HomeMy WebLinkAbout0525 FLINT STREET - Health IFF"I
525 Flint Street
LA
stons Mills F/R
- - - -- 101 021 - - - ---
i
I
c
R ` Town of Barnstable. Health Inspector
oFTM T, Office Hours
o Regulatory Services 8:30—9:30
Thomas F. Geiler,Director
1:00—2:00
1AxNSMUZ
MAS&
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE
1. General Information: Size of Property:
Address: (D,5-( (� Map d/ Parcel �Ao�
Name: APhone #: - p
2a. How many bedrooms exist at your property now?
2b. Are you planning to add any bedrooms? If yes,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d. Please include a copy of the.floor plans for the entire property-showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label .
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or ONO
"��.Ifxhekdwellmgas connected to public.sewer slap�questLa�nsy#4�through#9`-�be�'ow �
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
5. Is the dwelling connected to an ONSITE WELL or to LIC WATER?
6. Is a disposal works construction permit on file? YES or NO
� I
6a. If yes,how many bedrooms were approved according to this permit? Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES . or NO
.8. Is there an engineered septic system plan on file at the Health Division? YES or NO
9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
-----------------------------------------
("1 FOR OFFICE USE ONLY
y
The Public Health Division has no objection to bedrooms at this property. _
Special Conditions:
oe
Signed: Date:
0;/healthhvpfiles/amnestyapp
1`Y
b�E 6R— �
McKean, Thomas
From: McKean, Thomas
Sent: Wednesday, September 07, 2005 3:16 PM
To: Dillen, Elizabeth
Subject: 525 Flint Street
The septic system questionnaire submitted by the applicant is denied. Four bedrooms are not approved.
This property is limited to three bedrooms because the site is located within a zone of contribution to public water supply
wells and he size of the parcel is only 0.94 acre in size.
1
AT
XX _
•, ' 611
' 17-7-1,�(5�_ : -
:67
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COMMONWEALTH OF MASSACHUSETTS RECEIVED
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
z F DEPARTMENT OF ENVIRONMENTAL PROTECTIO OCT 2 2 2003
m r
A 9 o TOWN OF BARNSTABLE
HEALTH DEPT.
,
o�
FAILED INSPECTION
O,,M 5y0�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A [AAP
CERTIFICATION PARCEL :Property Address:Address: 525 FLINT LANE MARSTONS MILLS,MA 02648 LOT --
Owner's Name: MARSHA WEAVER
Owner's Address: PO BOX 534 PRIOR LAKE MN 55372
Date of Inspection: 10/1/03
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ Passes
_ Conditionally P ses
_ Needs Further valuation by the Local Approving Authority
X Fails
Inspector's Signature: 1 Date: 10/1/03
The system inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti . 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
SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN OVERFLOW CESSPOOL IS FULL;OVERFLOW
NEEDS TO BE REPLACED.
****This report only describes conditions at the time of inspection and under the p y p 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.
Title 5 lncnantinn Fnrm 6/1 S/'?On 1 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 10/1/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ 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:
SYSTEM FAILED TITLE V INSPECTION.LIQUID LEVEL IN OVERFLOW CESSPOOL IS FULL; OVERFLOW
NEEDS TO BE REPLACED.
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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please 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 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.
ND explain: n/a
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
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
it
ND explain: n/a
i
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
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
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 n/a
"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:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
D. System
y Failure Criteria applicable to all systems: i
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 ''/z 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 nLa.
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.]
YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
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
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I1 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.
d
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 525 FLINT LANE MARSTONS MILLS
,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
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.
X _ 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)]
i S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Ili PART C
SYSTEM INFORMATION
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design; Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: n/a
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): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):,ULa— 0 2 , 1000
Sump pump(yes or no): NO
Last date of occupancy: 9/1/03
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
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): n/a
Approximate age of all components,date installed(if known)and source of information:
1970 BY OWNER
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: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 10/1/03
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 0"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 10/1/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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
n/a - �� �U
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
6' X 6' BLOCK CESSPOOL overflow cesspool, number:
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.):
LIQUID LEVEL IN OVERFLOW IS FULL; CESSPOOL NEEDS TO BE REPLACED. BOTTOM IS AT 8'.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
"Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
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 within 100 feet. Locate where public water supply enters the building.
Vv
MF
Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 525 FLINT LANE MARSTONS MILLS,MA 02648
Owner: MARSHA WEAVER
Date of Inspection: 1011103
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
tt
TOWN OF BARNSTABLE
LOCATION �� � i~ Tom. SEWAGE #.f7ffy rl'e'e
VILLAGE �le-eTASSESSOR'S MAP & LOT,-'*p/- 2 l
INSTALLER'S NAME&PHONE NO. �� ��`•�P1"v� 77�O 07
SEPTIC TANK CAPACITY -0;ea 9.C1, CXi,TTi�dg
LEACHING FACILITY: (type) i�%CLiJ (size)
NO. OF BEDROOMS X3 C'v4,4.ae-?s
BUILDER OR OWNER /��`'�� �y
PERMIT DATE: Io ` ' COMPLIANCE DATE: 6
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
A? y
243 5-/ ' r
No. -0 � ' Fee
►� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Ofp plication for r3iZpoga1 bpotem Conotruction Permit
Application for a Permit to Construct( . )Repair( )Upgrade(XAbandon( ) El Complete System O Individual Components
Location Address or Lot No. <1 f��Z J7 1 olP? Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /0 / I
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
1_��f77 Ze476'e- ;7 Vr—O 70,7 e::5C d%o -,5>. ,,if✓'o:'�J'.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow - gallons per day. Calculated daily flow �. gallons.
Plan Date �o—i3=o Number of sheets / Revision Date
Title
Size of Septic Tank Type of S.A.S. ��`�d l. �ed AIK�,Z
Description of Soil c•yrti,BF�'.r /y' �`
Nature of Repairs or Alterations(Answer when applicable)
Date s a e last t 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 issu by s Board of Health.
Signed Date I - '
Application Approved by S - Date
Application Disapproved for the following reasons
Permit No. ®���� Date Issued /v 2 2 o.3.
"Noz�'p3 r . 3 n. n, .»..._ Fee 1 P"
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
1 Yes
f: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS i
2pprication for 10i5pooal bpotem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade(XAbandon( ) El Complete System O Individual Components
Location Address or Lot No. S'J�t- �.G/i✓T VA7 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
��Ali LF�Oe vir :7Vr— 707
i)
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 �G' gallons per day. Calculated daily flow o gallons.
Plan Date Number of sheets / Revision Date -
Title
Size of Septic Tank /000 q�j �,rirT�%✓9 Type of S.A.S. A-leZ6 /-f_X Z Pll x "
Description of Soil, c�s%i�'et�c�es�± %y
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 Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by thins Board of Health.
Signed c✓ Date
Application Approved by '- S • Date
Application Disapproved for the following reasons
Permit No. Z 023--Tl y Date Issued 10 2 21,03
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that th On-site Sewa a Disposal System Constructed( )Repaired( )Upgraded(X)
Abandoned( )by LT..' ��� y
at �".Z's' �'l/�✓�' �T /lam/�'!• has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2003'S 14 dated ►e;17.7 w 3
Installer kl'/-Ii ZC4L!PP4"vim Designer e-P. /WA/fV'y .DP jh
The issuance of this permit shall not be construed as a guarantee that the s(ys�te wil. function ' esigriedr
Date I(� - 29- 03 Inspector ` - ,.ion
. V S
---------- ---------.---- ----.
No. ZG�1�S(`1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
33iopooar bpgtem Lon.5truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade)Abandon( )
System located at :S":, S'
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:Constructio must be completed within three years of the date of this pe t
Date: ���2 U:� Approved by
�—r
I
TOWN OF BARNSTABLE
LOCATION �� Ci�-'7` ��• SEWAGE #
VILLAGE 'd'To9✓r/"/e-efASSESSOR'S MAP & LOTt!:�,0,/- J
INSTALLER'S NAME&PHONE NO. ��� ZC-`•�'��'�s� ��rO a o7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /CLD. (size)
Flo cEt� gv ��J7xl�C0 •r-o0�,ct.
NO.OF BEDROOMS
BUILDER OR OWJN ,_R
PERMTTDATE: --"Q y-T-Z"p COMPLIANCE DATE: 6
Separation Distance`Between the: '
Maximum Adjusted Groundwater ble 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
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ASSESSORS MAP : ®./�. - ----- ------ -' ---- --
-101 ---- - TESTr HOLE L088
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SOIL EVALUATOR :� wl f 1 '�` G�� NOTES:
FLOOD ZONE:
- WITNESS : �
1 REFERENCE: �._o_.t'5A__ /OCe/ �.?� DATE:
— PERCOLATION RATE: � 1) The installation shall comply with Title V and Town of Barnstable Board of
Health Regulations.
' �� 2) The installer shall verify the location of utilities, sewer inverts and septic
TH- I TH-2 components prior to installation.
3) All septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.
5� 4) This plan is not to be utilized for property line determination nor any other
�/ / 6► O (,Ova purpose other than the proposed system installation.
11 I� 5 All septic components must meet Title V specifications.
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6) Parking shall not be constructed over H10 septic components.
LOCAT 1 ON MAP /I► ►I�Lj� [ Yj _
C -a (� 7) The property is bounded by property corners and property lines as depicted.
Yam, ��0r1 Glib 8) The property owner shall review design considerations to approve of total number
of bedrooms to be considered for design. Receipt of payment for the plan and
Alb installation based on the plan shall be deemed approval of the number of
„� / ,� �� �✓ 5� bedrooms.
9) The existing cesspool(s) shall be pumped and backfilled per Title V
Abandonment Procedures.
b G 9 UJI 1b ....�� 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut
grade as permitted by the Board of Health.
SEPTIC SYSTEM DESIGN
FLOW ES T I MATE
00 ----- BEDZOOMS AT �� GAL/DAY/BEDROOM - M GAL/DAY
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(�C� � PpT I C TANK
a2GAL/DAY x 2 DAYS - GAL
` USE WD GALLON SEPTIC TANKls�lhl
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SOIL ABSORPTION SYSTEM
1"�y
O S'I DE AREA: ��' �
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a._ SITE AND SEWAGE PLAN
LOCATIONM9Q
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PREPARED FOR :'���Cl.'� 6 oo� V -
SCALE:
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DAV i D B . MASON � DATE:
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a DBC ENVIRONMENYf L DESIGNS
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EAST SANDWICH . MA
DATE HEALTH AGENT ( 508 ) 833- 2177
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