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HomeMy WebLinkAbout0450 SANTUIT-NEWTOWN ROAD - Health 450 Santuit-Newtown Road Marstons Mills 029 030 I COMMONWEALTH OF MAS�t�C LJSET S r� ' ExEcI3wvE OFFICE OF ENvgRONMENT-AL,AFF_AJRS t DEPARTMENT OF ENVIRONMENTAI.aW ` )Ud)9C.VON SPP 0 12004 TOWN OF BARNSTABLE i HEALTH DEPT, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �Sa S",i 4k,-4,, f2,C/f +� ' MAP Owner's Name: r Owner's Address: &/iD PARCEL ®� - r� � OT Date of inspection: S�S'�O S� 44- Name of Inspector: plea a primt) ` e X Company Name: �.� i�o� :!K� �Ra ( Mailing Address: oa6v Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3I0 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails / Inspector's Signature: r Date: The system inspector shall submit a copy a tb ewon report to the Approving Authority(Board of Health or DEP)within 30 days of completing this-;' sa shared system or has a design flow of 10,000 gpd or greater,the inspector and the syste 'slsall sttiport to the appropriate regional office of the DEP.The original should be sent to the fl �rtti`= s sent to the buyer, if applicable,and the approving sy cogs Y PP PP g authority_ Notes and Comments ****This report only describes condo aat the�meef, °'and under the conditions of use at that P Y time.This inspection does not addre� w t r in the future under the same or different f - - conditions of use. Title 5 Inspection Form 6/15/20F0: :I L ` Page 2 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C CERTIFICATION(continued) Property Address: d�V i /V424, 1W Owner- Date of Inspection: 5 Inspection Summary: Check A,B,CD or E/ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"secti need to be replaced or repaired.The system,upon completion of the replacement or repair,as appmv the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follo g statements.If`riot determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or;:ralion tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying s as approved by the Board of Health. *A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o is available. ND explain: Observation of sewage bac p or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b settled or uneven distiilution box.System will pass-inspection if(with approval of Board of Health): ' broken pipe(s)as obstruction is T moved distribution bax is J vwled or replaced ND explain: The s tem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass iespe on if(with approval of the Board of Heahh): broken pipe(s)are replaced obstruction is removed i ND explain: 2 f Page 3 of I I OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: y3v i —A. ",uw l�s� Owner: kP Date of Inspection: O C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to termine 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 0 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health afety 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 we and or a salt marsh 2. System will fail unless the Board of Health(and Pu c Water Supplier,if any)determines that the system is functioning in a manner that protects the p is health,safety and environment: _ The system has a septic tank and soil abso on system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface ter supply. _ The system has a septic tank and SA and the SAS is within a Zone I of a public water supply. _ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. _ The system has a septic d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". shod used to determine distance "This system passes fifth well water analysis,perforated at a DEP certified laboratory,for coliform bacteria and volatile o is compounds indicates that the well is free from pollution from that facility and the presence of amm is nitrogen and nitrate nitrogen:ai equal to or less than 5 ppm,provided that no other failure criteria are ggered.A copy of the analysis mug tie ached to this form. 3. Other: I I_ - I Page 4 of i 1 OFFICIAL,INSPECTION FORM---NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE Dry SYSTEM INSPECTION FORM PART:A- CERTIFICATION(continued} Property Address- 4 Owner: i Date of Inspection: a ff D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes Np •/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _41 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'h 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. _ 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.j'Y'his system passes if the well water..analysis, performed at a DEP certified laboratory,for caret 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.} 10b (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E. Large Systems: To be considered a large system the system must serve-a d igo flow of 10,000 gpd to 15,0oo gpd. i s - You must indicate either`yes"or"no"to each of the wQt� (The following criteria apply to large systems in on m the c na above) yes no the system is within 400 f f a surface drinking water s Vply — _ the system is within feet of a bibutary to a surface drinking water supply — — the system is I ted in a nitrogen sensitive area(Interims Wellhead Protection Area—I WPA).or a mapped Zone II of a blic water supply well If you have ans red'yes"to any question in Section JE-'the sysjm is considered a significant threat,or answered "yes"is Sec ' n D above the large system has failed.TbiowntOOT operator of any large system considered a. signifi threat under Section E or fair under Section D shgrade the system in accordance with 310 CMR 15.3 The system owner should contact the appropriate regioqW-ogke of the Department Page 5 of i I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ,C,�Hyy.,(E,��CK.�LIST Property Address: tf �''t"((�]4`� v ViEwl 5 Owner' a �A Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each ofthe 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 �1 Has the system received normal flows in the previous two week period Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of�the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper rntte_nance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)-the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Fly., V` — Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CUR I5302(3)(b)J � 5 Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:4 Q�� /W W Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL 3 Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: ? Does residence have a garbage gender(yes or no):00 Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no)AJQ Seasonal use:(yes or no):POO Water meter readings,if available(Iast 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/s cJ: Grease trap present(yes or no): Industrial waste holding tank ent(yes or no): Non-sanitary waste dischar d to the Title 5 system(yes or no):_ Water meter readings,' vailable: Last date of occup y/use: OTHER(d ribe): GENERAL INFORMATION Pumping Records \ ' Source of information: Was system pumped as part of tWe inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ,X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): w Approximate age of ll coppo nents ,5e ins ailed(rf own)and source of infortrta#aora: Were sewage odors detected when arriving at the site(yes or no): AO 6 i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM[ INSPECTION FORM PART C SYSTEM[INFORMATION(continued) Property Address: i 'O u•` 1ti Owner: • Date of Inspection: BUILDING SEWER(locate on site plan) . U Depth below grade: 49 l Materials of construction:_cast iron ,�e_40 PVC!other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: / (locate on site plan) Depth below grade:�[s Material of construction: d concrete_metal_fiberglass____polyethylene other(explain) _tank If is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:- Q• Sludge depth: 3O•. Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 02 •� Distance from top of scum to top of outlet tee or baffle: ? Distance from bottom of scum to bottom of outlet tee or baffle: 14 How were dimensions determined: I/YA: coev Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related too tlet Inv evidence of leakage,etc.):Q c!K ac c GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_ 1_fiberglass`polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum t op of outlet tee or baffle: Distance from bottom of um to bottom of outlet tee or baffle: Date of last pumping: Comments(on pu uag recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to out invert,evidence of leakage,etc.): . A 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V�9�1 a- Owner: Date of Inspection- TIGHT or HOLDING TANK: (tank must be p at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete etal fiberglass__polyethylene other(explain)- Dimensions: Capacity: allons Design Flow: allonslday Alarm present(yes or no): Alarm level: arm in working order(yes or no): Date of last pumping' Comments(condi - n of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) � Depth of liquid level above outlet invert: t k_Vfl Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): p v!C W 1-7 P1 PUMP CHAMBER: (locate on site pl Pumps in working order(yes or Alarms in working order(y r no): Comments(note conditi of pump chamber,condition of pumps and appurtenances,etc): 8 Page 9 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:— ltVTaam A4 Owner t e Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type teaching pits,number._ of leaching chambers,number: 6 Z 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, etc.): b f X 6 CESSPOOLS: (cesspool must be pumped as part of ion)(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 groundw inflow(yes or no): Comments(note co Ilion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note conditio f soiI,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 L Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C z SYSTEM INFORMATION(continued) Property Address: �S� c! N Owner: Date of Inspection: d SEETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. vvx, Yr �n Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR!!lI PART C SYSTEM INFORMATION(continued) Property Address: xxlklk Owner: Arw , Date of Inspection: SITE E M Slope Y 1S Surface water Check cellar Shallow wells (�a Estimated depth to ground water_altf 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 ISO 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 levation. Jf� as U .S —cn CA 0 "i. N II i T rTOWN OF BARNSTABLE ` G LOCATION ISD /j/�t�yTOarlti SEWAGE # Oa- VILLAGE G0/.Wt-S,2021,0e-,?Zw ASSESSOR'S MAP & LOT o29 030 INSTALLER'S NAME&PHONE NO. 623 Sle JDSf�Li D.c ��.s�NHs� SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) 2-5619 614 `y(,r/!_}Csize) —52S x /-57 NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: �,- 2; - OO COMPLIANCE DATE: 7^(/- O,�, 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 ya:�a ,�� �/_ - � lil/�i 01!'��/y ,.. - guc� 4l, � �$. ` _` _ ` . �b !� f _ �M ,�^- '" 's" tk�->5i: k-��,F� 'y��"'"�''." ,�" "�°�g,�. �.- i•^r.. ? as t '" ,',; " .�ij �"iL.7i � 1lR. ..�'rG.Z'G x� -33 �+Y ^ xn..t° L. �3 Y y itii.1)hS" ^C R.. .r4` "S.Jk-. L^c,N :.7SP Y`1 4b i X:.'Y' .T ,': 'fig' R^-'F.t"` " iC':. �.".- -eta x ,.,g-"r;""'�'.,": c11 `�- _ "'7 .st C h �.-:.. ,�.-_""t ^S�M-� -:.:.,, Y "K,`"`- *"'-->-,, C`'`__': b' r- ;''., `ice-.3' „`.•-,-�5 's•> '^' YW �- - _ TOWN OF BARNS ABLE - - - _. - � =" 7"1 LOCATION Y�SD: _�7^O�JG1 _ SEWAGE # -OD_ 3�S �""'�;. _� ;a _ . -- `V I AGE 'A,; A—sroti.j !2'�Lls ,..- - _. ASSESSOR'S MAP`& LOT 0, .030 ` INSTALLER'S NAME&PHONE NO `7 7-d 3 Si f �/051i Dom:. �vrsnr� I SEPTIC TANK CAPACITY lDob r :LEACHING FACILITY (type) 'SD is , size) - �� y : .�,ryy 4" :: NO.OF BEDROOMS 5 . y {z! s Y;1 BUILDER OR-OWNER F�l��i.�iio - PERMTTDATE: C-- 3 - p4 COMPLIANCE DATE: 7^//- en . 4 . - _. . __ . . . . . . . L ` Separation Distance:Between the. F{t .,7 ,tih +. - Y._. n; Maximum Adjusted G"roundwaI Table to the Bottom of Ledching Facility tk Feet�: `� Private-Water:Supply.'Well.arid Leaching Facility .(If.:any wells east; F r -r_ _ -.� .x, _ - { �a . i �� �� on,site or within 200 feet of leaching facility) Feet ' ,L, "' > _-edge©€Wetland and I eactung Fact- V(If an wetlands ezis, N y f w t ,„ E_ "r I' , `. �, K 300 feet of leaching faciL►�{{�/ Feet ., a • ..++iS x.tP''S"' mtn.Y t�$3. i - 2S •J) 7 Sty t r r$�- i- l tIi Y.. �S ei4,h) 'mil`2t '- , ..."1� � . 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P h _ No. 4 10S/6� -12-- y w Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for niopool *p5tem Con!truction Permit Application for a Permit to Construct(repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.4TO 4y-W TOIZ,4 40,4 Owner's Name,Address and Tel.No. . '; m � !`yl,?& iark W,�s�/�p Asses'sMS4Map/Parcel 10 9 t/50 � Otli f2 12! Installer's Name,Address,and Tel.No. y77-05<1 f Designer's Name,Address and Tel.No. ✓as,1.0h 0, grras' ` ✓osrp4 0, d#xm,S -G)7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 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 ,a/ Nature of Repairs or Alterations(Answer when applicable) 1l-STkr// — T !l 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 f Health. Signed Z12Date Application Approved Ir�tDate � Application Disapproved for the following reasons Permit No. Cr" Date Issued _�— No. �FO,06,- Fee i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS S Tipplication for Migpotal *pgtem Construction Permit Application for a Permit to Construct(d.4�Kepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.4TO ./Yh((/Tpwy KaI� Owner's Name,Address and Tel.No. Assessor's Map/Parcel yN, �,i� �Ia�'/� Gv,hsl�p 2 0�0 �sv o %0 Installer's Name,Address,,and Tel.No. 4171-0 3 4�l 9 Designer's Name,Address and Tel.No. Jas�ph !.� I�.r�rroS ✓oscpa 42, !3g'^mw5 2 Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets 1 Revision Date Title Size,of�Septic Tank Type of S.A.S. Description of,Soil 5AA1 A S 1 Nature of Repairs c Alterations(Answer when applicable), Zsm4 nrel/ 2-5;:W 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 f Health. Signed Date Application Approved Date w� - Application Disapproved for the following reasons U Permit No. W nr" Date Issued ) --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertificate of Qcompliance THIS IS TO CERTIFY, that the On-site Sewage Disposal Syst m Constructed( 4-Repaired ( )Upgraded Abandoned( )by Jafg rem 5. at 9s4 A&E",Z lz z,�, /2 ll&WrStovy S -M,A, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Po2 ,f * t�. f dated •°" Ll Installer,fos� G d� p�v�v_� Designer �/�sn= /�sos9� I i The issuance o`7a f ;t shall not be construed as a guarantee that the sy4e irl.function as designed. Date // /( s�� Inspector / ---------- -------------------'--------- No. 4Zf" 29 Fee THE COMMONWEALTH OF MASSACHUSETTS s PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mopogal *pgtem Construction Permit Permission is hereby granted to Construct(repair( )Upgrade( )Abandon System located at 952 f1115!r j'o6&iy 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 e• 't. Date: r` �•A-�Ga-f -Approved r NOTICE: 'This Form Is To Be Used For the Rep'air Of Failed -] Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, o tlfev�wg , hereby certify that the application for disposal works construction permit signed by me dated G — Q$'- oo , concerning the property located at ySd /1/f�vla'�h �� 121, 6�i/� meets all of the following criteria: A-- The failed sy:;tem is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. g /--- 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 'k*--There are no private wel ls within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no,ariances 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 Frim t method when applicable[ g p or �• If the S.A.S. Mll be located with 250 feet of any vegetated wetlands the leaching ter tay will vat be located less than fourteen(14)feet above the maximum adjustedproposed groundwater table elevation. Please complete the following: A) Top or Ground Surface Elevation (using GIS information) H) G.W. Elevation s +the Adjustment DTFERErICE BETWEEN A and B a SIGNED : (Sketch proposes !an of DATE: 4:Stu folder� p system on backJ. `, _ t d 00,91 /JHi�s/11� �� ,fcr►o� 0041 iw1StXg s 2-K � K- �5- i. 7//c �j 141q r cv--s 2- -T—H,-,-3cs 15c i 3 Imo'(_ �,,_;,_�t G:;.�✓.,., ,LS;=u;:..�.: •7 '� rr �` �-- 16> f4 i 1--MCl-,7,JC J4- 2q 1 716 yw �i a OQ y C-.. 2 � F rv) -L4 00, V/6tCi //v- I %V I •Z�� GJ�u— ,� c L -Z 3°� r v 7/'6 c{s Oo