0f 0,•.`
L0 AT SEWAGE PERMIT NO.
i0 —
V LLAGE
9�ZX P 0A/< &iG/�g
I N S T A LLE 'S NAME i DDRESS
Or
e U I L D E R Olt 0 NER/�
DATE PERMIT ISSUE
DATE COMPLIANCE ISSUED
C�
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II THE COMMONWE
ALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�✓_ ....................oF. ...............................
ApplirFa#iou for Disposal Works Tomitrur#iun. Errant
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
11721 .CZ..._ ..__:�?__c r_e.._�l�..L':.......... ,��7w ..... .........................................
ocation-Address^ or Lo 14 .
t
�y
a k rYGO�Lw � Address
.......................................... �.��E�. •- •••-•-•••-••---•- ----•-•----------/---•--•-----••-----•--....�
Installer Address
Type of Building Size Lot...
st kff ....Sq. feet
.. Dwelling—No. of Bedrooms-------�...............................Expansion Attic ( ) Garbage Grinder ( )
________.__. Showers —
a Other—Type of Building b�(}nr��(.............. No. of persons......�_._� ( ) Cafeteria ( )
dOther fixtures --------------------------------•--..-..--------------.•--••---------------•-•-•--••-•••-•-•-•-•-•-•--•-•••••---•--...._......--•-•••--.........•_----
W Design Flow.............. .......................gallons per person per day. Total daily flow........P?.PR 0..........................gallons.
WSeptic Tank—Liquid capacity--fir ._gallons Length_o'�_`..____ Width.--S...........Diameter---------------- D��e,yPth_-____-___---_--
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....MR-1......sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by..l01�!_ PJ..... _____________________ Date..... ...............
Test a Test Pit No. 1-----9 L.......minutes per inch Depth of Test Pit---i 31"....... Depth to ground water....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-••-•r--•-•----- -----•------------------•-------..........--------...--------.............__...----•---.........._..----•---......._•---•-
O Description of Soil-_��'_ZL4 f.....___..�Pw OL-1...a,e
"W
V ......_..-••-•••-•...--•-••-----•••-•••................••-•-----._._._...----•-•-._...........•-•-•........•---------•-••-••••---._...---------•--•••----•----•-•--•--•-.....--------•-•--•-----•------•-
W
---------------------------------------------------------------------------- ---------------•----------..............................................................................................
V 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 TIT11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by ke board of health.
S ned__ S
to
Application Approved By.
10_lif
Date
Application Disappro d r e following reasons------------------------•----------------------------------------•-------------------------------------...••-••-
............................... --.. ..--•--•--•••---•--•-------•-•--....-----•--........----•--•••--...-•----••••••-••--•---••------------------....---•-----------•-•••--------Date--•-----•-----
PermitN ............................•-••••-••-........._.._-_._.. Issued.......................................................
Date
w
t- z
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................I ------.....0F..,S.'l 1
Appliration for Uispoii al Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( Y) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
r �
Owner * Address
... f f ............/ /it. .....�A'.., 1 .....................•------...---..............---•--..........---
Installer Address
" l �r
Type of Building Size Lot...._.::`------------------Sq. feet
U Dwelling—No. of Bedrooms......:.: ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building � .............. No. of persons......... Showers —
a Other—Type g ----=-----=--- p ( ) Cafeteria ( )
dOther fixtures -----•----------••---------------•--------------------................................................
W Design Flow............................................gallons per person per day. Total daily flow............:................................gallons.
WSeptic Tank—Liquid*capacity...........gallons Length.l....':....... Width................... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....ti`:..%......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........................................
as Test Pit No. I...... ........minutes per inch Depth of Test Pit.... ......... Depth to ground water........................
fX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................
R'+ ----...-•.......................................................................................•............................................................
0 Description of Soil---.... _ ......:..._...G...:
U -•--••••---••••---••--•.........---•••------••••••......••••••.....................••---••••--•-••••--•-.........-••--------•--•-•---••-•--•-•-•----••....------------•----•-----•---••----•--•-•---••--
W
---•------------------------------------------------------------------------------------------------------------------------•-------------------------------------......---------------.....---•--.....
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 y g g p y
S of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been/issued by the board of health.
//:
, ` S ------------------- ------ .....-•---
ate
Application Approved BY = ..fi -----•.......................•-------. _....
Date
Application Disappro r th ...........e following reasons:----•-------•-------------------------------•-----------------•-•-------------- •-•-•---------
.. r
f Date
PermitN ........... ......:....•--•-----------.....-•----_. Issued_.....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......r .:............................OF... ' r..:..`....... ....
•- TatifirFatr of Tlantph anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by :.................. c_.............:.:...........•-----------•••-----••-••••-----•...................................•-----••-•-----•-•-•----.............-----•---•-•-----•--•---.
Installer
at..:r:................ .F /'/'G rf `/ J r:.
:- ••-•••---•-•......•-•--•................ - --------------•-
has been installed in accordance with the provisions of TITLE r of The State Sanitary Code a� dibed in the
application for Disposal Works Construction Permit No...�+.�.�_�.1.$z................ dated..- .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUP AS A GUARANTEE THAT THE
SYSTEM 1�� F NOTION SATISFACTORY.
DATE....S.... .- Inspector.. ...... ._.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
girt/ ��
...........................................OF...t`�.-�; �✓/v /'/,�.>' ,�
No.. .,/
.................................................
....�...�!!..... FEE.. -i---------------
�t��rr��t1 nrk� �n�a�#rnr#Uan rruti�
Permission is hereby granted.......... _:........f......�... .�- ..^! ................ ..........................................•-•-......
to Construct or Repair ( ) ari/Individual Sewage Disposal System
at No.....:�-._.......... 1/ . r / r- s .r �!..._ / -----------
Street
..............................................••--•-...--•-•-----•--•••• -- ;o�_.;Z.NtZK
---•---------- •---• -• -
Street
as shown on the application for Disposal Works Construction Dated. ' ' _--._....•,.•
............ ..... ...................................................................................
••--•••••••-••....••••-----••---•..........................••................• Board of Health
DATE.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
L-:O : ATION SEWAGE PEILNIT . NO.
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I.NSTA L L E 'S NAME i �DDRESS
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d. U.IL0ER O/R_ 0 NERD_ p
DA'T E P ERMIT I S S U E 6o
Q;AT E COMPLIANCE ISSUED
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