HomeMy WebLinkAbout0174 RIVER RIDGE DRIVE - Health 1-74 River Ridge Drive
Marstons Mills P
A = 059 007007
TOWN OF BARNSTABLE
LOCATION I�iv� Rjd4 e )9r i Lo SEWAGE #
VILLAGE /1'1�rt`tys �, s ASSESSOR'S MAP & LOTS
INSTALLER'S NAME&PHONE NO.
l _
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Ali /,aldrs (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMPTDATE: 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) N�� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) 'Q Feet
Furnished by ;-°tin P. Re,1 to
4 f
v
its- To c Q✓!r
cow"
y
i
29
'l \ COMMONWEALTH OF MASSACHUSETTS
;Ws, e ,ExECUTIVE OFFICE OF,ENVIRONMENTAL AFFAIRS
4.,, *r, rf+�r- -r..•+a ,x,r'r :'i r n .- �o -.`t`ty .w?"� 2. •1:y:'.
a DEPARTMENT OF ENVIRONMENTAL; PRO
TECTION
3 ■
x t ECE-1 ED
�.�
'. iYU taPG.l.��'Y°— .!J V� •� Vi4 � � f�� 1 4. .� a
Of 1.2005
TdWN 4'F'BARMS�YABL^E
-H�.aLTH`DEPT. g.. .
TITLES ... .._. _ . ...
OFFICIAL INSPECTION.FORM-NOT„FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ;
PART A z .....
r, CERTIFICATION
Property Address:
Owner's Name: Jph.. C. s E%vrh R4/
Owner's A `•7 ddress: 7 i
Date of Inspection:
Name of Inspector: (please rint)
Company Name: �a / Hck of
Mailing Address: B� . tik
Telephone Number:_ .,�`D$ -�1?$ -99 79
s'•':t sf;t' l�..�v� °fir{ <�' v.. °- .,k.+�. .t3 .. $�'r.ir a ,�.'» Y ;v" fi�'4it�.:i i�.. i':S`?':".,
CERTIFICATION STATEMENT f r
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
belowis..true,accurate and complete as of the time of the.inspection.The inspection was performed based on my-
; i training and experience.in the proper function and'maintenance qf.on site sewage disposal systems:I am a DEP
approved system inspector pursuant to Section 15.340 of Title.5(310 CMR 15.000).:The system:
'• 'i
1,Q Ai_�!. :.
11-I"Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority 14
Fails
rk�i �..�E..i�p'. !r; r-':t�, •."`t 3�. t�: .� :�`. '.�;f y`. :f • _x� ,�t1� � e-. „t(." '�'.:;. � .,..
Inspector's Signature
The system inspector shall submit a co of this ins ection re ort to fthe A''rovin Authority
Y P PY P P ,PP g (Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
'.`Notes and Coinments-,r;
sax '1 a13,"Y'r10 st�_.,.�ra� �t a .?'x �x,:�.•lt -F.^2,.
1 > F -
.,
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.-
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL.INSPECTION,FORM NOT*OR VOI:UNTARYASS ES.S►i�riEK'FS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,k' �'''
PARTA
CERTIFICATION(czmtinuedj.
PropertyA�ddress: I7y ff,' .e-
• /17ar s e+s � /s A g
Owner:. ZOA C, /9a It,
Date of Inspection: -17—ef
Inspection Summary: Chgck,A,B,C,D„or E A ALWAYS complet6V of$et0A&.D
•1" 1!
A. System Passes:
I have not found any information which indicates that'+any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
�A
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. .
Answer yes,no or not determined(Y,N,ND)in the 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 fiffirm 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. f R
ND explain;
Observation of sewage backup or break-ouI 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.System4ill pass inspection if(with.
approval of Board'of Health)'
•$ t broken pipes)are ,>
obstruction is removed ; s w.
4 s distribution boic is leveled or replaced
ND explain:
The system required pumping more thati 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction is removed
y"`'s�., • � :��lt�,,�;"k P,i: ..d.�. :^oe, ,.,t• xi`9. . .. , , ;�`�,t t .. : `.ra.4'C ,:ri: .,.,.� r, . .
}..:w.sr•a i,.x :«.:„yh,rc��o.t . �.' `F�'k"~..;X ,sa#'t; ;tC:: r.• r ,4'',�..r .. ..._ 'f'. t, - ..
ND explain:,
Page3 of 11
OFFICIAL"INSPECTION FORM'-NOT FOR VOLUNTARY-ASSESSMENTS
# SUBSURFACE'SEWAGE DISPO$AI;;SYSTEM INSPECTION FORM
4
PART .;
CERTIFICATION:(continued)'
Property Address: /7'! Ri v1 r /r ij �r VIP
AYE CJh t /r t
Owner: �G�ti C f�nvr a g4 .Date of Inspection: S /7—O
C. Further Evaluation Is Required by the Board of Health:
Conditions exist which require fu ther'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
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 aseptic 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 froid a
private water supply well".Method-used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no-other '
failure criteria are triggered.A copy of the analysis must be attached to this form:'`,' "t4
3. Other:
•±l . ,.N •t�-J••v X•
3
Page 4 of l l
OFFICIAL INSPECTION FORM-NO'T,FOR VOLUNTARY ASSESSMENTS °
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTIONYOIZN.,-I'
PART A; .
CERTIFICATIO N-( �)
Property Address: 17 )PigV o
;,+
Owner: eIPyK C-%Ana 4e
Date of Inspection:
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspectioris�
Yes No
— .✓ Backup of sewage into facilityor 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
_.L/Liquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow
_ _Z 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 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. .
r,
_/`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.
r/•_Any portion of a cesspool or privyAs less than-100-feet but greater than`S,O feet fromaprivate water
supply well with no acceptable water quality analysis. [This system passes if the�wm waler analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
Indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
„,,,are triggered.A copy of the analysis must be attached to this form.],,,,. r ,.
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
- w,'
E. Large.Systems:,q1 . .f ;. f
To be considered a large system the.system must serve a facility with a'design flow of.10,000 gpd to 15,000
gpd. ,
You must indicate either"yes"or"no"to each of floc following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system"is within 2001eet of a tributary to a iiirface dcinkuig-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.
4 M1
Page 5 of l l
a OFFICIAL INSPECTION FORM NOT,FOR VOLUl'TARY ASSESSMENTS
SUBStMFACE_'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. . . PART B ,
.." CHECKLIST
Property Address: /741. .R,s.1, "o
Owner: 4),06f C,FAnnC flletfo
Date of Inspection• , S—/Z—or
Check if the following have been done:You must indicsate`"yes"or"no"as to'each'"of.the following:
t! r, i --Yes No f: Y 4.. . �
— — Pumping mformationwas provided by the,owner,occupant,or Board of Health-
.. ' ✓.Were any-of the system componentspumped 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 N/A)`
Was the facility or dwelling inspected for signs of sewage backup?
— — Was the site inspected*for signs of break out
— Were all system components,excluding the SAS,located on site?
r� 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 information on the proper
maintenance of subsurface sewage disposal systems,?;
• ., i .. Ali '.t a •,•.t•4.1 IA,. a .. t:, ,A..:E F ie'J-' .4, /t�A . S.,Y � 1.
The size and location of the Soil Absorption System jSAS)on the site has been determined based on:
Yes no
✓'— Existing information.For example,a plan at the Board of Health. a.1
'P t Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR.15.302(3)(b)]
p ,
�.i i:3i�'.;�--'�3tA� 3. �_....1 .... "'I-e •.4Y_�;.t i �. `�.M .l v � _ .�.. . n'{*-'• - '
Page 6 of l l
OFFICIAL INSPECTION.FORM NOT FOR OLUNTAPW ASSESSMENTS . °
SUBSURFACE $EWAGE DISPOS�YSTEM INSPECTION FORM.
tiro '. ... .PART C
Y
SYSTEM INFORMATION
Property Address: l7`1 /jwav /Qial 1 �riv� ,
r
Owner: 0,94-1 C, + An o.t t7o It;
Date of Inspection:
FLOW CONDITIONS'
RESIDENTIAL-` '
Number of bedrooms(design):. I Number of bedrooms(actual):' -9
,- DESIGN flow based on 310 CMR 15.203(for example:-110 gpd'x Wofbedrooms): '330:'qpd
Number of cu rrent,residents: o '
Does residence have a garbage grinder(yes or no); 11 o
Is laundry on a separate sewage system(yes or no):Alp [if yes separate inspection required]
Laundry system inspected(yes'or no).-
Seasonal use:(yes or no): Ns
Water meter readings,if available(last 2 years usage(god)): N 11'<4;e4t4m PT f pr%H 44P
Sump Pump(Yes or no): Wo
Last date'of occupancy: S 8 QS M _r
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203) - 7. mod •,
Basis of design flow(seats/persons/sq%etc)
Grease trap present(yes or no):
#y . ... .,:
Industrial waste holding tank present(yes or no):_ x
Non-sanitary waste discharged to the Title 5 system(yes or
Water meter readings,if available:
Last date of occupancy/use: ,.
OTHER;(describe)i.
GENERAL INFORMATION +
Pumping Records:: ,.., f ..;. . ., •. ,: _:,. , r E;;. e
Source of information: obyne.- '+6 towr, r.Edhhd> h0./ R y,n 416r ylarS�
Was system pumped as part of the inspection(yes or no): Alto
If yes,volume pumped:_gallons How was quantity pumped determined?
Reason forpumping: A10 f D++r'+c4.tc� �y .t a��rpsf'a�f OWr1I/
.Y}. •'d'�' . !.±4g. a,,.it. r� [ .. x,'k. , - .. '4"�!. ..Tk.. 4` .{ • tr. ,id:. -. .. .. '. I
TYPE OF SYSTEM
!/Septic tank,distributionbox,soil absorption system
_Single cesspool ` . . . _- , ,, a pl ": c s
_.Overflow cesspool +
.. Privy .;14y f ..p :. . Yj P.`r .. ,. .. +. {;.�{• +ry t j , r ,r y r b`
_S•hared s stem(Yes or no)Cif es attach previous inspection records,if anY)
_Innovative/Alternative technology.Attzch•a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval.
Other(describe):
A roximate age of all components,date installed.(if own)and source of informs ion:
� O
u,NJr
�tpto� yarJA 4 D6aX w/,t•. �i0iisl- �� If, ,�pp�c� �plol �nS ���t® y ytars Csfye C�
Were sewage odors detected when arrivin"at the site(yes or no):A/,
6.
Page 7 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
A SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
, •.�.of�t dZe.�Mi .,Y:.y ,t,l�` ..N s.t��,s++. ,.x. �. yt ' 3 :fPi"1Jc1a Cf.�.. .,:+ . a ..•8 t,?:`i-+. .. 'A Ste;'
SYSTEM INFOR IATIO_ N(continued)
3An
Property Address: /7zy �/v+✓ �� �r/vF
Owner: Job,., C. * .q..Ht /dal • k,
Date of Inspecgon: S—/7-0f
BUILDING SEWER(locate on site plan)
Depth below grade.
Materials of construction: cast iron 40 PVC other(explain):
Distance from private.water supply well o . ine:
Comments.(on condition of joints,venting,evidence of leakage,etc.): .. _
SEPTIC TANK:_(locate on site plan)
Depth below grade: IS
Material of construction:_ oncret metal_fiberglass jolyethylene.'.`t'
other
(explain) 4... . . . . ...
tank is metal list age:_ Is age confirmed by a Certificate,of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: S 6 x" T �
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: /g"
Scum thickness: 3"
.Distance from top of scum to top of outlet tee`or baffle:
Distance from bottom of scum to bottom of outlet.tee or baffle: 20 -
_ How,.were dimensions determined.:``'`iyll6tKrinq .r00 >; `
Comments(on pumping recommendations,,inlet and outlet,tee'or-baffle condition,structural integrity,liquid levels
as related to outlet invert,
Sep7�•Gevidenc eof.leaka e,etc.):
+;", 4- co-di " s at'-s r-do-ry of l HGDy9 ....4tr,f 1 (�
Grphy
GREASE TRAP: (locate on site plan) "
Depth below grade:
4, Material of construction: concrete metal_fiberglass polyethylene_other.,,._. ...,_....
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum.to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7. ..
Page 8 of,l 1 .
��`". �'L ,�t�r'b-s. , � .)••r-r s�" & s;^yq ,. +•+-'•''.� .�.. � sPt "` 'gin°'p•<"
OFFICIAL.INSPECTION�FORM ,.140'"* 'I R V�1�.uNTARY ASSESSMENTS
SUBSPACE SEWAGE DISPQSAI,■/'SYSTEM.INSIiECTION FORM: .
SYSTEM 1'40RWATION(continued)
l i
e
Property Address: /9 41 /Pint r lPi � pry v.� ,t._; .'x.•.,,., j .�, t •i"
Owner•
HG o
Date of Inspection: 5'—/'7—oS" -'
TIGHT or HOLDI
NG TANK: tank mu
st be at time of'
( an siteplan)
Depth below grade:
Material of construction:'_•"-concrete metal fiberglass t polyethylene + other(explain):
Dimensions:
Capacity: gallons.
Design Flow: gallons%day
Alarm present(yes or no):
Alarm level: ' Alarm in working order(yes or no):•
Date of last pumping:
Comments(condition of alarm-and float switches;etc.):
Y present
DISTRIBUTION BOX: (if must be,opened)(locate on site plan)
., i
Depth of liquid level above outlet invert:""® "
Comments(note if box is level and distribution to outlets equal,any,evidence of solids carryover,any evidence of
leakage into orout of box,etc.): A
•9Flow k'vd- . 0'.• air. Cv✓-?i' cv.
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 ofpmnps and appurtenances,etc*.
.. M:;.5 i r'.��'.i+k .. a t .. ..4n e'.jl., •� .r..,:'1.. r :1 t ,.E..;y -.ir. " �.%)L r. .=f .i±.v •1 V • •a.,Y.i '
Page 9 of I I
` OFFICIAL.INSPECTION FORM: 'NOT.,FOR VOLUNTARY ASSESSMENTS
: SUBSURFACEUWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address k7l
%> #
fir#4rS Ok1 s
Owner:-Jd4N
Date of S"—/7—os" }
1lIISpeCtiOII: ,
SOIL ABSORPTION SYSTEM(SAS):— (locate on site plan,excavation not required)
If SAS not located explain why:.. �> y
Y
Type
leaching pits,number:' .�
leaching chambers,number. w
leaching galleries,number.
leaching trenches,number,length:
leaching fields,number,dimensions: - - ~--
overflow cesspool,number:
r innovadvelaltemad.ve system Type/name of technology: J'g
_C rat rJ
" omments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
ys .14Ai 4.9try lei �4 0k�-e -foot. �J;i,i '." tv hp ���N•� s�ow�'* .
Q eyt2 •f iroQ OH ba M— J//1w4P by Zys4 /�N` eOr
-- -
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 or no): '
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
t
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.):
• erM �r +ar`?S�t�a�s ,ay ay;•ii'.>,t xwrt�.M�"u
9
Page to of 11
� OFFICIAL,INSPECTION- OI �rFOA
T CORM-�NO� '�OLVNTXAY-ASSESSMENFS
M`SUBSURFACE SEWAGE I)TSPOSAY;`SY�'FENi INSPECTTON.-FORM "
• , PART C . N:;t� • ' �
,XY TEM INFORMATION(continued) ,
u
Property Address: /77 IZ/�/✓-1r /1 01
• Q 3 Ohl IY1,11s MX _
Owner: 7Aq C, f a.�.e ,*•.
Dsta of Inspectlon:_ •J-•17—OS ,�' s'•,,;;. .. ,, #_t s; a4 ,.
4':r?. ., :,�a�."'nr.. .. , .. ': it .. ad >s •�•�.� '•_rr_ .. 1 . •%
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent;eference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. .
dV.r A ,12
,
,
-yam;Coe
ON
vt .. lip t[ovri. 9#, "*>
J
IT
-
10•
Page 11 of 11
OFFICIAL'INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE S-..WAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
-Property Address: /7y iv fr Dri r-�
Owner: `croAki C,. .+ i7144- R4 / I : ...
Date of Inspection:
SITE EXAM
Slope
Surface water ... .
Check cellar -
Shallow wells
Estimated depth to ground water 4/$. feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record'-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 156 feet of SAS) '
Checked with local Board of Health-explain:
Checked with local excavators,installers-'(attach documentation)
V Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
�"mt E�,ev I�Y4 iS 75-.1
' /3e ow• 0 3 �S Q ,' -70 '
s of ato&t r.e . 30'
60 ra e.&. ARy " 0. o 17 S�...4 G 1 W P4 Ai y 6
7 �7 TOWN OF BARNSTABLE "�3� �/
r .-U.
LOCATION Ili 7/ -iYr �_ SEWAGE # —
VILLAGE ,,*,\ ASSESSOR'S MAP & LOTV ! �
INSTALLER'S NAME & PHONE NO. _V*iCt=-iC Cey� 5�
SEPTIC TANK CAPACITY , 0-00
LEACHING FACILITY:(type) (size) (gyp
NO. OF BEDROOMS 3 PRIVATE.WELL O �P�UBLICW&TE
BUILDER O OW �T\rJ �JC.�
DATE PERMIT ISSUED: E3 L�3
DATE COMPLIANCE ISSUED: -
VARIANCE GRANTED: Yes No
30
• � w
'L0
�7
ITT .. . .... ... Fss..... �,� .
y THE COMMONWEALTH OF MASSACHUSETTS 160—.1
( � BOAR® Off` HEALTH S q - 7 -7
70-w.& ................OF..... l s4lS Lames------------....................................
Appliration for DhipmFal Workg Tomitrnrtiun rrranit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
... ............. � ------- ----------- ------------------------------------------------
.q
eLocatio -Addr/s or!�t �o.
im -----------
Owner Address
a •--...... �.1'1T..l. �� ........................... ................ .........................................
Installer Address
Type of Building Size Lot___--1�'f 547....__Sq. feet U
Dwelling—No. of Bedrooms........... ...........................Expansion Attic (A►') Garbage Grinder , )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -----•----------•-------•.....................•-------.-----------••-••-------•----------•-•-----••------------------•--•--•------•-••-•------------•-
..tea---_gallons per person per day. Total daily flow.............. ...........gallons.
W Design Flow.............................. g P P Z Y• Y
WSeptic Tank—Liquid capacity,14A.Z.Ingallons Length.S...P`..... Width+!:1Q'__ Diameter-_._--~---. Depth..0;Vie!..
x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.__s'AL ........ Diameter.....&......... Depth below inlet...6............ Total leaching area..!��P ...sq. ft.
Z Other Distribution box (A ) Dosing tank ( )
aPercolation Test Results Performed by...VAx3'W=..t �'� .. '�1419..U ............ .................. Date... 7•..__..........__.
Test Pit No. 1.._Z--------minutes per inch Depth of Test Pit...../: ._.... Depth to ground wat ........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground DF ,_
a .............•-------•---------------•-•......-•-•----•----•-------•............-----•-•--•••.•-•-••.................... -------------- -
O Description of Soil------0-_-'`�--Q. '�• 'N .. .51b5_tz:�t. .......... N
x �,
W d -L q. 'fin = G4F _._ . .........= -------------------------------------
x --------••------------------••---•-----•---------------•--------•-....•-----•---...----•...--------------•--------------------•-------------•-•------------------
—Answer when applicable...........................................................
0 Nature of Repairs or Alterations __ $►o �StST�+�_�
----------------------------------------------------------------------------------------------------------------------------------------------------------------- - ---
Agreement:
c�i4
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy accordance wit i/ �,
the provisions of 4-
p 5 of the State Sanitary Code— The undersigned furti�er agrees not to place the system in
Operation until a 7C e of Compliance has been issued by the board f heal q
igned _.... ?...
to
Application Approved By........... �~ _ _____ ____ ____________ .......... �
......
Application Disapproved for the following reasons-------------•-•----------------------------------------•------------------•-••----------._...--•-----...........
Date
Permit No.------� � .. -•---...
•-----
Issued........-•- •----;LL---'��(�-•- -----------------
lo..��. ://� .. Fss. _....._
.f THE COMMONWEALTH OF MASSACHUSETTS 100
BOARD OF HEALTH
1vw�L . ............OF..._i&a, ' r.to
ApplirFation for Disposal Works Tonstrnrtion Vrrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
� _. ._. .:
.....................................' .... .� ... . -
-------- - ---------- --•-------•-
•Location-Address / ��/,C/Jl1/\{!IA)pn., � or Lot No.
................ -c,Y"t 4R....._. ............:.. _l_ .. --•----CaJ -._L v-KI..T :_.._..!vZr__.!�Cr c4------ �r'"°'5---•-•---._...------....------...._
wne Address
---- �' 1 ....1�� a' ?1: ...............•-•. ................gom4l'Z ..---Mf_.l ..........................................
Installer Address
Type of Building Size Lot._..IA.,_�`17.......Sq. feet
Dwelling—No. of Bedrooms........... ............................Expansion Attic (t,,) Garbage Grinder4/q)
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures ____________________________
W Design Flow________________________________ �.__--gallons per person per day. Total daily.flow--.-..-...____Z_--3 C....____-___._.._.gallons.
WSeptic Tank—Liquid capacityt gallons LengthC.T __-. Width`+•:A0.__.. Diameter-.--'�'-- Depth_.........
x Disposal Trench—No_____________________ Width_- -_-.. Total Length._.__.._______._._ Total leaching area.................... ft.
Seepage Pit No...�??c ------- Diameter.....a........... Depth below inlet............... Total leaching area_�o®____sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
'" Percolation Test Results Performed by. x T"�!?-__E_.�J YS=___________________________________ Date-?�� 7-.�� ___-_-____._-_---.
aTest Pit No. 1... Z--------minutes per inch Depth of Test Pit -_1A6<<____ Depth to ground water-----------------------
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground w �F
P4 •-•••--•••--••••••.....------••--•--••••••••-••--••-•-••-•----•.....•••••-•--•--....•---------•----••-•-•----•-------•---- ---- Ass
O Description of Soil-__._b_='o`'__ 10 i 1 .
P `.._... r �TEPNfi�F �G
V - 3&'-:•141" rY ca- Cackp_t_e :1csv%,A € &ruv�C ,n
-•- --•-•�-•---------•----- ----•-- ---•-•---------•-•-----------•---•------------- ALUYIN--------�
----------------------- ---•--------------._.-._...---------------------------------------------..__ .............................................................. •--••- vi
V Nature of Regairs or Alterations—Answer when applicable----------------------------------------------------------- VA o_30216 Q
-------•---••-•-----•--------------••--•--••--•---••--•----•-•--•-------•----....-._._..--------------------.._..-----------....----•-----•••--_....-----•--••....... 90 _G/STE
Agreement: S N �
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste i c e with 4Wwe-
the provisions of TITLL
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
opera ion until a"1C • e of Compliance has been issued by the boar of healt
boar'
,�
�r igned -•-- --...••••••••-•- fl` ` ........
Date
Application Approved By--•------- . ..... --'`"` •-•- •-•- -•--•-•- J= - '.......
Date
Application Disapproved for the following reasons:--_-_-_-•-_-_-_•--_-_______•_______________________________•...................................................
•-•---••---•----•--------------------•--------........--------------------••-•-•••-••--•••--••ti-••• - -4'••-
T Date
Permit No._:j'46 T=-- - -- ------------- Issued_------
e-
THE C MMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... ......................-.-.......
Trrtif irFatr of Tomplianu
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) Repaired ( )
.. ------....-•---•--••-•--•---------------------------------•-•----------...--•-----•--••--------
Installer
------------
has been installed in accordance with the provisions of TITIE 5 of The S ode as described in the
application for Disposal Works Construction Permit No....... � .___ -____ d--- --------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO RUE® AS A UARAaNTEE TH T THE
SYSTEM WILL FUNCTIO S F TORY.
DATE............................a- -�._.. .._ •..................... Inspector-•--- • ---•-----•-•--_••---. -• •-- ---•----.....................--
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD �OF HEALTH
...........
.....
FEE .............
Diopoo Works�01�
ion rrntit
Permission i ereby granted...... ......:..-- -• .._ _ _.....,.t� ' � ! ...`—� u , ':._....
to Construct ( ) or Repair ( ) n I dual Sewage DisposaYSystem
- 7.....................................
as as shown on the ap licat• n for Disposal Works Constructi mit N ;.___e{ __ DWd................._ __Q_._.
Bo d of ealth
DATE ••- - -•q ---__-----•-------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN OF BARNSTABLE
LOCATION, /7 / If ree A-e4e 1q1 SEWAGE it a 001 — /7 y
VILLAGE_ lf o 5 All,AS ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. C, /J<, /l'o
SEPTIC TANK CAPACITY /'x. SL-;2 /OHO
LEACHING FACILITY: (type) sLrr*rK79v3 (size) lD W)(3 0'c
NO.OF BEDROOMS 3
BUILDER OR OWNER /Mo!2 16
PERMITDATE: 3~ .23 a o� COMPLIANCE DATE: �� I
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
,. ,- ,
�� _ .,-
S g• i .�
�-- �uX
� � - -.r_ % �.X�f
• y-1�,�''�fNasr'7
a: 7 a M
( � K ..-
f
���� � � �I
�,,�
1
2
o. ea / * Fee
1V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYtcation for 30i5pogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(i/)Upgrade( )Abandon( ) El Complete System []Individual Components
Location Address or Lot No. /7� /�v��Q�r/g P /Q�/ Owner's Name,Address and Tel.No.
/G
p
Assessor's Ma /Parcel ' " "Ef�G"v +fin '� /vloy rp
U (� f3 �rR�;v1�f
Installer's Name,Address,and Tel.No. ya�_gSys Designer's Name,Address and Tel.No.
74C A4/tom 1,
R,9 AY
� a•, `l o�Gy�
Type of Building: ,'33 AG 9,hJ.'�,'s:�) �
Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder(Al)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) lye 7fp�� nsc w L«,ti gr,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 Certifi-
cate of Compliance has been issued b this Board of Health.
Signed Date 3Pa3'o�
Application Approved b Date
Application Disapproved for the following reasons
'Permit No. (mil l--� Date Issued
�� I
No. 9-0"d! `- / ' ., ' Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yee
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
121-Mication for Mioogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( A Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /74/ If, e /V Owner's Name,Address and Tel.No.
Assessor's Map/Parcel All,4'4 J7V
G .�h
Installer's Name,Address,and Tel.No. �sog) y�&_yg "r Designer's Name,Address and Tel.No.
T-C AFmd,
21•, �s OOGyF1
Type of Building: ,33 a,- (� �i14• 6 bJ.�•n�')
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Al)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures +
Design Flow 3 3 4 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
t Y
Nature of Repairs or Alterations(Answer when applicable) f %��j To/� ti��. L�.r ti G�•u
/tvy>�►^s i0'WA �X R"D
Date last inspected:
''Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed;. A Date
Application Approved b Y V r. 1.� Date � "�2.
Application Disapproved for the following reasons
Permit No. __0 60 0- `:/ ,4�7 Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS ` "`
Certificate of Compliance � 1
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandoned( )by ,ii-1 140
at i#r. 4-VI , ,- '- .! has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nd,;O r dated e. A- � � ar~ l
Installer f. Aw //o Designer
The issuance of this permit s all not be construed as a guarantee that the syste W71 fun 'c on-as detigne
Date hi jot Inspector
r
No. I Fee "a t
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Dioogal &pgtem Construction permit
Permission is hereby granted to Construct( )Repair( ,/ Upgrade( )Abandon( )�
System located at /7`/ Rv,-t-- R�g& X--W
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this perrmit.
.>
Date: 1 / Approved
f
ails. .��'-.�k •, ,+ i„+m"•y^ct.dr .+-'fi >2'0
f. fk �ik-•�. `�'=3--•"� { -.! r {jam
TOWN OF BARNSTABLE
LOCATION %7�� /�,yr� IVI-d�r �� SEWAGE # a04j — l7�(
VILLAGE__ /N�vS 5 iYJ�/ ASSESSOR'S MAP &LOT —7-1
INSTALLER'S NAME&PHONE.NO. S. C. 1-9 //o
SEPTIC TANK CAPACITY Y. St "7
1
LEACHING FACILITY: (type) �r (size) lQ WX 3 0 Z K d (7
NO.OF BEDROOMS 3
DT T"TT T\ O/l,DERyri ER All-
/0
. .. .. R O\
PERMITDATE: 3 3 .2 04 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
1: within 300 feet of leaching facility) FeeC.
Furnished by
„/ Y ..
l 4�-
K '
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated
� , concerning the
property located at meets all of the
following criteria:
This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
✓• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
i/ • There is no increase in flow and/or change in use proposed
(� There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation, [Adjust.the groundwater table using the Frimptor method when
applicable]
V• If the S.A.S.will be located with 250 feet of an vegetated wetlands the bottom
Y veg b o om of the proposed �
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation a 7. +the MAX. High G.W.Adjustment. = a 7 5
DIFFERENCE BETWEEN A and B
SIGNED:— DATE:
[Please Ske proposed plan of system on back].
NOTICE
Eadd
ed upon the above information,a repair permit will be issued for bedrooms maximum. No
itionall bedrooms are authorized in the future without.engineered septic system plans.
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