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HomeMy WebLinkAbout0033 PENNYCRESS DRIVE - Health 33-PENNYCRESS, LANE A=122;069, ve- l i I . f TOWN OF BARNSTABLE LOCATION SEWAGE # V`,LLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 SEWAGE PERMIT NO. ;!�g� WATER TABLE „e LOCATION NO. STREET 47 Wonyer INSTALLERS JNAME A//DDRESS,:J�, �'l"� �Od� D ATE PERMIT ISSUED DATE OF INSTALLATION DRAWING OF INSTALLATION ON BACK ��� l� �i `� P� � - ' �t\ i` t _ � � '� °� . . � � n TOWN OF BARNSTABLE t/ LOCATIO N3 SEWAGE VILLAGE ,1�L� A SESUS MAP & LOT INSTALLER'S NAME&PHONE NO. + o 7 7 7"=0(, SEPTIC TANK CAPACITY EX LEACHING FACILITY: (type) FIrG (size) NO.OF BEDROOMS 3 BUILDER OR OWNER_A PERMIT DATE: _ `C COMPLIANCE DATE: 'Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r y91 i a l vT 4. A . _ t i 1�10. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Iigpogar *proem Congtruction Permit Application for a Permit to Construct( )Repair(-4 .Upgrade( )Abandon( ) O Complete System Xrtdividual Components Location Address or Lot N4P?V P CY esslUkle Owner's Name,Address and Tel.No. Assessor's Map/Parcel I ZZ_Wl�plOb -T4f- \\kb ti�:Y 5-T-0 ae Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. adT� Type of Building: Dwelling No.of Bedrooms 7-2 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow d gallons per day. Calculated daily flow ��� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /� �- Type of S.A.S. r CR Description of Soil Nature of Repairs or Alterations(Answer when applicable) t22-0 y 14, e P Y1, w{j L-r c' & 0— 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 n ' tal Co and not to place the system in operation until a Certifi- cate of Compliance has been i y this d H alth. _ Signed Date Application Approved by n. Date Application Disapproved for the following reasons Permit No. Date Issued Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I/ w. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migogaf *pgtem Con!5truction Permit Application for a Permit to Construct( )Repair(144Upgrade( )Abandon( ) El Complete System XIndividual Components Location Address or Lot No.' (�/ CY Pc �Gt V� Owner's Name,Address and Tel.No. Assessor's Map/Parcel p � ¢ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ( Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. f,Persons . f Showers,( ) Cafeteria( ) Other Fixtures Design Flow U gallons per day. Calculated daily flow gallons. Plan Date Number of sheet'§ Revision Date Title Size of Septic Tank `Lis d LA Type of S.A.S. 14 r 46 CU Description of Soil ./U 04-wi Nature of Repairs or Alterations(Answer when applicable) ( -���( 1421 ✓a 1�C-� d1=/ !�� dc", t�4L1 _5rl�+r�U �a�- 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 /th n tal Co and not to place the system in operation until a Certifi- cate of Compliance has been i ` Signed / Date Application Approved by f Date Application Disapproved for the following reasons ; Permit No. """' Date Irssued ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(N Abandoned( �ennucp-e,&5 by Pi/'b- C�`1"i0 5E � at a ®s r has b e constructed injaccordance with the provi 'ons of iitle 55 and the or Disposal System Construction Permit No. 0-1dated Z �l Installer o Ha e-r I6 be l4 S Designer The issuance of this permit shall not be construed as a guarantee that the sysstt fund o�designed, �G, (/Date q —7 S- 9 Inspector ^�r -fivl/t�t v No. � -- - �� ---------=----Feet THE COMMONWEALTH OF MASSACHUSETTS ` f PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogar *pgtem Coi5truction Permit Permission is hereby ante to Construct( Repair( )Upgrade Abandon( ) System located at yes�' I a4-1 - (0 �' 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`Constructi n mus be cpmpleted within three years of the date o "s p t. (� l Date: Approved by { �0 r L3 /-13- TOWN OF BARNSTABLE LOCATION /= ri+A/ / sae SEWAGE_# 9 9—6 VILLAGE ,/lid. /YJi L C� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. .L— ' 7 7 Q(, �Y SEPTIC TANK CAPACITY rX LEACHING FACILITY: (type) ti FJ� ,¢7'`G C(size) '_h� NO.OF BEDROOMS BUILDER OR OWNER hA LI-L,, tf'�, PERMTT DATE: 1 —L( ``� r—T COMPLIANCE DATE: 2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland-and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by • , 't, fit. t` _ Used For the Repa Ir.Of Failed NOTICE: This Form Is To Be r, Septic Systems 0111Y• _ SKETCH AND APPLICATION FOR A CERTIFICATION OF SKE ITHOUT 1 WORKS CONSTRUCTION PERMIT (W DISPOSAL ENGINEERED PLANS) ' hereby certify that the applicstion for d1spoW k dated , the -don pectnit signed by me ;. "i meets all of the ptopetty located at ,j following criteria. ; o le�hinp hdiib► � I j • 't%m are no wetln+ds located within 100 Poet of die propoeed }, welb wlthM ISO Poet oh o proposed owk ; i '1'ltete w Owe ` I i d no bmw M dog►mWot danpe in tie , pO110 Valffficmmw or raede�. of the ' Kg flea f h►wm be hopted withis 250 het of ant►wetlands,the button+ /Itdte proposed be toasted less then fourteen(14)feet above the tnaxiMum adjusted rM6ilitY will OQt ► ` lem table eleratim J the fenemer 1 , F please complete , ion(amwin0 to the gnsineettns Divl�lon G.I.S.map) ?op of orednd Elegy Table Btevatlon(eocadMs to Health t)Ivlslon well.map).1-- ,, ; z ;;i g) rNer i SIpNEO: WALLER M THE TOww OF BARNSTABLE NUMBER_._.. LICBNBt t)SEFMC swifwd oh*dten• tANN&•dw1&00 etdn pN/ewd•yM".'AM•Ire»tl•en»d haAatlw mow. this Oho should be snbnllltedl• a � � y ' � iMa1B iW�cot t J i TOWN OF FARNSTAB VOCATTN� �� 5 SEWAGE VII.LAv rss,SSESS0 S& LOT INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY kC= °l , LEACHING FACILITY: (type) (size) 1000 4.'1h-'1 NO.OF BEDROOMS BUILDER OR OWNER Q,OaJc to �DVLA. EOMWDATE:--em,`Cl�i, COMPLIANCE DATE: Separation Distance Between the: Marimum Adjusted Groundwater Table and 10 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 ' (✓`—� 2 3� 3 b4- 35 COMMONWEALTH OF MASSACHUSETTS } � � EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS,, ` DEPARTMENT OF EN iRoNMENTAL PROTECTION sF,O. J WINTER STREET BOSTON MA 02108 (617) 292-5500 �® ONE n to ®e + yntir g,, WILLIAM F.WELD OXE> Governor Sec ta rery, ARGEO PAUL CELLUCCI DAYIDA FSTRUHS Lt. Governor V4fter ��2 SUBSURFACE SEWAGE DISPOSAL T p LSYSTEM INSPECTION FORM PAR CERTIFICATION Property Address- DateS Address of Owner G v C1r'rl\4c�Q�,y� of Inspection: v't`5 (If different) Name of Inspector: M yr— I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: 'r L- Mailing Address:'? i—� �r3 a.� � T T. M►� CjZ,��� Telephone Number: CERTIFICATION STATEMENT have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and I certify that I p y p I: P . . trainin and experience in the proper function and maintenance complete as of the time of inspection. The inspection was performed based on my g p P P of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evall Approving Authority F ils Inspector's Signatur uatio t a Date: OA L The System 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 Environinemal Protection. The original should be sent to the system owner and copies sent to the buyer• if applicable, and the approving authority. INSPECTION Si,NZlA.RY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be 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/ZS/97) Page I of 10 f� 1 1 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 P due to a broken. settled or uneven distribution box. system The s will ass 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 DETERMII'Yi FS THAT THE SYSTEM IS NOT FUNCTI0NM' ;G IN A . MANNER WI-UCH "'ILL PROTECT THE PUBLIC HEALTH AND SAFETY A:ti'D THE E\'VIRONhfENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AN SAFETY RIND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. AS is within 50 feet of a private water supply well. "c tank and soil absorption system and the S p PP Y _ The system has a septic rP Y _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or-more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (appro)dmation not valid). 3) OTHER • I I (revised 04/25197) Page 2 of 10 . 1 1 1 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection` D] SYSTEM FAILS: 1 LJ 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 I 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. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public 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 II 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 INSPECTIOI'FORM PART B CHECKLIST property Address: SSS Owner: 41'AaNF6L)SZ�QsL Date of Inspection: \CL Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No NoPumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped 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 NIA. _ 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, naterial 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. l\ _ Determined in the field (if any of the failure criteria related to Part C is.at issue, approximation of distance is unacceptable) —1 [15.302(3)(b)] (revised 04/25/97) P2ge 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: CN'��-1 Date of Inspection:`k ci C i, FLOW CONDITIONS RESIDENTIAL: Design flow: _,SC p.d./bedroom for S.A.S. Number of bedrooms:C-'3 Number of current residents: 0 Garbage grinder (yes or no): fJ Laundry connected to system (yes or no):� Seasonal use (yes or no):_L, ) Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): t-21 Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GE`'ERAL INTORINIATION PUhIPNG RECORDS and source of infgrmation: N l to, System pumped as pan of inspection: (yes or no)_L1,(( If yes, volume pumped: gallons 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) I/A 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)=U (revised 04125/97) Page 5 of 10 t � 6. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: � Date of Inspection: $i t. Ct BUII,DING SEWER: Pro (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) t Depth below grade: �Zl Material of construction: &concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list ace ` Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 99 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 relati n to outlet invert structure tegr'ty. evidence of leakage, etc.) r '�'^ '� T U. �'' �� � 1 C�i►\ 1 V 4 — 0r C,` 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.) I (revLsed 04/25/97) P2se 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ''j etJN yCt�xss �� Owner: +r►4`; 5�� Date of Inspection: gkk$19� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 2. . � 3 y a► - ,3� ���a3 3s (revised 04125/97) P2gc 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 .+r'v.{CcLtSS Owner: Date of Inspection: Depth to Groundwater �1 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation-of Site (Abutting propeny, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) 1 � t � (revised 04/25/97) Page 10 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: P2N N N — Owner: V 0"C-'i `M X_ Date of Inspection. ������ TIGHT OR HOLDING TANK: t—�3 (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/day Alarm level: Alarm in workinc order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) )ISTRIBUTION BOX:LS (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.) IJ'i-fi t '�SLQ\C'ce or z0,1s�1 PUMP CHAAIBER:-7 (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 04/2S/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -—W'IA A� Owner: ��SZ Date of Inspection: `\, SOIL ABSORPTION SYSTEM (SAS): �1 (locate on site plan, if possible: excavation of required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:A�-Xb leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: 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 vegetgtiott, etc. CESSPOOLS: L� (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: M3 (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 s of to THE COMMONWEALTH OF MASSACJ-fUSETTS BOARD O H EA T -.... .. ......... .. OF........ .. , 3 Application 'for hipoottl Workii Tonmrurtioo Vrrn it h� Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: N _ ` I 4.4d.-, -- �'r �C q /,L�caation-Address or Lot No. ....... ...:�............---•------------•................................ Owner Address .......................................................... ---------......-----•---...-•---...........---•-•-•---.....--------•--•--...................-•---- Installer Address U Type of Building g Size Lot. `/11?:— ------Sq. feet Dwelling—No. of Bedrooms---_---__.�..........................Expansion Attic ( ) Garbage Grinder aOther—Type of Building __--_'_—............... No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------............................................................................................................................................... W Design Flow...............:� _.._.......___.____-__gallons per person per day. Total daily flow........... A.c___._--_____-.---.....gallons. WSeptic Tank 4 Liquid capacity_--.___-__gallons Length---------------- Width................ Diameter..........------ Depth.-.._--_-_-_.._ x Disposal Trench—No. .................... Width.................... Total Length-------_............ Total leaching area--------------......sq. ft. Seepage Pit No-____-..Kl______ Diameter.../Pe!:�Pj Depth below inlet.... .............. Total leaching area----__-__-_-----.sq. ft. Z Other Distribution box ( ) Dosing lgJ( d/6 - ��, �'— 6 aPercolation Test Results Performed by.__ _ ,��4......_ ... ...................... Date-___-------_---.--.-_-______•_----...... Test Pit No. I................minutes per inch Depth of Pest Pit....... ---------- Depth to ground water..................-.---. rX, Test Pit No. 2................minutes per inch Depth of Test Pit---------------_.... Depth to ground water------------------------ -------------- - ................ / O Description of Soil._._....... A-L-1 .'� _.- ..,------------------------------------ x P `'... .... - �L V - � ------------------ W x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------_---._--_-.. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- Agreement: The undersigned agrees to install the afgredescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has- ee issued by the be�ar. of health. ned ` �'� t -------- ------------ Application Approved B ,.�............ Date Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ---------•---------•--•--•----------------••-•----------•-----•------•---•-----•----•------•---------•---------------------•----------------.....--------...---'' x Date PermitNo......................................................... Issued..................... Date r 6-1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH fry............OF....... /...� .. ;!,�1 ......................... Applirtttiun -fur Uhipviittl Works Tatuitrurtiun Prrntit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal yst t / vtv --•--- SS Scat`n-Address or Lot No Owner Address ------••--•.....................•........... Installer Address U Type of Building Size Lot_Z!1if7S......_.Sq. feet Dwelling—No. of Bedrooms..................................................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building --.- _-____ No. of persons---_______________________ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow............. d......._._____........gallons per person per day. Total daily flow...........Z. 6........____...__..__gallons, WSeptic "I'ank / Liquid capacity_- __--_---gallons Length..... .......... Width................ Diameter--.------------- Depth..-..-__...... x 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 W Percolation Test Results Performed by.._t_-(C, _.. __� �.A_______ �_ >_- Date-------------------------_.-------- ._. 1 Test Pit No. 1----------------minutes per inch Depth of "Pest Pit......... -_____-- Depth to ground water_-_-.--._--._---.---. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--------------------- -------------- ... W O Description of Soil C)__-_..1.. y •. ---/ i<a ' -^- - -- x ----1Z '` --------------------------------------------------------- ---W U Nature of Repairs or Alterations—Answer when applicable.--------------------------------------------•_---.-____-_-_.----.-----------------.-..--------- --------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-b ee n issued by the b areof health. Signed 5S !. ---�----5---�-------------------------------- ......o/!z � ' Application Approved B — ��`"-" _n.r=-----f. ./. / Date r Date Application Disapproved for the following reasons:---•--.-.--•--_-•----•------- --••--•---••-•-----------•-•-•---•-•-•-------•-•-•---•-•--------------•---- -------------•----------••----.....-------•-••--•-•-----•-•-•-----•-•---••-------.--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............!.r7,7_7......OF........ . .............................................. Urrtif irtttr of f.1,11ntplittnrr THIS'/IS PTO C,#RTj FY,�That the Individual Sewage Disposal System constructed orRepaired ( ) b ---•--` .. '--------- .. alter y.._.. c ....:............ !�........_.....__._...__.._..__._...._................_._.__....._........------..............._......__. t 1'n has been installed in accord;,tnce with the provisions of XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit ---------------- dated...� ..`..r z:..__" --C- THE ISSUANCE OF THIS CERTIFlCATE,SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................................................... ---- Inspector.................................................................. ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1........OF........�: .............a!:%--....---................................... No_...../..��. / /J �i��u�ttl urk,�,(�un�tr/ur�iun rrutit Permission i`s,hereby granted-' ✓, -! /- ,/-,t ----- ................................................... to Con >' (� ) or Repair ( ) an Individual,"Sewage Dispo 1 yste ~- / atNo. - �./Z'!'- I� � -_ C�--�--y -------------------------------------------------------- i✓ - -_ - 7K.1........1.�. -. - _.._ I// Street as shown on the application for Disposal Works Construction Pe -'it No..._.._._.�-:;r�� ated_-/d- /. •-_ - ...- -- (f _ Board of Health DATE.................•........-=- I FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L o T S : 2I,, Zq -7 s,F, 0' �1lr+G } LAV. i wel L - - : co 1000 l Ca': f at. . +� eac�lnq 'PI C. 20 1 15ePt 'k 1x L e8 c Y►1H •` 10070 +yre_..exPansio»`� �2 re �� TeS+ hole .loea�ioh .< . tv >w. { s CERTIFIED PLOT PLAN AIE�J CONSTRUCTION ONLY _ + " Lo-r 5 SuQRE}' D>���E' USTERUI�LE ; TOP OF FOUNDATION IS 2•? FEET ;y IN : # ABOVE LOW , POINT OF ADJACENT � SAgnS SS " t�. a ROAD. SCALE: 1 "- 44 DATE: ocT B 197 � L1?RE` E ENGINEERINS COIN so i CERTIFY THAT THE yn�'p�U+�1 M} CLIENT Rass Gip r SHOWN ON THIS PLAN IS LOCATED y GISTEREO REGISTERED CIVIL LAND JOB N®• �`�-- 0.N THE GROUND AS"IGIOICATED ANt? ' S CONFORMS TO THE ZONING LA1�S � -ENGINEER SURVEYOR DR:'8Y=,: _ OF BARNSTABLE H. } x ` Of ` CH.BY*, 3?► NO. MAIN ST 712 MAIN ST. `E ^SO.YARMOUTH, MASS. HYANNIS, MASS. SHEET 1 OF 2 DATE REG. LAND $URVIlYO�t`y� t� k �- 'x � y Moog I .., .S- .:_ ��=: ;=+ x �- �. s. :;�� of i f,>,rw^-P `';4 _*>gr,=� .^"."€ :;"�` -rS,:.�-. ,u�X... ...�""""t"^+*`:�``S°^ •c �,:;.. r^+a;�t�s.+..;r:..<r.,.x. .�. IN.. , N t> n MIN. lot. � z PfPEc4CR CwEley.= IOO. ^AN SAND COV ERS �tt PITCH13 F� 4 T CONCRETE If3 COVER L.IQUtlD a = L E1f£t too + 4" CAST IRON PIPE 2" LAYER MIN m Il4,tt PER'tC1i_ y$EPT# `; W . . . . ; • OF 1/8 3/8tt TANK # IS' :. V4tASHEO a FT ^ ° +� o. • . o STONE of } i IT�TI ' • .�! ,. ytSHED STONE a . r#.• � a' ear♦ , _�^ ! ♦ •f ♦ a` f ♦ # a * ,PRE; ST: -BIEPt�it3E Rw� i• .- �r-,�-,. ar' .... -_. c-. p - 7. $L's - .•eta J''TF. .�'. - '�" _ i �_. � d'•y�„'^a�� :.'�"h'c-^a+' - :.�,.-�.- :; pg.+ ..' ''.....' ;4;..._.. ._eti v- RK DIThy1y}��., y(r{( _.f x+ •i:� lNL:I`TEE PAGE:. 1 I T T 9 5 SGALF' : 1/4 /-0 .9 f " UsU.LATION _{ DESIGN . CAITERIA - DIMENSION A _ . F MISER OF BEDROOMS Z DIMENSION' " 8__' FT..' r GARBAGE DISPOSAL UNIT 1 DIMENSION C_ 4- FT TOTAL ESTIMATED FLOW 2 00 GAL/DAY SQL LOG SOIL TEST AMBER OF SEEPAGE PITS � l _ ELEVATION SIDE LEACHING PER PIT S DATE —_1_.�SQ FT Loam,_. _ _ ._.__._.�._ -OF SOIL TEST BOTTOM LEACHING PER PIT ,U8 SQ. FT RESULTS WITNESSED BY TOTAL LEACHING AREA G 6 _ PERCOLATION RATE Lc ss 1 ham Z. M!N/IWCH RESERVE LEACHING AREA 2 66 $ ." FT. 24 a . '�, ,- 'S' Fti•l,�yT.'g,u �+`��� a t�,f� �. •1Alf, - ... • - E o a El.D AGE. S NG1NEERING tNC MAi1��S"t'r 7t2 MAIN ST. ` y x., +. -. 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