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COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
i > DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SY �'
PART A RECEB\/ED
CERTIFICATION
Property Address: 17 Captain Baker Marston Mills MAY 2 4 2002
Owner's Name:Paul Andersen TOWN OF BARNSTABLE
Owner's Address: Same HEALTH DEPT.
Date of Inspection: 5/9/02
Name of Inspector: Timothy Lovell + `
Company Name:Accurate Inspections IZ(p
Mailing Address: 550 Willow Street MAP
W.Yarmouth,MA. PARCEL • ��o
Telephone Number: 508-771-3 i00 4-
LOT ------
CERTIFICATION STATEMENT
I certify that I have personally in-spected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 5/9/02
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
'.Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
_N/A One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
I
explain.
_N/A 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 infiltration 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.
ND explain:
N/A Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if
(with approval of Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
N/A_The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system
will pass inspection if(with approval of the Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 519/02
Further Evaluation is Required by the Board of Health:
_N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_N/A_Cesspool or privy is within 50 feet of surface water
N/A_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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_n/a_ 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.
_n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_n/a The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
n/a_ 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
C. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_x_Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_x_Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_x_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_x_Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
_x_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_x_Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
The system is within 400 feet of a surface drinking water supply
_The system is within 200 feet of a tributary to a surface drinking water supply
The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H 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.
i
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SS SSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
_x _Pumping information was provided by the owner occupant,or Board of Health
_x Were any of the system components pumped out in the previous two weeks?
_x _Has the system received normal flows in the previous two-week period?
_x Have large volumes of water been introduced to the system recently or as part of this inspection?
_x _Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_x_ _Was the facility or dwelling inspected for signs of sewage back up?
_x_ _Was the site inspected for signs of break out?
_x _Were all system components,excluding the SAS,located on site?
x_ _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?
_ _x_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:
Yes no
_x _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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330 Gal
Number of current residents:_3
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required]
Laundry system inspected(yes or no):n/a
Seasonal use: (yes or no):_no
Water meter readings,if available(last 2 years usage(gpd)): 66000Gal(2000)59000 Gal(2001)
Sump pump(yes or no):_no_
Last date of occupancy:_current
COMMERCULANDUSTRIAL N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): god
Basis of design flow(seats/persons/sgfl,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Town of Barnstable Sewer Facility
Was system pumped as part of the inspection(yes or no): No_
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_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)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
10/28/98
Were sewage odors detected when arriving at the site(yes or no):_no_
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
BUILDING SEWER(locate on site plan)
Depth below grade:—2.5 Ft
Materials of construction:—cast iron _x_40 PVC—other(explain):
Distance from private water supply well or suction line: 30 ft
Comments(on condition of joints,venting,evidence of leakage,etc.):
No evidence of leakage Joints look tight and in good condition.
SEPTIC TANK:_x (locate on site plan)
Depth below grade:_1 Ft
Material of construction:_x concrete—metal_fiberglass—polyethylene—other
(explain)
If tank is metal list age:—Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: 1250 Galloon
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_3"
Distance from top of scum to top of outlet tee or baffle:_8"
Distance from bottom of scum to bottom of outlet tee or baffle:_16"
How were dimensions determined: Infield measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Recommend pumping every 2 years, structurally tank looks in good shape,No evidence of leakage,water level a
invert out,baffles in place,Tank is level.
GREASE TRAP:_N/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(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
TIGHT or HOLDING TANK:_N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: g (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.):
Liquid level is fine its at invert out,No evidence of solid carry over,Distribution box in good condition.
PUMP CHAMBER:_N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
S.A.S. was located dug small hole to verify they were infiltrators no sign of ponding or hydraulic failure at time of
inspection
Type
Leaching pits,number:_
Leaching chambers,number:—
4_
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.):
No sign of failure at time of inspection,no ponding,soils and vegetation normal,
CESSPOOLS:_N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_N/A (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells wi-,hin 100 feet.Locate where public water supply enters the building.
10'
4 Infiltrators
2 49'
Distribution Box
8
1000 Gallon Tank
29' 31'
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Captain Baker Marstons Mills
Owner:Paul Andersen
Date of Inspection: 5/9/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_16'_feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
_x_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Information provided by Cape Cod Commission U.S.G.S Map and Well information Well SDW 252 shows that the
water level is 48.9 including adjustment the topo on the map show ground elevation approximately 65.0
Permit Number: Date: S1O1OZ
Completed by: //
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot No. Q6 - a Iry
Owner: AAv/ 4ti&rSe l Address: 51-9n1-k
Contractor: I@RyrAk AtAr, eL~'w,S Address: "MOQ sir tAVAAA,'5
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. .............................................................................. .Date �A y 9 mdt
month/day/year
STEP 2 Using Water-Level Range Zone
and Index We!I Map locate
site and determine:
OA Appropriate index well.................................................... pwZS
OWater-level range zone ...................................................: r
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 26) U
determine water-level adjustment ..........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water �6
levelat site (STEP 1) .............................................................................................................
Figure 13.--Reproducible computation form.
15
I
TOWN OF BARNSTABLE y
LOCATION /7 GBi�Dfi,4n SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO. _/h-')peJiun i40L-vI-Af-e (►1siaedfunl
r� 4cvtg�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS -3
BUILDER OR OWNER c r5ciA C.2esLK �
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Mr.ximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wedand and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by __
I
l„
q
• � i
' 7
TOWN OF BARNSTABLE
LOCATION 17 CA4t SEWAGE #
VILLAGE� . �.�`I l� ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. ..d — > (P. x
SEPTIC TANK CAPACITY 0m.� ...�lti
LEACHING FACILITY: (type) (size) n'> �
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE: l 0•-� -��?
Separation Distance Between the: :'.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
143
.
J
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppYication for M-4po.5al *poem Con6truction Permit
Application for a Permit to Construct( )Repair( )Upgrade jb(`, )Abandon( ) ❑Complete System NJndividual Components
Location Address or Lot No. ( � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 96 Mv YV\`'Vv�� I`
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
:;�o Ls- �S—
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 —3 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank !i--- L<F S"t'LA� �.b- Type of S.A.S.
6 cc, c
Description of Soil
Nature of Repairs or Alterations(Answer wh n applicable) S U c ` Ca n v
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 a Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been ' t���e G
Signe Date -7`�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
TOWN OF BARNSTABLE
LOCATION 7SEWAGE #
VII.L.AGE ASSESSOR'S MAP& LOT1;�
INSTALLER'S NAME&PHONE NO._ — t
SEPTIC TANK CAPACITY
LEACHING FACIUN: (type)L c (size)
NO.OF BEDROOMS
BUILDER,OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
. on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
� 3 �� 3
5,
No, _ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
�. Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
3pprication for Migpogal *pgtem Congtruction Permit -
.Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ❑Complete System N-Individual Components
1 Location Address or Lot No. G r Owner's Name,Address and Tel.No.
t
Assessor's Map/Parcel Nnii�
cel
� V
Installer'' Name,Address,and Tel.No. Designer's Name,Address and Tel.No.s
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 3.3U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision�Date
Title I i >
Size of Septic Tank ��F 5�� - E2 16 Type of S.A.S. 6 4
Description of Soil {"'
Nature of Repairs or Alterations(Answer wh n applicable)
' o( _T_Yt,. 2S SY`Gce_ `4-60.,A2 -¢- !(IT l//1 C°. 0--f
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 a Environmental de and not to place the system in operation until a Certifi-
cate of Compliance has been . ea
Signe Q Date �7
Application Approved by to Date
Application Disapproved for the following reasons
} t s 1
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded x )
Abandoned( )by t 'Q `G 50; C
at I Gf4 t �� �A- � � ha onstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. � .ated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
f Date l - qg Inspector
.e
No. ------------------------Fee
/ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
MigpogaY 6pgtem Congtruction .Permit
Permission is hereby granted to Construct( )Repair( )Upg�,H
e( Abandon( )
System located at 1 C
G
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. /
Provided:Construction must be corn �e/
ed wa in three years of the date of thi ie
Date: (� Approved by (/ `c� i� y(�✓
_ ( t
10/9197 ,
y ;r. J NOTICE: This Form Is To Be Used For the Repair Of Failed
Septie Systems Only.
CERTIFICATION OF SKETCH AND'APPLICATION FOR A
z ' DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
itY ' ENGINEERED PLANS) 4
r
p ✓y Y> ! ; I; r� � or disposal works certify that the application f 3
f Ays
a�-gypp
Construction Permit signe by me dated CJ S
concernin the ;
located at meets all of the
Pe�3'
fo11 wing criteria:
1 I
ere are no wetlands located within 100 feet of the proposed leaching facility
'There we no prhitte*tells within 150 feet of the proposed septic system
There is n0Ina In Ao*and/or change in use proposed
' I ed or needed.
^�,.r � � ��"`.There air•f10 variat�cd t'�gtlest 3 k
' l/• It the propped lesft facility will be located within 250 feet of any wetlands,the bottom of the
.proposed lftdittg facility*111 no be located less.than fourteen(14)feet above the maximum adjusted �*4.
groundwater table 616rvation .
M
> 1 lcytsa complete the fo�06MBg:
P 1FP1 4^+ a e ys
€; A 1' of OM Elevation(according to the Engineering Division G.I.S.map)
Top
xf .
8)Obs�Gtotthdwito Table Elevation(according to Health Division well map)
h
o1
SIG
NED� DATE. �`�
E
� LItENSRD SLPI"i+r SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
�%1t<k'h i silicon plan btdW prtipesed"em.Also if the licensed installer posesses a certified plot plan,
t r �
b'LAM .;A }y.� '•
10,,W plan should be raWitted)4 k
l
)fir# `
Y �S S t"4 A t t. E •' d � ��.NA
# F • t d R - ^"` ivy• •.• '• .. ' S }�`'�i'
nnS::.`�:;+.4.a J•w.y ........�... .�- _... ...+.,ws�+xs.yw,..., _ ..,.,,.�- .,_.,. . .. ,„ ,•. ,.,.....,. .., �q,?
v y
fff f �4
existinghouseaster bedro'OM suii 5
amily liivibg roam f,
4
f 4
f \
f k
f 4
existing house
pp f 4
f k
I
I I
I I
1 I
1 I
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f
aw
Ld 61W
Proposed first floor plan
Proposed
second floor plain
Pro)cct Name
Proposed addition.
Mlqn,�
e M tie m Name armd Address - a- diduck residenUe
17 Captain Baker Rd'.
ICI arsto�n 1 ialis, MA
:h flamer hest.`> 11�
floor Plans Al
1:2
6-9 12
2
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El I
FEI
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ar elevati n
Side letan
Pronased addition
Cfle nt mame and , dress
17 Captain Baker Rd.
Mars-ton iili ,
Shwt, Ira shm4 ` Ale
12
'12
Front elevation
Front
o Edo I W
Prgoct Name
Proposed addition
Memt Name and Address -
17 Captain Baker Rd'.
ar tons ' !ii i , MA
Sheet. Namer hmt T1110
front elevation ,,+ ,
adjust foundation heip ht for
112 joist on single t PTSYP
sill'to matchtopofItl'nolst..
. _.
LL
•�yr••'x
fti :. .'r.._.. :....'r-.t.......�! �k'. +.� •. ...}.. `. =fir.
�*
w.h
(D46M
•: r _3c :i:r
€ iL
W Poured concrete wails on continuous footing
+•R ;;?�
, .
L. f�fw, � .� ,f. y'.�.r. �•..�•.:�:f+ ..� � ...ram: dS
u -u
f u roc ate n �ctaon
Foundation plan
n V
Prq�xt Name
Proposed addition
Client Name and Addmss toi uck U U c
17 Captain Baker Rd..
Mar on Mills,ti MA
Sheet Namer Sheet lMe
foundation
112 KID 1611 00, hung from exiting mouse—�
First floe r fi r i - g
1I fr�rye
Project, Name
Pro loSed addition.
Client Maros arW ►ddress i
duck residence
17 Captain Biker Ind.
Mar ton Mifi , MA
hect Namirf?ir k' floor framing Sheet °trIM 1
c10 IKD 1 W OC hung from existing house
C
second floor f r m- -in
SHOWS
ale: . _ .
,ra)ect Uwe
Proposed addition
Cram ck, rasidenue,
ClIent.Name and AWOSS
17 Captain Balmer Rd.
Mar tons Mills, MBA
Sneet Na cond floor Pram i 4 shearme S2
all rifter�'2xlib ate„ 1 e llDd
1.75 x 1'V LVL-,dd`�
1.75 x 111.88 LVL'valley raft
12 widge
IN
Roof framing,, pal n; vie
04cOTV�-_
ft
Projoct Name
Proposed, addition
Cile-nt iName and Addross
17 Captain Baker Ind
Marsh on; Mills, MA
Sheet Namur Shoot i u
roof framing
Rollvent at ddge
115 x 14 LViL ridge
W,framing anchor each rafter'
Match existing roof plane
1) 1.75 :x 111,88 ridge
2x11O rafter,, 1161",0 ,, R-312rnsulation typi'dal
propavent above each bay continuous
Ile CDX fir roof sbe.athin
Al'urnr[num drip edges, 3" oaf ibe and water, asphalt ship. les typ.. �
Continuous vent at eave--
Simpson rafter ties (H2o5) every rafter �
2x4 galls„ 1 W OC R-1 3 insulation typical
314 T&G pl ood sublloor, glued and naffed
2x11O KD fbor joists 16r O ,, hung from existing
white cedar shingles over 15# felt, tarp.
'4 T&G ply%vood sub-loor, lured and naffed
W PT silli,, sill seal
1i11� iris�ulati n ,.ire basement ceilin 2x1!2 IC1D flea r joists 1 - , thong from exist!'n structure
�• r'
' All work'to conform to version 6 of the Massachusetts Building Code.
r.: Roof loads to be posted per oode. Pic t of ridge in existing structureto
r_ be determined in field,
{
Project Name
Proposeid addition.
1 Section-1
c e: 1 a' _ 1'-Dl
Ctlem, Name and Address
17 C ptl ain Baker Rd
Mar ton s Mills
hcet Narner Sheet Tittle tle
Window Schedule
Nominal Size Odle Op-nit Optnit Window Dom,
0 0
Mark d d ash, 01peratibn � � Mfr Model Nlo. Accessorias Comments
B T9 718 41 112"' casement T95 4'�" Andersen �+0- �'�-�� 00 series
A 111 1/,2" 3'11 1►2" Double 'Hun ZO" '01 Andersen eni 244-D'H2040 .20;0 series
�`� � ' `� °� d�� `� Dub9e Hen, `� `� dleren !�. � ?0'0' serrss
A 1"11 1/ " T11 1/2" Dou.ble ,,Hun 2`0 °0" i dlersen, 2-440H2040 200 series
A 1411 JIT T11 1/2 Dou'ble .i Hun, 210" 4"0" i der en, 244DH2040 200 serfs
A 111 1/2" 3'11 1 f2" Double Hun. Z0" 4,'0" Andersen 244 H20401 200' series
1°11 1/2" 2�'1 i 1 ' "l Double Hen "[�`; °�@" ndei ens 'D:H �D O! '0'0 series
1 !1; 112" Z11 112" pD�oublleII, Hun+i.�i,�p �ZOIFI TO" ndlersen 24��4pQH; 040 ��#y �g �3 y�����3 �;(010� miseries
' �4J 1J 711 ��n�pt ®II® :li�Lll itd 4/'IP7 a7��,� ni� '"�I'.9of 470 1 2" A Ede Andersen ti;.I'hP Y�2'�1!' 'e li!leass7 haridl are 200 sefies
Door Schedule
Nominal Size Dome Fire Ratina Openin s Door Dal
Mark M; Door 0 ration, 0 0 Mfr Accessories Comments
3 ZWO 68" 1 3.14" Pocket. Sri le &511 Ti if
3 2`6"1 68" 1 r314" 'Pocke r Ir�l te, 61 , T1 si
.2 1 Z80 it 1 3141 Swing Sim We Z I On ulvil
Project Name
Proposed ad duition
Cila r ame and Address a '
ulUck residence
17 Captain Baker Rd.
M arstion s Mills, MA
h[et Namer Sh"a 11110
Revisions: Date:
24' - 24'
—15-2 6'-10 n 134r3 � 10'-11
Sd�s-Te
BATH
F 0
u N
H O H BEDROOM Z0BEDROOM o
DINING °^ 10•6 x 9'-0 w to
6'-4 x 1 T-6 e 8 x
IL
KITCHEN
14'-6 x 6'-3 q - C>
- O
q U) co
1� L0
H LIVING. Y y LO
CU � (cli
00
19'-10 x I V-6 OPEN BELOW � oN
19'-10 x 1 V-5
•� vi 3
m N o
E O
C
O
0 _
2q• c
_ C �
24'-0 _- CU p Cca
-
Existing First Floor
Existing -Second Floor r
576 sq ft
289 sq ft
24'-0
3'-11 4'-s•2 1s•-p1 -
W
E
q q
o O
s T
_ EO q 0
q
q �U
Existi. n9
Conditions
q U
q W
0
q � �
24'-0 r< Drawn By: NAL
264
Existing Foundation Date:os-°'-°s
583 sq ft Scale:114"_V -
' Sheet:
EX-1
Nd LVW.1 I SOIL 119-l 30Vd-1300W ld ZV lV°JNIlSDG NOSSIS-.