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Home My WebLink About0240 MISTIC DRIVE - Health 240101 TIC pijVMARSr MILLS A = b�d � ��ti _ i J /� I a� � ;. �, �Av- kq "n TOWN OF�1BARNSTABLE ul-OCATION i�„e �/�r i,� i C. A yc,- SEWAGE# Z 011 1 0 VILLAGE %�o�� ASSESSOR'S MAP&PARCEL 6 57 0 - t�- ik,qS`fALLER'S NAME&PHONE NO. 6: rP11iJU Syr_*77 0 7 —r SEPTIC TANK CAPACITY G 7.0 LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER -bp-plorcid PERMIT DATE: . N-,Z 2-13 COMPLIANCE DATE: + 2.3- L o I3 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 (-44A!)2 06 A-1=30°3 y - a a=33 e No. Fee yam/ /— �V THE COMMONWEALTH OF MASSACHUSETTS Entered incemputer: Yes, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21pplitation for jBisposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2.t4 a Misr" ,c ff 4-1*"^41) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0 a-p ® %a- Al Der ltrzi o Installer's Name,Address,and Tel.No. G°s+ d e Gw*xp-ytS Designer's Name,Address,and Tel.No. J LjZ��1� Type of Building JLI/ �It3 Jijxk Err WV,f t-,c Dwelling No.of Bedrooms I Lot Size �2t 000 sq.ft. Garbage Grinder( ) to & ; Other Type of Building No.of Persons Showers( ) Cafeteria( ) !� Other Fixtures Design Flow(min.required) gpd Design flow provided gpd #_bo+1_ Plan Date jAL Number of sheets Revision Date e�f 1- (r Title JJ5 Size of Septic Tank Type of S.A.S. f U/ Description of Soil Y, q� -f Nature of Repairs or Alterations(Answer when applicable)_ 14—l-0 l t) h . P, i5�o 6 4� 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 Certificate of Compliance has been issuedttv this Board of Health. S 17n Date q_ 2 a j 3 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued Fee D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS \I 4plitation for Disposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.Za0 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel D S-D - p la Al )a`la rz%J l,pr, Installer's Name,Address,and Tel.No.GtA(Ae_-,,4t Designer's Name,Address,and Tel.No. ) Type of Building: I��V 13 0,1,j 1 v V' t t�,c J-1 v ✓�� Dwelling No.of Bedrooms Lot Size ( t$+ �0 0 f— sq.ft. Garbage Grinder( Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ^ I t Design Flow(min.required) gpd Design flow provided gpd - J Plan Date � '� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. fUr Description of Soil <� J 4 G j�l�l Nature of Repairs or Alterations(Answer when applicable) llD.d` 4-<.ti (�Oo (�-1,0 11C�c7 4 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 Certificate of Compliance has been issued by this Board of Health. Sg ed Date - Application Approved by �/ ( _ � �i �� Date Application Disapproved by V Date for the following reasons Permit No. Date Issued ---------------- ---------------------------------------------------------------------------------------------------------------------- Tlti E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-'site Sewage Disposal system Constructed( ) Repaired V Upgraded( ) Abandoned( )by L L r- at Z`� (� t'(i 5 T+�L !11 r3+� � (��` has been con tructe 'n acco . ance with the provisions of!Title 5 and the for Disposal System Construction Permit N dated Installer (�4eej Z c1`, 1bg1.1Vev,1 e, a L� Designer /_j_ #bedrooms y Approved design flow y V gpd The issuance of this permit s all not a construed as a guarantee that the syste�•w,ll`fu ct.o '3esigned. L Inspect( Date � �3 �3 o�-� X.�(L.y=• ! ^' ------------------------------------------------------------------------------ ----------------- No. � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,-MASSACHUSETTS Misposal 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair(u ) Upgrade( ) F Abandon( ) System located at 2qu M+S + G D(;J C M 4.f_,kanf, ✓k\�S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with + Title 5 and the following local provisions or special conditions. Provided:Construotio 44� W_sbcompleted within three years of the date of this permit. Date Approved by Town of Barnstable Geographic Information System v April 26,2013 5�a -..�C� '44 C" • � } �n M 4 ". . * �-.�' `�'. ��f � .p. t' � tJL�i � r 4 r m e_, w 3 , t a e $ s il u r s y f w - , �. ��.,,� ink'-� YoB i mu iw�r hln om1gnmippgl i ... w 1.� rn, m. U121 �p��tii nm iiruD!! i_ i nVlvi0.i 4 °j,: ""Nw'-Wi CuU7�m '�➢II�IIo yw..}�..+,. _'111�7Q�Ni{a I�WWAn IRIS P� r IIN lrli,�m{(�I �fiNI' pr ,. � i �yii�J' {!.:•�U��ii��n WN of wgpiAi..i➢von;: au. A k� L t � s>� '�Cn u^ a .§r�n,_ v e,� .�.+ i, '- .wn ef'my R e 77t` . #`` r" a vft E; a Hamblin Pond Use r t� m a. r � +g 3 x Y _ a r&r ` It� h � z � .e +4,. ••k:, x q -x,.a .,s q^i�. ., t \. a• .y;..°s.. �. 2 , �4 28 Feet . ° DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:080 Parcel:012 Selected Parcel boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:DE FLORIO,ALBERT R&DONNA Total Assessed Value:$703400 1"=100'may not meet established map accuracy standards. The parcel lines on this map w are only graphic representations of Assessors tax parcels. They are not true property Co-Owner: Acreage:1.11 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:240 MISTIC DRIVE such as building locations. Buffer Aerial Photos Taken April 19,2008 AsBuilt Page 1 of 1 1✓- TOWN OF BARNSTABLE LOCATION SEWAGEV T �. SEWAGE # VILLAGE AS1SESSOR'S MAP INSTALLER'S NAME PHONE NO. SEPTIC TAN CAPACITY- () r9�s :j LEACHING FACILITY: type) anQ�,L, (,,,J (sue) T1 NO. OF BEDROOMS_'�_PRIVATE WELL PU C WATER IJU. L BUILDER OR OWNER yV RN 1�� J r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: � VARIANCE GRANTED: Yes No AAa sc&<- A 4 � Q-b (orsA aka('r� http://issgl2/intranet/propdata/prebuilt.aspx?mappar=080012&seq=1 4/26/2013 01 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 240 Mystic Dr. Property Address AI Dc Florio owner Owner's Name informatl#)n is re Marstons Mills required for every MA 02648 4-23-13 page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important When A. General Information filling out forms o``%��utt rrppr�ri on the computer, �.�` (N OF iqg.... I lv use only the tab I /► _ ��`ya� key to move your 1. Inspector. t/l/�1\�J � y cursor-do not =�:' JAMES James D.Sears =� . use the return =c):. 617AM5 m,'r key. Name of Inspector o ;cry CapewideEnterprises,LLC Company Name 153 Commercial St. /�� 1�I1INStP1G�� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was,performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 51310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ,1� 4-25-13 JRgectors Signature Date 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. ""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. LQ,,4t5hs•3113 TAIe 5 Of icial Inspedsurface Sewage Di osa!System ge 1 of 17 Apr 26 13 07:1 Oa p.2 1 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13 page. City/Town State Zip Code Date of inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E 1 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 16.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,°please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): tSlns•3113 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 2 or 17 Apr 26 13 07:11 a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Ownefs Name information is required for every Marstons Mills MA 02648 4-23-13 page_ Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ire•3/13 Title 5 Olfidal Impedion Form:Subw lace Sewage Disposal System•Page 3 of 17 Apr 26 13 07:11 a p.4 Commonwealth of Massachusetts �VTitle 5 Official' Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13 page. Cityrrown State Zip Code Date of Inspection B. Cerditcation (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in e. l is less than 6" below invert or available volume is less than %day flow 64Cfllwl. t5ins•3113 Title 5 Omdel Inspection Form:Subsurface Savage Dleaosal System•Peg-4 or 17 Apr26 13 07:11a p•5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k 240 Mystic Dr. Property Address AI Dc Florio Owner Owners Name information is required for every Marstons Mills MA 02646 4-23-13 page. Cityrrown State Zip Code Date of Inspedion B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a.private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) urge Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to IS,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Aupection Form:Subsurface Sewage Disposal System-Page 5 of V Apr 26 13 07:12a p.6 Commonwealth of Massachusetts Title 5 Official inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owner's Name information is every Marstons Mills required for eve MA 02648 4-23-13 page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done, You must indicate"yes"or"no'as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with infiormation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): - 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Tide 5 Orlldal Inspectlen Form:subsurface Sewage Disposal System•Page s of 17 Apr 26 13 07:12a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owners Name information is required for every Marstons Mills MA 02648 4-23-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal tank D Box four infiltrator's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes JZ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011A0.000GaIs 2012-43,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gaaons per day(gpd) Basis of design flow(seats/personslsq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Tille 5 Offidel Inspection Forrrc Subsurface Sewage Disposal System-Page 7 of 17 Apr 26 13 07:12a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owners Name information is required for every Marstons Mills MA 02648 4-23-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank Attach a copy of the DEP approval. L1 Other(describe): t5;ns•3113 Title 5 official Irrspectlon Form:Subsurface Sewage DBposai system•pop a ct 17 Apr 26 13 07:13a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owners Name information is required for every Marstons Mills MA 02W 4-23-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: D Box and leaching permit#95-796. Note: New Tank 2013 permit #2013- 140 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 5'&' feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 5'rest Material of construction: M concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-20 1500 Gal.Precast Sludge depth: Dry-New Tank trtins-3r,3 Title 5 MUM Inspection Form:Subsurt"Sewage Disposal System-Page 9 of 17 Apr 26 13 07:13a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address AI Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13 page. cityrrown State Tip Code Date of Inspection D. System Information (cost.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Dry Scum thickness Distance from top of scum to top of outlet tee or baffle Dry Distance from bottom of scum to bottom of outlet tee or baffle Dry How were dimensions determined? New Tank Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): New H-20 1500 Gal.Precast Tank in and outlet Tee. Both cover's at 6"below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-W13 _ Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Apr 26 13 07:13a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete. ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins-3113 Title 5 Official Inspection Form:Subsurrece Swage Disposal Systerr.•Page 11 of 17 Apr 26 13 07:14a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form a s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 240 Mystic Dr. Property Address AI Dc Florio Owner owners Name information is required for every Marstons Mills MA 02648 4-23-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover; any evidence of leakage into or out of box,etc.): Camera out to box. Box is clean and solid. No sign of over loading or solid cant'over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): `If pumps or alarms are not in working order, system is a conditional pass_ Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.3f13 Title 5 Oft"inspealon Fwx Subsurface Sewage Disposal System-Page 12 of 17 Apr 26 13 07:14a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address All Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13 • page. Cityrfown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number leaching chambers number: 4 --- ❑ leaching galleries number- 0 leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): Leaching is four infiltrators wl 4' stone per asbuilt camera to D Box. No sign in box of over or solid carry over. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction -- ---- + Indication of groundwater inflow ❑ Yes ❑ No Mns•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Apr 26 13 07:14a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address All Dc Florio Owner Owner's Name information is Marstons Mills MA 02648 4-23-13 required for every _ page. cEtyrrown State ZIp Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): tsins-3113 Tllle 5 Mehl Inspection Form:Subsurface Sewage Disposat System•Page 14 of 17 Apr 26 13 07:15a p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owners Name information is required for every Marstons Mills MA 0264B 4-23-13 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks- Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ( 02 1 13 1_4 3 3 z 3 i' O 13 3 t5fns 3113 Tine 5 Dftal ftpedion Form:Subsurface Sewage Disposal System•Page 15 of'7 kpr 26 13 07:21 a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13. page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallowwells N� 28' Estimated depth toFigh ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: pate -— - — ------ ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: No G.W.28' Per past report on file at B.O.H.9-8-99 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5i ns-3113 Title 5 Official lnspedion Form:Subsurface Sewage Disposal System-Page 16 of 17 Apr 26 13 07:21 a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Mystic Dr. Property Address Al Dc Florio Owner Owner's Name information is required for every Marstons Mills MA 02648 4-23-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ire-3113 TWO 5 klWal lrtspeaior Form:SuDswraae Sewage Disposal System page 17 0177 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI^ %8_I j=1 ION DEPARTMENT OF ENVIRONMENTAL PRO t�T ONE WINTER STREET. BOSTON. NIA 02108 61'-292- bb Sip Fo F.VYILLIA�' WELD 1`99 TRL'DY COXE `� Govemo: Secretan DAVID ATRUHS ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A �� 1 CERTIFICATION 4�0 ''` � Address of Owner: Property Address: 02 °�y- ✓J�� ' Date of Inspection: e'1 _61 ^55 (If different) r Name of Inspector: I am a DEP ap ro ed system in ector pursuant to Section 15.340 of Title S (310 CMR 1S.000) Company Name: . ,�r� c f u' '..•� 'r`r� ' Mailing Address: -Ce 4/' J-P-SL - —Zode — Telephone Number: S 0 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 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 _ Fail ^� Inspector's Signature: . ' 1 Date: - The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental 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: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM R 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 replaced or repaired. 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 the 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 04/25/97) Page 1 of 10 DEP on the World Wde Web: http:/twww.magnetsiate.ma.usidep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY,PASSES(continued) Sewage backup or 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 if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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'JS NOT FUNCTIONING. IN A MANNER .� WHICH WILL PROTECT THE'PUBLIC:HEALTH AND,';SAFETY AND THE ENVIRONMENT:;- _ Cesspool orpw� is wtthin:SQl_teet of,a surface water;' Cesspool or privy is within 50.fiiiv of.a.bordering•vegetated wetland,or a salt marsh. 2) SYSTEM WILL FAIL UNLE55 THE BOARD OF HEALTH IANQ'PUBLIC`WATER SUPPLIER, IF APPROPRIATE) DETERMIN , ES THAT THE"SYSTEM IS FUNCTIONING" IN A�MANNER THAT€.PROTECTS THE PUBLI,G HEALTH AND SAFETY AND THE . 'ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAShand 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,sol absorption system and the SAS is within.'_a Zone i of a public water supply well• The system.has a septic tank and soil absorption system and;the.SAS is within30 feet:'of a private water supply we The system has a septic tank and soil absorption system and the SAS is less than 100 feet but,'50:4eet or more from a private water supply.well, Unless a well wateranalysis for ebliform'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 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 02 t(0 Owner: Date of Inspection: q R D) SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: 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 identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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. Ej 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 health and safety and the environment because one or more of the following conditions exist: 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 ll 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 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: g Q—q, Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yesr No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have beenpumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components. excluding the Soil Absorption System, have been located on the site. 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. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/2S/97) Page 4 of 10 e _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `® PART C SYSTEM INFORMATION Property Address: C�,2 C/o Owner: A14611 / Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:-��.PA/bedroom for S.A.S. Number of bedrooms:�i Number of current residents: 2— Garbage gnr.der (yes or no):4L- Qs ' Laundry corrected to system (yes or no): Seasonal use ryes or no): Water meter readings, if available (last two (2) year usage (gpd): 'Sump Pump (yes or no): iJZv Last date of occupancy: COMMERCI.AUINDUSTRIAL: Type of establishment: Design flow: t:allons/dav 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: System pumped as part of inspection: (yes or no)!yLt7 If yes, volume pumped: ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) o (revised 04/25/97) Page 5 of 20 d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 02 Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: 7 Material of construction: _cast iron _40 PVC vother(explain) Distance from private water supply well or suction c Diameter L Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade:�� Material of construction: oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) i Dimensions: Sludge depth: A i r Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: ✓ "'-e Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: 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.) GREASE TRAP: (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 04/25/97) Pago 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Ad ssss:: -2�0 � Owner: �`/� Date of Inspection: TIGHT OR HOLDING TANK: (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 flow: gallons/da\ 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:_/ (locate on site plan) Depth of liquid level above outlet inven: �` Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (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 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -2 Va Owner: Date of Inspection: 01_ SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: �, y � leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.) . CESSPOOLS: _ (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 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: - qD 4all Owner: Date of Inspectidw. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells withbn 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSJTEEM, INFORMATION (continued) Property Address: Owner: L Date of Inspection: Depth to Groundwater-2g Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Deterimine it from local conditions :� Che -with local Board of health Check FEMA Maps Check pumping records Use local excavators, installers 1, Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) Page 10 of 10 I sf TOWN OF BARNSTABLE LOCATION Q 1 L SEWAGE # VILLAGE ASSESSOR'S MAP LOTg d—e,17, INSTALLER'S NAME & PHONE NO. ; SEPTIC TANK,-CAPACITY � .;. O Lp.L LEACHING FACILITY:(type) l(�A�L (_J (size) S NO. OF BEDROOMS _PRIVATE WELL PU ` C WATER BUILDER OR OWNER �n DATE PERMIT ISSUED: d� DATE COMPLIANCE ISSUED: ✓� 1°" VARIANCE GRANTED: Yes No Arlon a k9y At cl�V V TOWN OF BARNSTABLE "fir LOCATION M�(�'�'CLC. SEWAGE # VILLAGE ASSESSOR'S MAP & LOT0,9 e a-d,�� ., INSTALLER'S NAME PHONE NO. SnnY� 0 SEPTIC TAN CAPACITY �r LEACHING FACILITY:(type) T-1 W L,r (size) S NO. OF BEDROOMS- -(_PRIVATE WELL PU C WATER_ BUILDER OR OWNER VOJ � C r v DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No iAAa se& Ai-o Lt9 b A U 4-o 9 .. f' ) ASSESSORS MAP NO. O No. PARCEL N0: 3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rwt TOWN OF BARNSTABLE Appliratiott for Diopooul Workii Tomitrur#ion Permit Application is hereby made for a Permit to Construct ( ) or Repair lam ) an Individual Sewage Disposal System.�..t. �. . > .. ......................................t...Nd/p�. .,. _....._....(.. .... ............. .......------------ ..----- . ._... Loc Is °, -ok .................................... ...Cc-U... a Own r t`J�� Address ............................ C ................................... ... '.` ................ . .. ...... Installer Addres Type of Building Size Lot............................Sq. feet_ Dwelling—No. of Bedrooms--_...�.................................Expansion Attic ( ) Garbage Grinder V Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .................................................................. .................................................... .................................................:................. ....... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity.f0'.0gallons Length---------------- Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq, ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.............•••-•---••••-••••••-•-•--•............_...................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil.............................................................................'............................................................................................. ............................•--------......---............-----•---------------.............-•---------.....--------------...----------------.......----................................ --•••-..-. I.......-••-•••......•-•........ ...-••--.......... Nature of Repairs or Alterations—Ans r when applicable.._A3 d-....-- ----- - - �" ------•�tf-•�t4 Agreement: J The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with the provisions of TLITI U. 5 of the State Sanitary Code — The undersi :er agrees not to place the system in operation until a Certificate of Compliance has bee sued by the bo, d of Beal Signed........ . --- Uv! ...._.. Application Approved B .... ..... ............/. ...... Date Application Disapproved for the following reasons--------------------•---------..........---•-----.....----........-----------•--•-••-•--•......................_ .............................:...••--•----•--•--•-•.-•e rg-........._......--------.....-- ..................................Dat ...__......... Permit No....21 � _ ......... Issued................ ................. :...::. • Date e No....5.? ...2�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diopoiittl Worko Tonotrnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair V an Individual Sewage Disposal Systemat: I...... �� ..__r�. ... 4..�........ r............;cam... .........••• •.......••-•................. t ............................_.......... ss or .. ............. -Addre .. - Owner ........ �...V.- , ..... „l. ... . .. , .t.. ................. ---- . ...... �. Installer Ad ress Type of Building Size Lot..................I..........Sq. feet Dwelling—No. of Bedrooms.......3n..............................Expansion Attic ( ) Garbage Grinder (NO Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..............•--------------------------.....--------.-•-•--......••-•--••••.......---•-•--.......................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity../CoOgallons Length................ Width................ Diameter................ Depth................ Disposal Trench— No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.........--......... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) - Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water............................ Test Pit No. 2................minutes per inch Depth of Test Pit.......--........... Depth to ground water.............--......... ------------------------------------------------•-----......----......•••...........................••....................................................... Descriptionof Soil.........................................................•-•-•----...---.......-----------------------..................----.........-----.............................. .---------------------------------------------------------------------------- -------------------------------------------------------------------------•-..................... ---•............. --------------------------------------------------------------••--•••-•.....••-•------••---.......••••--•-----••-••••••.......••-••••....---•--.....••••--••••-•.....-•----•--•....... Nature of Repairs or Alterations—Ans(er when applicable.---A-Jr- - -------- -----f (• `-;;;sLs.� -------L f�.r- �> -..... �- "� c ..... ... ... N2 f!�` 7 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLI 5 of the State Sanitary Code — The undersigned fur =x-egrees not to place the system in operation until a Certificate of Compliance has bee sued by the bo o lie h. Signed..... - t �.:..: .. ........................... J�. . .. ........ Date Application Approved Bv..-.... .. ... .__- - : • tom - .......... Date ✓ l�vr% '.......... � ..............................Date.._ Application Disapproved for the following reasons:............................................................. ....•.••._ ...........................................................................•---......---.......----...........-•-•-----...._....._......---..__._......._....-•---....__........... .Date.............. Permit No..... '--� Issued •-:� . .._.... -• --- Date LP 5... z THE COMMONWEALTH OF MASSAC!-USE. .S BOARD OF HEALTH TOWN of BARNSTABLE Trrtifiratr of faomPHUM THIS IS TO CERTIFY, That the.Individual Sewage Disposal System constructed ( ).,or' Repaired by.. .c�..._ :.._ .. .............................................•------------•-•--•--...-----............................_ Installer {'• . -.� ------------------------------------------------------------------------ at...................... has been installed in accordance ith the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. ��,.niCUED dated.... �THE ISSUANCE OF THIS CERTIFICATE SHALL NJI; CO AS A GUARANTEE THA THE SYSTEM WILL FUNCTION SATISF TORY. DATF........... ..........�......•---------------••-••---- Inspect �r.. .... ..... .. . ....._.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` � i TOWN of BARNSTABLE FEE.........-4 Rio oottl orko Tonotrnrtion 11rrntit ^ Permission is hereby granted...... ti .._.-L`` to Construct ( ) or Repair ( )/an Individual Sewage Disposal System atNo... ! _._� .x. --------- -----------------------------------------------------------•--.--.---- ol -• ro`/ C j tr�ei as shown on the application for Disposal Works Construction Permiti�i�--��1�Dated`2.-�... ��.. :7 .. .. ..... - - I[eal DATE.. - j-�.—..��` ----