HomeMy WebLinkAbout0841 SANTUIT-NEWTOWN ROAD - Health 841TSantuit-Newtown Road
Marstons Mills F/R
A 028 032
TOWN OF BARNSTABLE �.
LOCATION � � / SEWAGE #
VILLAGE �.�i `� "-j' .�h�l��' ASSESSOR'S MAP & LOT
IN NAME&PHONE NOS/ ele�N�e&l
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /`���� (size) -, f
,NO.OF BEDROOMS s fp
BUILDER OR OWNER Y(-h2er
PERMIT DATE: `��d®� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ,i Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) i Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by (T�,--
A /7�
'A(5� li
i jib D
ev
4.
No. r 7 r y Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer. le��
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Migonl bpotem Construction Permit
Application for a Permit to Construct( )Repair(><)Upgrade(x)Abandon( ) O Complete System O Individual Components
Location Address or Lot No. JAA,T�?/ Owner's Name,Address and Tel.No.iv!`6vT w�
Assessor'sMap/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ry gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /�®ti Z: Type of S.A.S_e4, � �3X�4•X
Description of Soil,
Nature of Repairs or Alterations(Answer when applicable)
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 issu by oard of Health.
Sig d Date
Application Approved by Date a. /7
Application Disapproved for the following reasons
Permit No. a'0084 --�.S '7 Date Issued c� )-1 O
A, NO. Fee
T THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE,, MASSACHUSETTS
2pplication for Miqooal bpptem CotfMruction' Permit
Application for a Permit to Construct Repair Upgrade(,X)Abandon El Complete System El Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel � oD
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers Cafeteria
Other Ffktures
Design Flow 3 S% gallons per day. Calculated daily flow .7_?a gallons.
Plan Date .2 Number of sheets Revision Date
Title
o Size of Septic Tank g!1'xrP;1/- og e. Type of S.A.S. aL
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 isSu by this Board of Health.
Sign"e'd Date
Application Approved byKt!K�M� _ � Date I,-,L/
Application Disapproved for the following reasons
Permit No. a-0014 —77 Date Issued Q 1-7
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Complialice
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired(�k Upgraded X)
Abandoned by 7-z -A Z ex-9g,
at has been constructed in accordance
with the provisions of Tide 5 and the for Disposal System Construction Permit No. ,i I_vNC'7_dated /�L/
"vu 10�
Installer %,I%.,A— -e' A 40z,,, - Designer ad.&4&
The issuance of
f this permit shall not be construed as a guarantee that the systdm.Wi I function a-1 esigned.
0
Date �,a Inspector
-——————---————---————— ————---————————- ---
N'. Fee5c)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
wliqaoal *p5tem Construction Permit
Permission is hereby granted to Construct Repair(�Upgrade(<)Abandon
System located at 7b 09 0. %h4v J'
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 his pe-m-i"
Date: Approved by Qt�_
Town of Barnstable
Regulatory Services
Thomas F.Geller,Director
_ F Public Health Division
Thomas McKeari Director
200 Main Street,HYannis,MA 02601
Fax: 508-790-6304
Office: 508-862-4644
just ler&Desi ner Certi cation Form
Date:
Designer: )q v1,Z) �25 m4 w/ `�S Installer:
Address: G Address:On
014
7
�-�� ZC-�i�c�U J'�'�'C s:was issued a permit to install a
(fie) (installer)
/ � � basezi-on adesign drawn_ y _ ---
septic system at 8'Y� (address)
� Y�� 0. 4c dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design,which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i_e.
greater than 10' lateral relocation of the SAS or any vertical relOm ion of any component
of the septic system)but in accordance with State&Local.Regulations. plan revision or
certified as-built by designer to follow. 114
OF
r (Insta er s Signature)
` IF 11 �� Ire
(Desi 's Signature)
p Here)
p As2;RETURN TO BARNSTABLE PUB C IIEALTH DIVISION. CERTIFICATE
OF CAND AS
OMPLIANCE D yE ISSUE$ARNSTABL E UBLIC BOTH S FORM
�HEALTH DIVISION.
BUILT CALK
THANK YOU.
Q:HeAWSepticMesigner certification Fonn
TOWN OF BARNSTABLE
v
LOCATION '/ SEWAGE,#
VILLAGE:f 4"'.S' 'f71ZZ r ASSESSOR'S MAP &t LOT
INSTALLER'S NAME&PHONE NO-7/ efe:PAe-&lf
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) /ty �� (size)
NO.OF BEDROOMS `
BUILDER OR OWNER 90 r,
PERMIT DATE: `o, ® COMPLIANCE DATE: _y�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility i Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) i Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching.facility) Feet
Furnished by (T _
A
, r
9
FAZED INSPECTION
ATE :7211213103
=��_—
PROPERTY ADDRESS: 841 Sarztuit Newtown Road M ��- `1�fC
-- - -------------------- ,.
JAN 0 �' 2004
02648
-- - - - ------------------- TOWNOFBARNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic system—at the above address.
Tnis system consists of the following; MAP t 0?-� '
1. 1- 1000 ya eion zelzt.ic .tank, PARCEL , 032
2. 1-L i,3;bz i9ut.ion fox,
3. 3 .in�i.Qtnatoaz in ze2.iez. (7'X22. 75 ' ) LOT
Baseo on my inspection, I certify the following conditions;
4. 7h.ie .iz a .t.it.ee �eive zepz'ic .system: (78 Code)
5. The zep.t.ic zyztem 1/3 .in hycdaauXic /a�.-uze.
6. A new iea.ch.in y ct2ea need.3 .to ge .in s.t ai eed.
7. Dag terst hole down gez.ide .in/.i-ta.tozz. . Kit wahte wa.te2
at -inl.iet2ato2 ieve.R.
SIGNATUR
'Fame _ _J_ _ P, _MaComb E—_ [ _ ___ _
�ompany : ,�4 �Qh p�- MS�S4mC2�� d_ Son, Inc ,
� aoress : __�Qx _� - ----- ---- --
(Z-e-PJDrYLLLP-,- Ja _ _Q2..6 ) 2-0066
T„15 CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanxi•Ceispooli•Leachfleldi
Pumped & Installed
Town Sewer Connectlons
P 0 Box 66 Centerville, MA 02632.0066
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
o DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
V.
TITLE 5
OFFICIAL INSPECTION FORM—NOT.-FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: . 841 Sant u it Newtown /2oacd
17aas.ton,3 (7ILL 12 a .6. 02648
Owner's Name:Ven.ice Dltaae)z
Owner's Address: Same
Date of Inspection: 7213103
Nameof Inspector: (please print) jozel2h l. 17acom9ea a2.
Company Name: 9. l,.NacamE~ea & Son Inc.
Mailing Address:
C e n eay.c e, a,3.6. 02632
Telephone Number: 5 0 8-7 7 5-3 3 3 8
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(310 CMR 15000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails a
Inspector's Signature: C �� ate: w - —'� I
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 101000
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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION (continued)
Property Address: 841 San.tu.i.t Newtown N2oad
a2.6 onzs 77TTz, a.6T
Owner: Venice N7aape2
Date of Inspection: 7 2/3/0 3
Inspection Summary: Check A,B,C,D 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 m 310 C7,7 15.30 exist. ny failure criteria not evaluated are indicated below.
Comments:
Jne.i_,O1_2r/ o .6 ate .in hudaaaiic R new ieach.ing
aaaa n00r]A fn QD A /Lai-ted
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.
,Q6 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.
ND explain:
CVO Observation of sewage backup or break out or high static water level in the distribution box due to broken.or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval:'of Board of Health): -
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
kb 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
ND explain:
2
Page 3 of 11
OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION=FORM
PART A
CERTIFICATION(continued)
Property Address:84 I San.tuit Nzw;town Road
Illa/zztonz 177,773, RETT
Owner:.Ven.ice DltaRea
Date of Inspection: 1213103
C. Further Evaluation is Required by the Board of Health:
�(1 Conditions exist whichrequire further evaluation.by.the Board:.ofHealthdri order to.detennine 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(l)(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 asurface 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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
A1e� 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.
,VJO The system has a.septic tank and SAS and thei:SAS is within a Zone 1 of a-public watersupply.
X10 The system has a septic tank and.SAS and the SAS is within:50 feet of a private water supply well.
Q& The system has a septic tank and SAS and the SAS is less than 100 feet.bu 50 feet or more froni a
private water supply:well**. Method used to determine distance f�
**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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Santu-i;t Newtown Road
.Naa.6ton,3 (7•iiiz, ('la '.3.
Owner: Venice Dzapez
Date of Inspection: 1213103
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to.each of the:followingfor all inspections:
Yes No
J35ackut)of se to facility or system component due.to overloaded.or,ii ed SA 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 0,a)f971-W7o—<5
squid depth inaesspeeks less than.6"below invert or available,volume is less than'h•day flow
a/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped�.
y portion of the SAS,cesspool or privy is below high ground water elevation.
_ �c/.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 withina Zone i of a:public well.
—any portion of a cesspool or privy is within:50 feet of a private water supply well. i
_ f/Any portion of a cesspool or:privy is less than 100 feet but greater..than 5.0 feet from a private water
supply well with no acceptable water quality analysis. [This system passes:if the well water.analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates:that the well is free from pollutiomfrom.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.]
ks (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 he.system:must serve..a:facility with a design flow of 1-0;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
_L__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 sha11 upgrade the system in accordance with 310 CMR
15.304.The system owner should.contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALISYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:841 Santuit Newtown /toad
a2z one Niiiz, a s,6.
Owner: Venice 2a/2e2
Date of Inspection: 1213103
Check if the following have been done.You must indicate"yes"or"na"as,to each..of the:following:
Yes No p.
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 notarial 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
t/ Were all system components,44cluding 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 o
_ 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)]
. i
5
I
Page 6 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Venice DlLa,
84I .Cnnf„ I Ala-4own /toad
Owner: 1�azziones 8-iiiz, l']��.s.s_
Date of Inspection: 12/ 3/0 3
FLOW CONDITIONS ,...
RESIDENTIAL
Numbcr of bedrooms (design): Number of bedrooms(actual): ��
DESIGN now based on 310 C)� 15.203 (for example: 110 gpd x N of bedrooms):0� ,a.
Number of current residents:.
Does residence have a garbage grinder(yes or no):Wd
Is laundry on a separate sewage system yes or no):Vb (if yes separate Inspection.requ'tred)
Laundry system inspected (yes or no): �
Scuonal use:(yes or no): 06
Water meter rcadings, if available (last 2 years usage(gpd)): 200.2=42, 000 ga eConn=115. 07 gPD
Sump pump(yes or no): bO 2003=3 , 000 ga e eons= 84. 94 gPD
Last ditc of occupancy:
COMM ERCLAL/INDUSTRIAL
Type of esublishment: AM
Design now(based on 310 CMR 15.203): d
Buis of design now(sc&Wpersons/sgft,ete.):
Grca-se trap present (yes or no): ALA
Industrial waste holding unk present (yes or no):s�
Non•saniury waste discharged to the Title 5 systcm(yes or no): )
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Souicc of in(ormation: None ava.i.iag ee
Wu system pumped as pan of the inspection(yes or no):
If yes, volume pumped: r) Aalio.ns — How was quandry pumped determined? A).w
Rcuon (or pumping:
Tyx OF SYSTEM
Septic urtk, distribution box, soil absorption system
AT Single cesspool
Overflow cesspool
XPrivy
Shucd system(yes or no)(if yes, attach previous Inspection records, If any)
A")Innovadve/Altcmativc technology. Attach a copy o(the.cwTent operation and maintenance contract (to be
obtained from system owner)
X10Ti0t tank VA Arucb a copy of the DEP approval
IVY Other(describe):
Approximate aee of all components, date installed(if known) and source of information:
SU.6tem .inztaieed 8130193 1 e2m.it#9.3-422
Were sewage odors detected when arriving at the site (yes or no):AD
6
Pigs 7 or
OFFICIAL INSPECTION-FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IT1SPIrCTIQN FORM
PART C
SYSTEM INFOPWATION(continued)
Property Address: 841 Santu.it Newtown Road
Owee.r:Ven-ice Dza2e2
Date of Inspection: 9 7 j 3/ 3
BUILDfiNC SEWER(Locate on site plan)
�r
Depth below grade:
Mateflalf Of CgnstiVCllgn: cut Iron ✓40 PVC�do,the`(explain), ^_
Distance from private water supply wcli or suction line:
Comments(on condition of joints, vcnting, evidence of leakage,etc.):
i 44. i4akcc e. Stlztem
.i,3 vented thizough the .eoo� ven.tz,
SEPTIC TANK; Zoocate on site plan)/&'-P" s
Depth below grade: lof�
Material of construct on: oncrcte�, mecah, ,fibcrgiass -polyethylene.
�Giother(cxplain) .CEO ,
i f wik is mcul list 4&C 4V Wage c04FWMC-0 by a Ccniticate of Cornpt ance(yes or no)i / (attach a copy of
ccrtifiaue) , ,� .
Dimensions:
Slud$c dcpthf�,,,r
Distance from top of sludge to bottom of outlei tee or baflle;7 � Q
Scum thickness: ,r&,_
Distance from top of scum to top of outlet tee or baffle;
Distance from bottom of scum to bottom of outlet tee or bafilc;�y ee�
How.wcrc dimensions determined: ?P
C.ommcnts.(on pumping recommendations, inlet and outlet tee or bafflc condition, structural integrity, liquid levels
as relate4 to outle! invert,evidence or.leakegc,etc.)):
p um the Ze t.ec tank eve-ay 2-3, yeaa . .Inlet out eet tees
ate .in 12,eace. 7he tank, i.6 3 auc u2u v .6ound 'and z owz .no
evidence o f .leakage`: Liquid -eve. at'-'the ;the', outee chveat
GI EASE TRAPX&(locatc on site plank
Depth below grade: v�
Material ofconstrictiop:4Yconcrctc4�metaY,,fibcrglasg_)�&olycthylcnte. other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum-to top of outlet(cc yr baffle �'IL14
Distance from bottom of scum to bottom of outlet tee or baffle: ZIMIs _
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 Ieaka:go,ctc,):
�nonAo fnnn !A not 'onv.APn,
7
f
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
S> SURFACE ACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
M
PART C
SYSTEM INFORMATION(continued)
Property Address: 841 Santui.t Newtown Road
lrl n n_,S t n n.s /9 N a z z.
Owner:- e-a ce D/La Qe2
Date of Inspection: 7213103
TIGHT or HOLDING TAN 4� (tank must be pumped at time of inspection)(locate on site plan)
Depth below.grade:
Material of construction:, 4 concrete metal V fiberglass 4�tpolyethylenl,-�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.):
7.c ght oa o .cn-v 4an .s aae
DISTRIBUTION BOX: 2(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:Z
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.):
ut con Sox ha.6 one a e�za eae .th v:tzt
ea22y oven. No- ev-idence . o f lea age .tn o oa OUZ Of-
PUMP CHAMBEIIf (locate on.site plan)
Pumps in working order(yes or no): A)A
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
1)u cham�ea �� no.t R2ezen .
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 8.41 Santui;t Newtown Road
Ra/tz.t one l -i tee, Na,s,s.
Owneml/enice D/zaR.ea
Date of Inspection: 121-3103
SOIL ABSORPTION SYSTEM(SAS):Zlocate on site plan,excavation not required)
3— ' Ptnn nn.t in Ao17JoA_• 71X27 . 75,
If SAS not located explain why:
" 1
< ....rlad ep, Hann 10
Type
,( 0 leaching pits,number: 0
leaching chambers,number: V'7
WO leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
V overflow cesspool,number: e
A70 innovative/altemative system Type/name of technology] /�• /�-
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,
etc.):
��. I_oorzmE/ .snarl In. ono Cann to Ana In s et2a o2�s ate .gin hUd2zau.eic �aieu2e
,4 new 91eachinG a2ea needs .to Pe n.,fl ),nf Voy111011nn j,3
rzoama e.
CESSPOOLSte'(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: AM
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: AM
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY4 (locate on site plan)
Materials of construction: s1�
Dimensions:_
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
,,7 1)) !A. nnf nno.tnnf -
I
i
9
Page 10 of l 1
OFFICIAL INSPECTION FORM—, NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE`SEWAGR DISPOSAL SYSTEM`INSPECTION-:FORM
PART C
SYSTEM INFORMATION(continued)'
Property Address: 841 Saniu.i.t Newtown Road
Naa-6-t ones N i e ez, Na.3/s.
Owner: Venice Dzapea
Date of Inspection: 9 2/3/0 3
SKETCH OF SEWAG.E•DISPOSA,L 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.
i 43 A7
o
Q
10
TOWN OF BARNSTABLE a
LOCATION SEWAGE # -� �-
VILLAGE /'fit ASSESSOR'S MAP & LOTQ•c;LF` �` a
INSTALLER'S NAME PHONE NO. ^��
'SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /Vf7L7-4' �-S (size) 7��`d��
NO. OF BEDROOMS - �I ATEt�' R PUBLIC WATER
I BUILDER OR OWNER ' , f c
DATE PERMIT ISSU
DATE COMPLIANCE ISSUED:
i VARIANCE GRANTED: Yes
i q3' A7' .
V l e
D '
I
• I r
Page I I of I I
OFFICLA.L INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
Property Add ress:841 Santu.it Newtown Road
Owner:Ven,re, �nnnnn
Date of Inspection: y 2.13 f a q
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Pleasc indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record • If checked, bate of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
tPChecked with local Board of Health•explain: �� 7dari 7 )g.,,Lj:'Checked with local excavators, installers• (arch documentation)Accessed USGS databasc•explain: _h 1 2.2. 11town. Paarzetagee. .ma. ue.
You must describe how you established the high ground water elevation:
deed: Gahaet 9 Niieea Nodei, 12116194 Gaound wa.tea etevat-iona move eea tevei.
deed:CISGS: .ion we-t?i data, June- 1992
-?9',?-'Q 1t7-?'APate-#2 Arznua %ia iyao.' rz'
rvp v Mroum-
3-Zn/"iitaatoae. 1
7'X22. 75 ' ,t
Groundwater: Feet Below Bottom f '
o Pit Nigh Groundwater Adjustment I,$ ft per Frimpter Method
Therefore, chic vertical.separation distance between the bosom
of the leaching pit and the adjusted groundwater table is r
feet.
II ,
t r, TOWN OF Barnstable BOARD OF IIEALTII i
SIIIISURFACF SEWAGF DISPOSAL SYSTEM INS1'FCTION FORM - PART D •- CERTIFICATION I1
..._..._r••.-•.:,--.ii-"--.,,,n,--n•n,air,s•.rt,.=-r-n„-,—•.�.-cnr•nY'..vr•.-nr.+er.,v,..�mnts-smrr. e.,,,n•....•,.,..a., -A
—TYPO OR PRINT CUARLI'—
PROPERTY INSPECTED
STREET ADDRESS 841 Snatu.it NewLown Road Nat-61-onz Niiiz (lass
ASSESSORS MAP , BLOCK AND PARCEL # 028-032
OWNER' s NAME Venice D2a'Rea
PART D - CERTIFICATION T
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME Joseph P. Macomber V ion Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or City Stat• tip
COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1.578
CUTI'FICATION STATEMENT
I certify that I have personally inspected the sewage dieposa7. system at
I
address and that the information reported is true , accurate , and
omplete as of the time of ;inspection, The inspection was performed and any
recommendations regarding upgrade , maintenance ) and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one ;
Syste6 PASSED
The inspection �ghich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILEt)
The inspection which I have con' I'vcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection. orin.,
Inspector Si nature Aix
te
ne copy of this c c.ification must be provided to the OWNER, the BUYER
( where applicable ) and the DOnRD OF HZAL1'II ,
* If the inspection FAILED , th'e owner or " erator shall upgrade ' the eyetem
wiehin one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CHR 16 - 306 ,
partd . doc'
r
�S
C&U4_
03Z)
NOV w
0 `0'"N0F2 4 199, r
y�(Ty
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 Ci
508-771-9399 508 428-8926 FAX: 508428-9399 L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
I'e
Property Address: ,' _
Date of Inspection: if %9 Inspec is Name:
Owner's Name and Addres le
a
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal,e`ystems. The System:
t/ Passes
Conditionally Passes
Needs Further tva ' tion B the ocal Aproving Authority
Fails
Inspector's Signature: ' ZI, Date: 7
The System Inspector shall sub a copy of this inspection report to the Approving authority within thir-
ty(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 sliall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYSTTj.NI PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exfiltration,or sank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1-
s
E .
SUBSURFACE SEWAGE
DISPOSAL SY
STEM INSPECTION FORM
PART A
" CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(sj are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN'A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY-AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and'is within 100.Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a.private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. -
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog
ged SAS or cesspool. _ `
Liquid depth in cesspool-is less than 6"below invert or'available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The'system is within 400 Feet of a surface dririking water supply
The system is within 200 Feet of a tributary too-a surface drinking water supply
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area.
(IWPA)or a mapped Zone II of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
1/ Pumping information was requested of the owner,occupant,and Board of Health.
Li None of the system components have been pumped for atleast two weeks'and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
1/ As-built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
✓ All system components,excluding the Soil Absorption System, have been located on site.
t/-The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
,depth of sludge,depth of scum.
Me size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
r ,
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
" The facility owner(and,occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL*
Design Flow:,&30 allons Number of Bedrooms: (.3 Number of Current Residents: U
(��� Seasonal Use: �
O Laundry Connected To System: Seaso U
Garbage Grinder: ry
Water Meter Readings,if available:
Last Date of Occupancy: ,(lyl.&M22A��
COMMERCIAL/iNDUST _
Type of Establishment:
Design Flow: .,� ••gallons/day 'Grease Trap Present: (yes or.no)
Industrial.Waste Holding Tank Present:
Non-Sanitary Waste Discharged To Th_e Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:.
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
, Z
PUMPING RECORDS and source of information: n
System Pumped as part of inspection: 62C _ ,If yes,volume pum allons
Reason for pumping:
TYPE OF SYSTEM:
_Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
APPROXIMATE AGE_of all components,date installed (if known)and source'of information:
_ .
Sewa a odors detected when arriving at the site:. U
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: /a,� Material of Construction: concrete metal FRP_Other
(explain)
Dimisions: -5 XCn'XS' Sludge Depth: " Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3`1 11
Distance from bottom of scum to bottom of outlet tee or baffle: Allep °
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in re on to oiWet invert,structural integrity,evidence of leakage,etc.) l;o Q. ODCJ
%,
GREASE TRAP: /L)d
Depth Below Grade: Material of Construction:—concrete—metal FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for,pumping;condition of inlet and outlet tees or baffles,depth of liquid... .;,
level in relation to-outlet,invert, structural integrity,evidence of leakage;etc.) =p-
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_metal FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alarm and„float switches,etc.)
DISTRIBUTION BOX: ✓
Depth of liquid level above outlet invert: Aft -
Comments: (note if 1 el and distribution is equal,eviden a of solids carryover,evidence of leakage into
or out of box,etc. ,t a 1 X ��. d_(�r , r" ajL
PUMP CHAMBER:_
Pump.is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):_
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits, number: Leaching chambers, number: 3 Leaching galleries,number:
Leaching trenches, number,length:
Leaching fields,number,dimensions:
Overflow cesspool, number:
Comments: (note condition of s=sidraulic failure level of nding,conditio of vegetation,
etc.)J�Q
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6
i
y�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate I wells within 100 Feet.
le- o'�
j
DEPTH TO GROUNDWATER:
Depth to groundwater: A' Feet
Method of Determination or Ap roximation: /�'� i�q 'G�
>�atz�4 .tiles
-7-
TOWN OF BARNSTABLE
LOCATION SEWAGE # -�
VILLAGE �? IU-S ASSESSOR'S MAP Q LOTGc;LF 6 a
.y
INSTALLER'S NAME & PHONE NO. 1'3'aP-UL6"
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /�l�-74-7-44gW ZS 3 (size)
NO. OF BEDROOMS PRIVAT - R PUBLIC WATER
BUILDER OR OWNER %0ed CJ-.)20(?AJ
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes
1 . ,-
No....� .�.v� Fps.....
THE COMMONWEALTH OF MASSACHUSETTS
APPROM BOAR® OF HEALTH
TOWN OF BARNSTABLE 63a-
l rtt Diripagal Work.6 Tomitrns#ion remit
Application is hereby made for a Permit to Construct ( ) or Repair (P^J" an Individual Sewage Disposal
System at:
.............. ..�.....��........2L..S�J.-•---•-- ....----------•--•-•..... �-----'/1')1(�L�.---•----•--•-----
......................laCY oc- atiot•.\dd�s �/ _ .......................................•____
v or o.
_......................... . ....................... .......... ------- --•----•------ -
�4P� (N�� Zddress
................................................................................................. ..'---•_.. __..._�
Installer Address
U Type of Building Size Lot............................Sq. feet
13
..� Dwelling—No. of Bedrooms___________________________________---____Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixture
Design Flow...................._...._.gallons per person per day. Total daily flow..__-_-_.___....��__...d.................gallons.
W -
WSeptic Tank—Liquid capacity_AF!..galIons Length________________ Width---------------- Diameter................ Depth................
x Disposal Trench--No. ......../......... Width........7....... Total Length Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1--4 Percolation Test Results Performed by.......................................................................... Date........................................
,4
,.� Test Pit No. I................minutes per Inch Depth of Test Pit.................... Depth to ground water........................
f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 •--••-•••••------------•-------'--•----------------•'--••••••••----•••••......----..........._-----•.........................................................
0 Description of Soil........................................................................................................................................................................
W
U ...............•--•----•••------•••••••------........•-•-•----.........-••-----•-•---.........-----••••-•----'----------'-------•••••-••--'••---••--•••-•-•---'•••..............._...---................
W
..•------•-----------------••---•----•------------.._...------•-------..........-•--------.......------------...--------...._._.........--••••......--•-----• ..................-•----- -....
x Natu of Repairs or Alterations—Answer when a llcable. t
U l ,j
� �LT............................. !^f ' .... ' ..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance h ee issued y e b I'd f h alth.
..
.. /0
......... ... .............. .......... . .... .. .. ............. -
Signed .......... .
Date
ApplicationApproved By ........ ..... ?.. ,c -- ------------------------------------------------------- ------$.....-1.-------------I.'3
Application Disapproved for the following reasons: ..... ........ ......... ............................... ......................... .................................
............. .............................. .................................................................. .. . . ......... ------ ....... . .. .......................................
Date
Permit No. ?..3--'-----t .2 .. Issued .......... ... ...�0-...: ........-......
e
a
..: 176
d .•
No.... ......�_'?- f ,r Fss.._.........................
.
THE COMMONWEALTH OF MASSACHdSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
liratinii for Di�� Harr 3fnrbi Tontitrnr#iu�� � n ramit
Application is hereby made for a Permit to Construct ( ) or Repair (,><) an Individual Sewage Disposal
System at:
,L�oSati,i-Address or Lot No.
........................................
Owncr dds
►W-a ............................... .._._1�1fa !� ...res
................................................l 1J
.........................................................
Installer Address
U Type of Building Size Lot............................Sq. feet
13
.-t Dwelling— No. of Bedrooms...................................__-.__-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type.
of Building -------------------------•-- No. of persons-------..................... Showers ( ) — Cafeteria ( )
Q Other fixtures ------------- -------- --- ------ --------....
w Design Flow.....................J. .._......__.-gallons per person per day. Total daily flow...._.._._...
...............................gallons.
WSeptic Tank—Liquid capacity.A4 °-.gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench—No. --------/......... Width........7------- Total Length__5s?x75-_Total leaching area....................sq. ft.
Seepage Pit No.--__---.---_------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) -
aPercolation Test Results Performed by............ ............................................................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---------•- -•.................••••••••---••----•--•----••--•---••••-•--•-•-•....•••-----•-••••-•------......••-----•--•--•---•........._......-•-•..........
0 Description of Soil................•-•----------------------•------------•-•---••--•------•--•----------------------------------•--------•---------------------•••-•.................._..
x
U .......................•••._...•-•---•--•-•••-•••----•------------•---•-----••••-•---•-••....••-----•-•-•--••--•-------••-•------•------•--••..........••-•----..._.......•---•--••----•---•.........---
w
UNature of Repairs or Alterations—Answer when applicable_. .' .% 1_>.._..1. �.9..,r qx -•i�?�L2-
•.... . . . Sew E
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has ,peen issued y t'e board of h alth.
- -__
Signed .............. /..........................................
./..� -'-.-...-`�.......-�t .......... ...
Date
Application Approved By ........ ------��-. . s._1...-....-.. R-... (..(?. ..-� 3
Dace
Application Disapproved for the following reasons: ........................ . ... .. .... ................. . ...............--......................--
....... .................... ......................... ... ..--....... . . ......... . . . . ..... ........................... . ........................................
Permit No. ....,�13...-- �}.- ._: Issued� ... '._..� --.
` --------------------. r .. ............fe--..--
^.r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' TOWN OF BARNSTABLE
(1elrtif rate of Compliance
e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by . .. ....... .............._........ .. ... 73� /A------_C._ 6.�5.).....-...- - .... ... -- . ..............
Installer
.........
at .-.. - ...... l � - � ./ � �-----------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _.........../_ dated .._..__.._-....-._..............._..__.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......_.............I. 3 ..."95.........__----.-............_.. .... Inspector ---- �............................................................
ate..----------r---cam ————— ——————.sw--T_.-------..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �J
TOWN OF BARNSTABLE
�- 1�-•�-. FEE---.:�.Ii............
Uispnsnl Workii Tona#rnr#ion rani#
Permission is hereby granted...............................1�5 C!.�c U%?77 (1' �•5-
...------•••-••-•..............
to Construct ( ) or Repair ( ,",,)-,an Individual Sewage Disposal System
atNo............................................................F ....•-•• .1. /ZJ-c l_---- �2�. . ------•----- •.............
Street qq
as shown on the application for Disposal Works Construction Permit No.G.3-fu?._)._ Dated........................................... I
................................... �- ........................................................
Board of Health
DATE ..-...I�� ?,----------••-------------•-••--
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS
ASSESSORS MAP : _ TEST HOLE -LOGS
PARCEL :
FLOOD ZONE— . �G,C�}fL-�
So I L EVALUATOR:: l 0 NOTES:
--- WITNESS - 1k
REFERENCE-Z?
. --_12_ _.. 1 DATE: V
PERCOLSOD
ON RATE: 4 IM) 1 1 1 The installation shall comply with Title V and Town of Barnstable Board of
, , Health Regulations.
TH- I TH-2 2) The installer shall verify the location of utilities, sewer inverts and septic
'v components prior to installation.
/ d 3 ) gravity P piping per foot.
3 All avit septicto be 4 inch Sch 40 PVC at 1/8"
4) This plan is not to be utilized for property line determination nor any other
LO -d / purpose other than the proposed system installation.
�W I� ✓� 5) All septic components must meet Title V specifications.
r �`°" 6 Parkin shall not be constructed over H10 septic components.
LOCATION MAP Chi." 3� �� Al ) g P P
7) The property is bounded by property corners and property lines as depicted.
8) The property owner shall review design considerations to approve of total
.f,
number of bedrooms to be considered for C design. Receipt of a g Pt payment for the
plan and in stallation based on the plan shall be deemed approval of the
number of bedrooms.
_ �� 9) The existing cesspool/septic components shall be pumped and backfilled per
I—lb Title V Abandonment Procedures.
rcJ�4�:�
10)Proposed leaching is to be within 36 inches of grade or provide venting or cut
�J I grade as permitted by the Board-of Health.
11 System components to be 10 feet from water line.
SEPTIC SYSTEM DESIGN
) Y P -
/J FLOW E3T I MATE
\ (/ BEDROOMS AT GAL/DAY/BEDROOM - %D GAL/DAY
i 1 SEPTIC TANK
f ��
YOGAL/DAY x 2 DAYS - fo O GAL
USE GALLON SEPTIC TANK Iik(�J�VQ
J � __I " _ __(lZit,�br� 1r.1QT.- mot✓
01L ABSORPTION SYSTEM -
� ( l �r-"" j..#j' .• - .. ., ,;.� 9 � �. r ,,� '1 r�e n Y ��. 7 i. �r•}� d�".� p; `
1 I
77
1+� t o j.
In M .�5C! 7r7ti /C- 7 �`;� ,� Z— ,�r�`l,�" �•t ;�
p �1 I SIDE AREA: 'y '1'
;. ;
30TTOM AREA: l ?�- o%-7
tp=
A3u ,
SEPT I C SYSTEM SECT I ON
10 ICI
r'
1
'A� /000 GAL _
\ Wf.,w.,,, -`'.•;* ____^_ SEPTIC TANLf&ter
Iblo
- K„ 8
SITE AND SEWAGE PLAN
LOCATION :
CL
5 1
PREPARED FOR : 41,14
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SCALE:
W
DAV I D B . MASON,R5 DATE: to
DBC ENVIRONMENTAL DESIGNS
W DATE HEALTH AGENT
EAST SANDWICH . MA
( 508 ) 833- 2177
W
Z