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HomeMy WebLinkAbout0419 RIVER ROAD - Health A 4I9 .RJ ver Ro .d Marstons Mills A= 060014011 i f -\ COMMONWEALTH OF-MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: J2xeh J Owner's Name. Owner's Address: C g Date of Inspection:. '� j� a_ 41 r-a Name of Inspectq please print) F r ».. cd Company Namee Mailing Address: jl® /l fln/) 09 m Telephone Number: fS"6 9 :2 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the in rmatiomEeported below is true,accurate and complete as of.the time of the inspection. The inspection was performed based ori�my training and experience in the proper function and maintenance of on site sewage disposal systems..- am a DEP approved system inspector pursuant to�Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa7Is d Inspector's Signature:__ Date: k The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall.submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection,and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title.5 Inspection Form 6/15/2000 page 1 Page 2 of l 1 OFFICIAL INSPECTION FORM NOT FOR'VOLUNTARY ASSESSMENTS% SUBSURFACE SEWAGE DIS�OSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ;2 ,l Owner.,. �I Date of Inspection:. a "0 i Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: i I have not found any information which indidates that any of the failure criteria described in 310 CMR 15.303 or.in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: 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 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. . i ND explain: i 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): PPi broken pipe(s)are replaced obstruction is removed distribution box is leveled.or replaced ND explain: i The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with.approval of the.Board of Health).: broken pipe(s)are replaced obstruction is removed i ND explain: r Page 3 of i l OFFICIAL INSPECTION FORM.-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION"FORM PART A / CERTIFICATION(continued) L�'� a Property Address: ��_ e Owner:t Date of Inspection: (Va C. Further.Evaluation is Required by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of:Health determines.in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if an.y)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 coliform bacteria and.volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no�other failure criteria are triggered. A copy of the analysis must be attached to this..form. 3. Other: 3 Page 4 of.I 1 OFFICIAL INSPECTION'FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 'y*' // C' � d Owner. :�, Date of InsP ection: , D. System Failure Criteria applicable to all systems: You inust indicate"yes"or"no".to.each of the following for all inspections: Yes No _ 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 closed SAS or cesspool Static liquid level in the distribution box above-outlet invert due to an overloaded or.clogged SAS or cesspool, V Liquid depth in cesspool.is less.than 6"below invert or available volume is less than %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 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. 4� Any portion of a cesspool or privy is within 50 feet of d.private water.supply well. Any portion of a cesspool or privy is:less than 100 feet but greater.than.50 feet.frorn a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at.a DEP certified laboratory,for coliform bacteria and volatile organic compounds S indicates that the well is free from pollution from that.facility and the,presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,.provided that no other failure criteria are triggered..A copy of the analysis.must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described.in 3I.0 CMR 15.303,therefore the system fails.The.systern owner should contact the Board of Health to determine what will be necessary to correct.the failure. E. Large.Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following:. (The following criteria apply to large systems in addition to the criteria.above). yes no _ 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: t 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 3.10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: „ y Owner. _ _ y Date of Inspection: ,{ c 30, , 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 N/A) 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 information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on-- Yes no -/ Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance. is unacceptable) [310 CMR 15.302(3)(b)] , Page 6 of 11. OFFICIAL INSPECTION:FORM NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: ,i7 5,1/ 64 Owner. Q ° Date�of Inspection: �l FLOW CONDITIONS RESIDENTIAL t-' Number of bedrooms.(design): Number of bedrooms(actual): DESIGN flow based on 310 CMRR 15.203 (for example: 11.0 gpd x#of bedrooms):3 Number of current residents: 10 Does residence have a garbage grinder(yes or no): f' Is laundry on a separate sewage'system (yes or no):/ [if yes separate inspection required] Laundry system inspected(yeVr no): b Seasonal use: (yes or no): �-"`-3 Water meter readings, if avail �C'w �able (last 2 years usage (gpd)): �r � � ` d00 /°M Sump pump(yes or no): y Last date of occupancy: COMMERCIAL/INDUSTRIAL N() Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq ft,etc.): Grease trap present(yes or no): Industrial waste holding tank.present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION PumpingRecords Source of information: i Was system pumped as part.of the i spection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined?. Reason for pumping: TY 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). _Tight tank Attach a copyof the DEP approval. Other(describe): Approximate age of all component , d.te installed(if known)and source of information: Were sewage odors.detected when arriving at the site(yes or no):✓VC) 6 Page 7 of 1-1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Z,9'1 ^ ;r i f zdw . A/jA Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Ale) Depth below grade: Materials of construction: cast.iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): d 'SEPTIC TANK locate on.site plan 15 Depth below grade: ,tLUJJ- Material of construction:,,concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list'age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ Dimensions: )c Sludge depth: , Distance from top of sludge to bottom of outlet tee or baffler . Scum thickness: pr . Distance from to of scum to top of outlet tee or baffle*-. Distance from bottom of.scum to bottom of outlet tee or b ffle: (" How were dimensions determined: ') tZv Comments(on pumping recomme dations, Inlet and outlet tee or baffle condition, structural iritecirity, liquid levels s related to outlet invert evid e of leakage, etc.): � m� V?4iW GREASE TRAP: ocate 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 oflast.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 I OFFICIAL.INSPECTION FORM-NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 1 Date of Inspection: &4- 4 -cw't-"' o 69 TIGHT'or HOLDING TANK::(tank.must be pumped at time of inspection)(loc.ate on site plan) Depth below grade: Material of construction: concrete tr.etal fiberglass polyethylene olher(explain);. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: • (if present must be opened)(locate on site.plan) Depth of liquid level above outlet.invert � ielpltC4) Comments(note if box is level:and distribution tequal,any evidence of solids carryover,any evidence of lea age into or out of box etc.): ' _ a�— 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.): 3 Paze 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address:. n A. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type i-Zleaching pits,number- leaching chambers,number: leaching galleries, number: leaching trenches, number, length: leaching fields,-number; dimensions: overflow cesspool, number: innovative/alternative system- `type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, CESSPOOL 3 (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no . Comments (note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:/t(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.): 9 Page 10 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART,C SYSTEM:INFORMATION(continued) Property Address: VZl . e Owne Date of Inspection: d SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate afl wells within 100 feet..Locate.where public water supply enters the building. r. 01 r0 _rcl'r) IJ <� 0 ]0 Page l l of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ PART C SYSTEM INFORMATION(continued) Property Address: 7f Owner . R Date of Inspection: C__)00 SITE EXAM Slope Surface water Check cellar Shallow wells } Estimated depth toground water 7 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators; installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 7 is -e: ' 11 `-il` T. Permit Number: Date: Completed by: �e,c_lp AW yv.L HIGH GROUND-WATER LEVEL COMPUTATION Site Location: / � � Lot No. Owner: �l f G Address: Contractor: + I C� A dress: � 6Y Ll f�j'j�` `✓r,� r. � Notes: .�✓Pa _''�� STEP 1 Measure depth to water table 7 to nearest 1/10 ft ........... ................. Date ° � '= month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well............................ ............. .��. OB Water-level range zone ................................... STEP 3 Using monthly report "Current Water Resources Conditions." determine current depth to water level.for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), , and water-level,zone (STEP 2B) determine water-level adjustment .......................:......... ............................. a STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ....................... ........................................................... i Figure 13.--Reproducible computation form, 15 Lj"! ' , 0( TOWN OF BARNSTABLE LOCAiONT ®� /U � SEWAGE # /� VILLAGE � /�/G ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.,$o2WOW G'G V,5%. 77/— � ,%SEPTIC TANK CAPACITY �q LEACHING FACILITY:(Cgpe)� (size) ' NO. OF BEDROOMS _ PRIVATE WELL OR BLIC WATBFt &UILDER OR OWNER S,7 j6 ,V DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: =a K VARIANCE GRANTED: Yes CIZ 1 391 R.- FEz............ THE COMMONWEALTH OF MASSACHUSETTS ............~ BOARD OF HEALTH �1^� ...........................................OF.................................................................--....................... Appliratio T for Disposal Works Tonst urtinn rumit 'Application is herebymade for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal System at: RA 2nrS T'A QL E' LcDr /' NR'2 R� In ,esroN c.c .....-. .__s......... ..... s Location-Address or Lot No. ..?' �`�-9 9/�--4kv E .............. .. P:d:.. ok.. a5E-y.II.Y--A..._.. Owner -•----•-•---•---•-•-------------Address Installer Address Type of Building Size Lot_L-3,,133..±.-Sq. feet U Dwelling—No. of Bedrooms._._. .Expansion Attic ( ) Garbage Grinder (440) Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtur s . d ............................................................................... W Design Flow.............LI..2..........._......gallons per person per day. Total daily flow....-. .....................gallons. WSeptic Tank—Liquid'capacity-Z©Oogallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area........--.........sq. ft. Seepage Pit No..........I.......... Diameter......LO....... Depth below inlet-S............ Total leaching area, 6.J?....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ! / Percolation Test Results Performed by.4'9.t�E .!@!!!t�S, ' Q V l N�__ Date:-J�--_/_Z-J11, .__._._..... 14 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.....4':' .... Depth to ground water...........W-- ................................••.............--............................................................................................................ O Description of Soil..d-a.�TA..�S 0►L � 5-u QS'O!L•••--C�_.11�'�..._A►7_`��l�M ��N... ••- x W --•--•--------------------------------------•---..........--------------------------•-•-....•-•---••---•-------•-------------------•-•-•-------•----------•-•-------•...---•••••.......•--...........--- UNature 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has =- s ed bVthe oar f health. ignDate Application Approved BY------}- =----- --•--• •-••--•---••-•-•• ..........••--•---•••-....•. -••••••. L Date , Application Disapproved for the following reasons:............................................................................................................... •------•---------------------•---------......•--..........-•----..............---..•...---------•----.....................-------------------------•----------------------------------•-----•-•••-..-•-•- Permit No....a.J. f -------_ Issued.-..-•----•-----•----------..•.............nac....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.......................................................................................... Appliration for Disposal Works Tonstrnr#ion F.e and Application is hereby made for a. Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �. .�_4 631. RJ� ................_....,.__.---.............---....--------.....--•-----------•---......---...... ..----•-------. ... -... -- .._.... _... .........__..._. // Location-AddressO'k or Lot No -A ---- ------------------..... ..... ..................................... Owner Address .......... a a ...................................................... ---.........-•--••-----------•-------- Installer Address . UType of Building Size Lot:. _.1.............=...Sq. feet Dwelling—No. of Bedrooms....,�...................................Expansion Attic ( ) Garbage Grinder ( 0) a`4 Other—T e of Building No. of persons............................ Showers YP g ---------------------------• P ( . ) — Cafeteria ( ) Other fixtures -------------••--------------------- WW Design Flow............l.LQ....................gallons per person per day. Total daily flow.........................--......_......•.......gallons. WSeptic Tank—Liquid-capacityZ'00Q.gallons Length................. Width................ Diameter--.............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No.........1........... Diameter.....I.. ........ Depth below inlet................. Total leaching area_.a..4a.E....sq. ft. Z Other Distribution box ( ) Dosing tank J '-' Percolation Test Results Performed bye` e ! ».,�� ` �'..____ Date-°''41... 1/ 7 a . 14 Test Pit'No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water... r _. ..... 44 Test Pit No. 2:1r.........minutes per inch Depth of.Test Pit.... �-..... Depth to ground water.......... ,/* .. 94 .............................................---.......................................................-----.----.. ..... O -� c 31 �.S o t L ?R im1 yq 9 Description of Soil -`.. ... x W UNature 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ZeOs ed b the oard- fhealthSign d.._ _...�!-_ ..�-------------- � ffa Application Approved By......e .!.fir ........................................................ ......... Date Application Disapproved for the following reasons:----•---------------------------------------------------------------------------•-•-•...... •--.....-•---•... .........................................................................................................-..........•-------•........_.....••-•---•--•-•-••••••--••....•-•-•----•••-••••.....----•••._.. _ Date Permit No.... .: a` -------•----------------------- Issued.----------- a - - ------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............Tb,.LI:).Ql).........OF............... f r�l5 :.Y `'^- ........................... k i " Tatif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--••..... a: ,�1:� ..................•--..........-••---•---•-----••-•---------------------...............--------•--•-------------•-------------........-------•--•--•------•-- i Installer at -•-------------------•--------•-•---------.....--•-----------------------------•-•-......------------. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in th application for Disposal Works Construction Permit No.--------- ............ dated...... ..... .... ..1.L...t.Ill?�� THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... ............5. .... Inspector.....................'.... ............................................... S C,THE COMMONWEALTH OF MASSACHUSETTS -BOARD OF HEALTH �L .V. .( .......OF......t:/..G"11114 -5.r.....•........................... ....... No.. ( . .• FEE..7.J................ Disposal lVork.5 C�unstrnr#ion rrrutft Permission is hereby granted......e j—j , f -.'C,�r".: -, --------------------------------------------------------------- to Construct ( 1/S or Repair ( ) an Individual Sewage Disposal System atNo..._0.+.tl....�t•"i-L...i4L-•--- ----------------------------------------------------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No.. ._dl.7 Dated.......................................... .................................. --1'3�..................................................... _ Board of Health DATE................... .............................. FORM 1255 A. M. SULKIN, INC., BOSTON I ' No.� ---- 7� Fee---- -- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationforVell Con0ructionPermit Application is hereby made f r ape it to onstruct (d), Alter� '), or repair ( an individual Well at: Location — Address Assessors Map and Parcel Wner Address Address — L -'� NN — --- _—_—_ --- - - - ------------------------------ - - Installer — Driller Address Type of Building DwellingL` -4fib 1_—__.-__--- Other - Type of Building-=------__--- No. of Persons------- --- /_/ '/ Type of Well— --f �i✓ -------- --- Purpose of Well-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Si �/ __ --_— _— ------- date 11 �l G Application Approved — ___—_—____—___— —L date Application Disapproved for the following reasons: ------.----- —--------- ----- date Permit No. v "� � — — Issued-- i�6 G^ ------ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS I ,TO CERTIFY, That the Individual*ell onstructed (Vf Altered ( ), or Repaired ( ) ----- ------ /n Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. � 6 ated--J)J_2A 4r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------- Inspector—____—_------____-- ------____-- i No. ------ Fee---- BOARD OF HEALTH TOWN OF BARNSTABLE Z(pp[icationArlVert Construction-permit N Application is hereby made f r a permit to Construct (X Alter or or epai r ( man/individual Well at: 1110 Location — Address Assessors Map and Parcel r Owner — -- -- �—�-_---�- Address ' Installer — Driller Address Type of Building Dwelling -- Other - Type of Building—=------_-- _ No. of Persons--- -.-----.--_—_—___. Type of Well �/ >�(/P --- — Capacity--------------- --- Purpose of Well �oi' � __---_---_-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Io na S date — ) i Application Approved �'""_—__—__—____--_— p /� date Application Disapproved for the following reasons: r ' date Permit No. �� — 7 —_—__- Issued-----_L !__I7A ---- - date .-_.,-._,�- ..... - -'- -------- - --_._-_--,-------'------------._�_---'--- �--------- BOARD OF HEALTH y TOWN OF BARNSTABLE Certificate Of Compliance THIS TO CERTIFY, That the Individual ell Constructed (!i), Altered ( ), or Repaired ( ) / ? Installer at,V /- p_�' -' _—P� /� ' �� --- - — —----------- ---------- ------------------------------------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection ,Regulation as described in the application for Well Construction Permit No. � --'� ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- --- -- Inspector BOARD OF HEALTH TOWN OF BARNSTABLE a Veff Cootructionjermit I � -- 5 No. Fee— ----- �� � _---- -- -- — I Permission is hereby granted �� ��/�/✓rJ��`/��/�=-1'' r___—___ to Construct Alter ( ), or Repair ( ) an Individual Wei at: a No. �-1 �i �L,i• _ �� �i/ 1 _--- -- ------------------------_------------- street as shown on the application for a Well Construction Permit l No.- (� G_— ---— Dated----- )./ 7--- —---------- ------------------- 14 --- 1 Board of Health DATE t , x r "� -rr.rrrr+�ar.r.urrnr+wrrr�r.w.rrn r rsr.arri -� --rr�rr�+�.r�•.r ,. . �� ".: ,.:. �. 959.2140 6 787 r 548. r 0#0 OF Foil"txw �. _ 1 1FIN GRAD t7 / COACRETE, GOVEKS cc6 .RErE COVER EL 5 9.4 4"sclwAi# 40 PVC ♦' i P/TC I L/B Phi' FT QX .i r f114 o B Ary IY�w • 1. IVVFRT __I CAsr rn� .:5G.5 56i4 ' < .s p b /l/2"NVERT 14 rac. , . ,/ 56.3EL. war 1�4 ,, o . . ' 4 64 ,. _- l087.9023 Io --j 714.2 6 6 9 PROFIL E: OF A10 GRXtD IVATER TASLE 62 4 /' 60 SEPTIC S YS T"E�t� 66 58 SOIL L OG 56 Fes, DAFE 5/21/87 „�,�� P-646z GENERAL NO TES 9 54 .,, rEs r has # 2 5 2 ALL PIPE IS SCHEDULE 40 PVC TOWN WATER IS AVAILABLE ' 50 0-2 T/L � c - 48 DESIGN DQ TA Q r- � 46 �� o,� a�n�oo,�/s 3 • � _ TOTAL FL 01Y — 330 - S . FT. 0 . � 44 BoTTC�� tFAct�� A� S FT. r � 50% kcf*ass 3A G, D f'GtSAL 4 2 GAR S _.. Sa FT. ` 62 .� _< IE� M/ TOTAL`L£A..!-,�JG AREA l I�EfrCU�A '0dv RA TE •,,� 4 0 36 N�Q wa T� E�otwr�n - _ } CAL CtX A T7kJrVa• ; O 'S 38 34 �,. . . . ,, r 5 I - -- - � -- .. 60 O w , 0. O30 28 \ G , _ . r AN L 56 �.� t318 l .. LL Q OCA L T DIN / c, iy lAAL 54 ly y � / O Q .� AM Q`0 JACOBI r�� P No.814 BLE 52 ?' oy o EALZH 50 PREPA RE9 FOR 4 P p , /.�4 Ik or „ N M 46 PAUL OA. l O 0. : 44 O O • No.s2oss AfCISTER``d Qa� 0 V _ v 0 � ca _ 951.96 30 60 90 o �16 P17LA _' IolS•0 0 � : � I O �' _ t YA ti SCALE: 1 3080 265 A E. 1431;1101 , ` ( RES. ZONE: R FLOOD ZONE. C LS MA Ra9 TONS ,AfL AM 02648 C 4 9/5 ' E F ATE. 4/19/89 PLAN REFEREN E. 2 _ _ JOB # 1767 _ - ---- _ REVISIONS: LOCUS INFORMATION No. DATE DESC. RD i CURRENT OWNER: JOHN HUTCHINS & OVERLAY DISTRICT: BARNSTABLE WP _ LOCUS `O�F� DEBORAH HUTCHINS NITROGEN SENSITIVE �qNF S TITLE REFERENCE: DEED BOOK 21307, PAGE 302 ZONE: ZONE II PLAN REFERENCE: PLAN BOOK 429, PAGE 5 FEMA FLOOD ZONE DISTRICT: "C", DATED 8/19/85 ASSESSORS MAP: 60 PANEL #250001 0015 C 149 PARCEL: 014-011 N MINIMUM LOT SIZE: 87,120 S.F. ZONING DISTRICT: RF 28 SETBACKS: FRONT 30' EXISTING LOT SIZE: 49,633f S.F. SIDE 15' EXISTING LOT COVERAGE: 2,315t S.F (4.67.) REAR 15' LOCUS MAP I CERTIFY TO THE BEST OF MY NOT TO SCALE PROFESSIONAL KNOWLEDGE, INFORMATION AND BELIEF THAT THE LOT CORNERS, / DIMENSIONS AND SETBACKS TO THE CONCRETE STRUCTURE AS DETERMINED BY IN #117 BOUND FOUND THSSRUMENT PLAN ARE SURVEY ORRECD AS SHOWN ONT. ', HI RIVER ROAD ,,yam MAP 60 PARCEL 31 ��• �h r NORTH A « Na 3000 SZ CONCRETE [ � •� � �/Z�d 8 BOUND FOUND N � PROFESSIONAL LAND SURVEYOR DATE a NEW FOUNDATION 20 14.4' 0 1� CERTIFIED PLOT PLAN DEPICTING NEW L FOUNDATION #435 RIVER ROAD MAP 60 PARCEL 014/001 AT #419 #419 RIVER ROAD MAP 60 PARCEL 014/011 RIVER ROAD IN MARSTONS MILLS 00 MAS SAC H U S ETTS N, o (BARNSTABLE COUNTY) W A � w rn MAY 129 2008 #401 O0 RIVER ROAD $ EXISTING MAP 60 DWELLING PARCEL 030 PREPARED FOR: Mr. JOHN HUTCHINS #419 RIVER ROAD MARSTONS MILLS, MA 02648 loulla 349 Route 28, Unit D West Yarmouth, Massachusetts 02673 508 778 8919 © 2008 The BSC Group, Inc. SCALE: 1" = 30, 0 3.75 7.5 15 r ETM 0„ W 1p-7 iiiia 65, 0 15 30 60 Fm IRON PIPE ,�915+0 PROJ. MGR.: CRAIG FIELD FOUND N FIELD: D. GAZZOLO / J. McCARTIN / N.M. CONCRETE 36 CALC./DESIGN: K. HEALY BOUND FOUND DRAWN: P. HAGIST CHECK: CRAIG FIELD FILE: 9172-ABF.DWG DWG. NO: 4805-08 IRON PIPE FOUND SHEET 1 OF 1 JOB. N0: 4-9172.00