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HomeMy WebLinkAbout0047 STONEY POND CIRCLE - Health 47 Stoney Pond Circle r -- Marstons Mills nr_ncn_n�o_nn� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owners Name information is required for every Marstons Mills MA 02648 11-14-12 page. City/Town State Zip Code Dabs of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form.- Important:When filling out forms A. General Information on the computer, ,INN\ IOFrbfgSVII, use only the tab 1_ Inspector: :ys`c9:•• sy� key to move your ; ., ) o cursor-do not James D.Sears = JAMES use the return - key_ Name of Inspector 0: SEARS CapewideEnterprises,LLC = *= • �'• �'? Q Company Name 153 Commercial St. i����/,F 5 INS? Company Address ,nano Mashpee _ MA 02649 City/rown State Zip Code 508-477-8877 S 1623 . Telephone Number License Number S. Certification 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-14-12 pectoes Signature Date 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. ""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. 1 1 . tSins•11110 Title 5 Off7eial Inspw%on Form. bs sewage Disposal sy Page 1 of 17 4 Nov 14 12 08:06p p.2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information i e required for every Marstons Mills MA 02648 11-14-12 page_ City/Town State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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"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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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 efiltration 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. ❑ Y ❑ N ❑ ND(Explain below): 15ins-I U10 Title 5 Official Inspection Form:Subsurfaos Sewage Dispose!System•Page 2 of 17 Nov 14 12 08:06p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner owners Name information required for every Marstons Mills MA 02648 11-14-12 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins-11110 Title 5 OMdal Inspection Form:Subsurface Sewage Disoosal System•Page 3 or 17 Nov 14 12 08:06p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V4 47 Stoney Pond Circle Property Address Barbara Coleman _ Owner Owners Name information is required for every Marstons Mills MA 02648 11-14-12 s page. Citylrown State Zip Code Date of Inspection B. Certification (cost.) 2. System will fit nl a u ess the Board of Health(and Public Water Supplier, if an Y { n PP � YI 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must 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. dogged SAS or cesspool © Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in axis less than 6'below invert or available volume is less than Y2 day flow /o,T t5ir.s-1 1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Nov 1412 08:07p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required for every Marstons Mills MA 02646. 11-14-12 page. Cityfrown state Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® 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 facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"bD each of the following, in addition to the questions in Section D. 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 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat; or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins• t/1 a Tille 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17 Nov 14 12 08:07p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is every Marstons Mills required for eve MA 02648 11-14-12 page. City/Town State Zip Code Date of Inspecdon C. Checklist 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: ® ❑ 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)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 L5hs•11/10 701e 5 Official impaction pedion Form:Subsurface Sewage Disposal System•Pape 6 of 17 Nov 14 12 08:07p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is* required for every Marston Mills MA 02648 11-14-12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Precast tank D Box and pit 4 Number of current residents: NA Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[dyes separate inspection required] ❑ Yes Z No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2011-102,000Gal g y g (9p »' 2012-15,00OGal Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment - Design flow(based on 310 CMR 15.203): Gallons per day d Y(9P Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tsins•11110 TAIs 5 OtTdel hupedlm Form:Substiftoe Sewage Disposal System•Pape 7 of 17 Nov 1412 08:08p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required forevery Marstons Mills MA 42648 11-14-12 page_ Cfty/7own State Zip Code: Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Q Tight tank. Attach a copy of the DEP approval Q Other(describe): t5ins-11r10 Title 5 Official trsspemon Form:Suhsurfaca Sewage Disposal System-Pape 8 of 17 Nov 1412 08:08p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name required fo is Marstons Mills MA 02648 11-14-12 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1988 Permit # 88 -517 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 40" feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 32" feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500"Gal lit Sludge depth: Wns•11110 - TWO 5 ORCial Inspadion Farm:Suosudaoe Sewage Disposal System•Page 9 et 17 Nov 1412 08:08p p:10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is Marstons Mills MA 02648 11-14-12 required for every _.._._— page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle 81 1 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? As-built-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank and outlet cover at 32" below grade, Tank at working level w/in and outlet tees, No sign of leakage or over loading Grease Trap(locate on site plan): ' Depth below grade: feet Material of construction: ❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain): I Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•11110 Tift 5 Official kspee im Forth:Subsutraw Sewage Disposal System•Page 10 of 17 Nov 1412 08:09p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form f� Subsurface,Sewage Disposal System Form-Not for Voluntary Assessments -- 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 " 11-14-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: [ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required)_ Is copy attached? ❑ Yes ❑ No t5ins•11110 Tile 5 official Inspedon Form:Subsurface Sewage Disposal System Page 11 ar 17 Nov 141208:09p p;12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is Marsions Mills MA 02648 11-14-12 required for every page. City/Town . State Zip Code Date of Inspection D. System Information (cant.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 16"x16"-3'below grade, Box is clean and solid w/one line out, No sign of over loading or solid cant'over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order_ ❑ Yes ❑ No Comments (note condition of pump chamber; condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tSins-11/10 Title 5 Official hspeMon Fomr.Subsurface Sevrace Disposal System•Page 12 of 17 Nov 1412 08:09p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required for every Marstons Mills MA 0264E 11-14-12 page. Citylrown State Zip Code Date of Inspection D. System Information (coat.) Type: ® leaching 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,etc.): Leaching is one 1000 Gal precast pit wl 3'stone, Pit and cover at 27", 2"water stain line at B", No sign of over loading, solid carry over or high stain line Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ms• 1/10 TOIe 5 Official Inspection Form:Subsurface Sewage Olsposal System-Page 13 cf 17 Nov 1412 08:10p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 11-14-12 page. cityfrown State Zip Code Dale of Inspection D. System Information (cont.) Comments (note condition 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 condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Dsposel Systarn•Page 14 of 17 Nov 14 12 08:10p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .' 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 11-14-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I �RoN� Q 101 :[0 /4 3- 7 3 -S tsins-.I IM a Tina 5 Off W Inspediann Form Subsurface Sewage Disposal system-Page 15 of 17 Nov 1412 08:10p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owners(fame information every Marstons Mills required for eve MA 02648 11-14-12 page. Citylrown State Zip Code Date of Inspectlon D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high groundwater. 1 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9-30-89 Date ❑ Observed site (abutting ro e !observation hole w'� 9 P P rtY withi n 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: T.H.on design plan 9-30-89, No G.W.at 12'+ bottom of pit at 8' 4'above T H Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Ti9e 5 ORidal Inspection Farm:Subsurface Sewage Disposal System•Page 16017 Nov 14 12 08:11 p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not For Voluntary Assessments f 47 Stoney Pond Circle Property Address Barbara Coleman Owner Owner's Name information is required for every Marstons Mills MA 02648 11-14-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r5ins•11110 TMe 5 Mciel fnspecYion Form:Subsurface Seurdge Disposal System•Page 17 or 77 TOWN OF BARNSTABLE LOCATION Vie- _3 Smlas,l Qoan e--itL-SEWAGE # M -SI 7 VILLAGE tna�� ASSESSOR'S MAP & LOT o64/: P-003 INSTALLER'S NAME& PHONE NO. ��C tS T Czv%s— SEPTIC TANK CAPACITY����'bp• LEACHING FACILITY:(type).. tS J z (size) NO. OF BEDROOMS _PRIVATE WELL PUBLIC W BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSCJED: VARIANCE GRANTED: Yes No A/o x,goo .. n 73 ts'oo © 1 NmsC?. THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH . ....................OF... Q t� Y b.4........................................................ ApplirFation for Uhipooal Workii Totutrnrtion tIrrmit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: •-------------------------------------•------•----------...--•---------.........--- --.............® ......----...-----....................-------------------•-----•---•---•-- Location-Address D or Lot No. ............El Y1e�F....1 e�l ..�C'-------•---•-------------------•--------•- .......... r!rld�r...��?f�.-.cJ•ral,.--•---------......--..................... Owner Address at 1 •-........................................................ ...........m4r��f�_A....M/.�k.------•---••------......---•---•--------------- Installer Address Type of Building Size Lot_._l__S, /7 ----Sq. feet ,., Dwelling—No. of Bedrooms............._-.............._........._Expansion Attic (Al) Garbage Grinder a'4 Other—T e of Building No. of persons............................ Showers Other—Type g -----•-•-•----------•------• P ( ) — Cafeteria ( ) QOther fixtures -----•--•-------------•-•-••-•--------•-----•--------.---•-----------------•-•- W Design Flow.....................................5�gallons per person per day. Total daily flow___.........................................gallons. WSeptic Tank—Liquid capacity.l4C�gallons LengthZQ.-6...__ Width.=�_7b'...._ Diameter--____ Depth��LS'`.-_.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-_____.._._____•----sq. ft. Seepage Pit No...a?A�--------- Diameter...../_Z---....... Depth below inlet.....6.1......... Total leaching area..�,9_.....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by....._.. xl�f._b`.!1 j1=._. ? ...................... Date..9�_ t Test Pit No. 1....7---------minutes per inch Depth of Test Pit...l_ ......... Depth to ground wat r=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground w '�4y 04 •••. •••..... � STEPH�Crd V. Description of Soil-..D:::Ae..._..Ta il- _ - aMot�---`f 8.� '4._.._. ...........................--------------- C3 -, v �4"-lU �,a�ll ��rrv .-----------•------- ------------•------ ---------•------------------------ l ---------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------- sst ?��' Agreement: G�u�v 9-a gF- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T4 IT%.E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has sue the board of h�alth. Signed........ . • •...•-•-•• .••--• .. ' Application Approved By.... ��C• .._.. Date B •• -••••••-• . --------••-•......---- ------------------------------------ Date Application Disapproved for the following reason ------------•---------•---------------------------------------------•-------------------------------------...... ..................................................... --- - -----•-------------------...-----•--•-----------------•-------------------------------------------------------------------- Date Permit No....SJ_G?:::. v. -------•---- Issued------------------------------------------------------- Dste 7 Fm3 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH OF....txtr.hslab-1e-------------------------------_-----•---...-__----- ApplirFation for Uisvoii al Vork,5 C omarurtion Pumit Application is hereby made for a Permit to Construct ( Vr) or Repair ( ) an Individual Sewage Disposal System at: •---••------......................... ...._ ....._...........-------------------•- ...............LT.... ......... . .... ------....... Location-Address ``or Lot No._..._....._s��l/!1_ ��/l�p.. a�./1C! Owner Address a = ------------------------------------------------•--- Installer f�'fAlaS /s��S-•--------------------------•-••----_______----- Address UType of Building Size Lot----45 .617t_...Sq. feet �-, Dwelling—No. of Bedrooms...............a_........................Expansion Attic (A/) Garbage Grinder ( vr Other—T e of Building No. of persons............................ Showers a Other—Type g ------•-•------•-----•-•---- P ( ) — Cafeteria ( ) dOther fixtures ...-•-•-•--------•--•---------------------------------...-••-•---•--•-•-- W Design Flow.....................................-gSgallons per person per day. Total daily flow..............3.�-_'_P.................gallons. W Septic Tank—Liquid capacity..}15�allons Length./O-'_-b''.. Width__5'-$ -,"._ Diameter_ __- Depth_SL �.._. Z Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._._� p,z,&-------- Diameter...../Z_./_.__.__. Depth.below inlet___..__..._..._. Total leaching area_.3a9.....sq. ft. Z Other Distribution box (X) Dosing tank ( ) aPercolation Test Results Performed by--......,c , t_.F. e__..�12c...................... Date__p-_3_G_-f�7 ____..._.. Test Pit No. 1....2........minutes per inch Depth of Test it.__�_4 .__._.... Depth to ground water .- . GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wat �sr,P ._._.__._ -,sy a ----•-------------- -------------------------------------•n•••--••.------------•-------------------------•-------------------xDescripion of Soil---U '--•-------•.......................•-•..... -----s-A�€LPYl�Nl;......t p V $!Q. ��,----j- .................................................................................................. 0 -WILSON y W -.... .o.'p No.30216 ���� 9 Gis7� U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------- v. �o L ----------------------------•---............................ • - Agreement: Geale- 9--A The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has sued.. the board of health. Signed_...... �.-„=�,-- ' -- ------•-•-----•---- ----•----•••--•-...-----•-- 0 Date Application Approved By..........-------------•--------------• •.------••-•----- Date Application Disapproved for the following yeas ---------------------•--- - ----------------------------•------------••----•--•••----•-•_••--- ................... .............................................. ....... Date PermitNo........ ��17------•-----•------ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOAR OF H ..../.....................................OF.... > l...f....(!. -••-• (9rrtif irab of TompliFaurr T Sl TIFY- That the Individual Sewage Disposal System constructed ) or Repaired ( ) by ................. y......i / nstalle r at........................�•-- - @...........-�( KJ �.�•- tom )7---- da 1l1 F = ----------------- has been installed in accordance with the provisions ofj4T' S Staate Sanitary o e descr'bed in the application for Disposal Works Construction Permit N .. '� ._ _____..... dated _� � ---e......-........ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CO STRIDE® AS A OUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... 9.1............................... Inspector............... ---•- ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOAIM.4F,4­1 E �..................... FEE .Y............. f .�aa�tr�rti�at rranit Permis o is hereby granted J --------- --••••--•--•-•••_••-•-• •••-•--•••..................... to Coryst ct Re ivid Dis sal at �- Stree - � .: as shown on the application for Disposal `'Forks Construction Permit ._ Dated. _. __ ._ �--------------- ------------------------ ----•---------------------- r w� Board of Health DATE------. •.••. ......................................... 1255 HOBBS & WARREN, INC.. PUBLISHERS ` 5tin�lc .Family •- 3 BccSlrocros . . .it/pT�.; /i1ax:�,�.;r '; �/��sst� .._G/�widsdwls�- [/f� DAIw Low I 10 x 3 = 330 Gpd " .Qapo�>r an c✓ur.(cr. vub�iv�s.[�2-_.. S�pr�c T"tNK 33o x zooJ'o = GGO GzAlons ___.._...._. Usc. ISoo Gc,l{oh Scp{-�c .•Twnlc DISPb514.1_ ;f i r l000 gallur� pit l41.-�j 3.�c�t c f erushe;Q Sfonc t. •C'AcPAC�T`t 226 x'2.5 = 56$•GpcQ • 0o'rr'om 13' S!�1 CAPAc�TY r I x I,o 1 13 Gpcp. TbTa 3 3 9•S 1= 678 Gfcl ��P� Qss9 �,LSIi OF,�q RICHAf3D STEPHElq BAXTER oo ALLYN rn s o 24048 Q �' VILSON r-- -- - -. o� N . `, .a .e No.3021r, a :X, Air' v%ru,tu6u-. •rnutEriii C shall loc rcvi,ovc �f i J pn 'Q s SISTER �� �j ---w1�h►n _w_ _1 D -fe.` _.cli�8�2�n s .tarb v rteQ 't4�¢;�'� `�ip�y4 �,�� �,ck�,c``-��S•r�j�F``'�- 1 c ► LA 1£- ate- re p laces-d +tA _c.lco:n SwluQ '�#*` _ .L F P-Co706 (4-ao-e7) �x•1er� Nye =r►c ; �, �cininiv� � � }•t...li•h 7i 00 �ft•. ��ZcvFayto) /Soo /.fiii 66.�65 /.VV 4 «c.t. .SEI-e IG -' .• '� G5�90 f��o.7 8q11 N (02, ncO 141—dw i GE.eT/,CY TfI,QTTy�' sos4� Syaw.tr '�E.�Eav cotlP�.Y,.s !-si�Tf/Tf�E s'ir��,r�f/E .CE'QV/2Eti1�Nr.S Th�� B,exr�,e �t/>E I've 7 , "axiv OF j�,4�zN5 rt3t �.. -.4tiz7 /.S NoT i2EGis,�2rO.L.av�-SlizvEYo,�s occr.�.o W/y`H/y TQtAs'7- T UN 14IV M-'572- "!/�I,EiYTIVl T.SiE ac�S s�!?�it�h�E.eE4rV Si�QUG • -- . To E.ST.�ll/G/Sy LQ�•,-.G/iV yaT--Q` USEp • FS; 8631 F jo 2 1_a3l-is \ ' � �.I�9�•`l Sjt tit�1 !� yr/ i i all i o • e� i' IE 07 00 all 1 1 y ^ t �N s< T :N. ._. 2. QQ I I h� I'- OW-4 SO.d S t9esseJ ED `r✓��rz.� A c,,s usrm-F_cu—i 1 .` 50 I 1 t ) 0� 1,�0 gq.Z3 4 ,3 y 3d �9 OW�1 - OW-2 i 49 OW-3 �.So C3 0 S3 .09 48 FIGURE 6: GROUNDWATER CONTOURS m LEGEND ® OBSERVATION WELL -52-GROUND-WATER CONTOURS _ -► DIRECTION OF GROUND-WATER FLOW SCALE 1: 1321 1 ci)mc. AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION_1Qr-K ��tz--SEWAGE # VILLAGE 6-,0,cL&nv4t Y����_ ASSESSOR'S MAP & LOT INSTALLER'S NAME Q PHONE NO. Gsm s — SEPTIC TANK CAPACITY LEACHING FACILITY:{type) (size) NO, OF BEDROOMS 2 - - _PRIVATE WELL PUBLI W BUILDER OR OWNER DATE PERMIT ISSUED: y DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No l o ' http://issgl2/intranet/propdata/prebuilt.aspx?mappar=064068003&seq=1 11/14/2012