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HomeMy WebLinkAbout0060 TANBARK ROAD - Health 60 TANBARK RD., MARSTONS MILLS A= 100 020.003 l Commonwealth of Massachusetts = Title 5 Official Inspec ion Form Subsurface Sewage Disposal System Form - N t for Voluntary Assessments c 60 Tanbar k Road Marstons Mills MA 02648 `� I�1 Property Address Karen Morrissey 00 _ 66-31— Owner Owner's Name information is 170 Tremont Street, Boston IAA 02111 August 8, 2008 required for every age.. Cityrrown tate Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r-0 reb 189 Cammett Road Company Address 6_ Marstons Mills MA Cj 02648 enan City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number ? B. Certification : I certify that I have personally inspected the sewa a 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 experie ce 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 15.000). The system: ® Passes ❑ Cond tionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority August 8, 2008 I ector's Signature Date The system inspector shall submit a copy oft is 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, th 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 addr ss how the system will perform in the future under the same or different conditions of use. 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is required for 170 Tremont Street, Boston MA 02111 August 8, 2008 --- - every page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C, 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 C R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at thi time, Infiltrators have no standing water or signs of hydraulic `k failure. B) System Conditionally Passes: ❑ One or more system component as described in the "Conditional Pass" section need to be replaced or repaired. The systern, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y N, ND) in the ❑ for the following statements. If"not determined," please explain. - ❑ The septic tank is metal and ove 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 in pection 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:. El 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 f Board of Health): k a ❑ broken pipe(s) are repla ed ❑ obstruction is removed 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form..Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official In pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8, 2008 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping m re than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(wi h approval of the Board of Health): ❑ broken pipe(s) are repla ed ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) 'determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface wa er 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. 08-210 Morrissey.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Tanbark Road, Marstons Mills MA 02 48 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8 2008 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 wa r analysis, performed at a DEP certified laboratory, for 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 clogged SAS or cesspool ❑ ® Discharge or onding 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 cesspool is less than 6" below invert or available volume is less than_day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pi e(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 3urface water supply. 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System orm - Not for Voluntary Assessments ^M 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is required for 170 Tremont Street, Boston MA 02111 August 8 2008 every page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of 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 n trogen and nitrate nitrogen is equal to or less than 5 ppm, provided that io 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is ithin 400 feet of a surface drinking water supply ❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any qu stion 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 threa 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. 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachus tts Title 5 Official In pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8, 2008 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been do re. 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 volu nes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built pl ns of the system obtained and examined? (If-they were not available note as N/A) ® ❑ Was the facility r dwelling inspected for signs of sewage back up? ® ❑ Was the site ins Dected 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, de th 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 to ation of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing informs ion. For example, a plan at the Board of Health. " ® El approximation in t e field (if any of the failure criteria related to Part C is at issue approximation o distance is unacceptable) [310 CMR 15.302(5)] 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm Not for Voluntary Assessments wM61160 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey. Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8 2008 required for State Zip Code Date of Inspection every page. CityrFown D. System Information Residential Flow Conditions: 3 Number of bedrooms (design): 3 Number of bedrooms (actual): 330 ` DESIGN flow based on 310 CMR 15 203 (for example: 110 gpd x#of bedrooms): 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage sy tem? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 144,000 gal. _ Water meter readings, if available (I st 2 years usage (gpd)): 197 gpd. Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date' Commercial/Industrial Flow Cond tions: Type of Establishment: Design flow (based on 310 CMR 15 203): Gallons per day(gpd) Basis of design flow (seats/persons sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank prese t? ❑ Yes ❑ No Non-sanitary waste discharged tot e Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date t Other(describe): 08-210 Morrissey.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachuse is W Title 5 Official InSpection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8, 2008 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cony:) General Information Pumping Records: None Source of information: Was system pumped as part of the ir spection? ❑ Yes ® No. If yes, volume pumped: gallons How was quantity pumped determin 'd? Reason for pumping: Type of System: ® Septic tank, distribu ion box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ElInnovative/Alternati 'e 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): Approximate age of all components, date installed (if known) and source of information: Leaching system installed 6/28/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-210 Morrissey.doc•08/06 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachus #ts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Tanbark Road, Marstons Mills MA 021348 Property Address Karen Morrissey Owner Owner's Name information is required for 170 Tremont Street, Boston MA 02111 August 8, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan) Depth below grade: 3 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.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction.- ER concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: • years Is age confirmed by a Certificate ofCompliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- { 8.5' long x 5.2'wide- 1000 gal. Dimensions: :Sludge depth: 2 Distance from top of sludge to bottorT of outlet tee or baffle 28 Scum thickness Trace Distance from top of scum to top of o tlet tee or baffle 6 s Distance from bottom of scum to bott m of outlet tee or baffle 14 How were dimensions determined? Measured 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm - Not for Voluntary Assessments ' 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is required for 170 Tremont Street, Boston MA 02111 August 8, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (con '.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of oLitlet invert, tees are intact and clear. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottol m of outlet tee or baffle Date of last pumping. Date Comments (on pumping recommend p0ons, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert' evidence of leakage, etc.): Y. ^ 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): 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System orm - Not for Voluntary Assessments 60 Tanbark Road, Marstons Mills MA 02648 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8, 2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) c . 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 Distribution Box (if present must b opened) (locate on site plan): 0 Depth of liquid level above outlet inv rt Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any fA evidence of leakage into or out of.box, etc.): No solids or high stains, liquid level 't bottom of outlet pipe. Pump Chamber(locate on site plan Pumps in working order: ❑ Yes ❑ No Alarms in working order: El Yes , ❑ No 08-210 Morrissey,doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Tanbark Road, Marstons Mills MA 02648 _ Property Address Karen Morrissey Owner Owner's Name information is required for 170 Tremont Street, Boston MA 02111 August 8, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: 3 Infiltrators. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative 3ystem Type/name of technol gy: Comments (note condition of soil, sig is of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Interior of infiltrators had no standing Nater or evidence of surcharge. 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachus is W Title 5 Official Inspection Form Subsurface Sewage Disposal System orm - Not for Voluntary Assessments °M 60 Tanbark Road, Marstons Mills MA 02 48 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8, 2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pump d 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, sig is of hydraulic failure, level of ponding, condition of vegetation, etc.). 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments — "� 60 Tanbark Road_, M_ ars_t_ons Mills MA 02 4 Property Address Karen Morrisse ------ _ ------------- - .. Y -- --- Owner Owner's Name Mpg 02111 August 8, 2 008 170 Tremont Street, Boston information is __ _ ----------- —-- -" Date of Inspection required for -- State Zip Code every page. City(rown D. System Information (cont.) Sketch Of Sewage Disposal Syste Provide a sketch nchma ks. Lo ate alp wells with n 100 feetosal system gfties to at.least two permanent reference'landmarks or Locate where public water supply e ters the building. Tanbark Road Water Service 0 23 32 26 34 •.' - Commonwealth of Massachusetts Title 5 Official In pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Tanbark Road, Marstons Mills MA 02348 Property Address Karen Morrissey Owner Owner's Name information is 170 Tremont Street, Boston MA 02111 August 8, 2008 required for 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (con .) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 25 feet Please indicate all methods used to etermine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abuttingproperty/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS topo map and town GIS. You must describe how you establisl ed the high ground water elevation: Town groundwater contour map shows water at el. 35 and topo map shows property at el. 60. 08-210 Morrissey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF tHE 1p� Regulatory Services iARNSTABM ; Thomas F. Geiler, Director y MASS. 1639. Public Health Division Arfp Mp'l� Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER .This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be .listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Y p QASEPIIC\Disclaimer Private Septic inspections.DOC ff' TOWN OF BARNSTABLE LOCATION �����^ SEWAGE# VILLAGE f-VI- 1 i11S ASSESSOR'S MAP&PARCEL 'S NAME&PHONE NO. r iG&, 6L)OnhvtJ SEPTIC TANK CAPACITY Ja LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNERsc,n Vmm�P 1 PERMIT DATE: CaNPWAN'E DATE`.' P 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 Tanbark Road ater ervice 23 32 26 34 TOWN OF BARNSTABLE all LOCATION SEWAGE # ?,41/ �Z 7 1 VILLAGE ASSESSOR'S MAP & LOT 0LQZD-oat INSTALLER'S NAME&PHONE NO. -T r{ L,i�k r->t f/-Z F Z X SEPTIC TANK CAPACITY 1000 G6aL LEACHING FACILITY: (type) 330S0'5 10d;4-k&AAX (size) NO.OF BEDROOMS BUILDER OR OWNER + PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist <; on site or within 200 feet of leaching facility) x Feet Edge of Wetland and Leaching Facility(If any wetlands exist Within 300 feet of leaching facility) 'Feet Furnished by ' Y- uo� 5/_ 20 fi No. ,`7 71, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / Yes. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplic Lion for Miopool *p$tem Conmrurtton Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) El Complete System LA'Individual Components Location Address or Lot No. 1 O 7 ,7 A/6 0 IK At Owner's Name,Address and Tell..No. /' Assessor's Map/Parcel 100 '^ 0 —O O � H� 5 Q��V L� 061 L V I t —/A l G /— C`' 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ! helz 7 - 2 2 /Y" Type of Building: Dwelling No.of Bedrooms rrS Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow To gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Er 15t/.N i000 &_&_& Type of S.A.S. 30 S-o 1�i�1L 71�12��1�s Description of Soil Ini i�r10 Nature of Repairs or Alterations(Answer when applicable) 111_S�-4& 110x- !vl PI L'-&���le�,/ �/ ` >ovh S" ` �� I z Z tl 2 ' 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 issue this B ealth. e Signed Date /�76-2S—©/ Application Approved by AN2& V Date (— Z&-CJ/ Application Disapproved for the following reasons Permit No. 'Z,.dV I L4 0 Date Issued TOWN OF BARNSTABLE LOCATION `T��/ wr{:: -J3f� SEWAGE} VILLAGE_ . ta, s ! !�� 'ASSESSOR'S MAP &-LOTI�O'OZD<aa� INSTALLER'S NO. `�i/j,� . fin ''I!�"I Zy°lz _ J' SEPTIC TANK CAPACITY I D D Q. G#L LEACHING FACILIT'K: (type) 5 ?&C-n d m (size) 2 1 k Z NO.OF BEDROOMS- BMDER OR OWNER COMPLIANCE DATE. Separation Distance Between the; IvlaumWn Adjtisted Groundwater.Table and Bottom of Leaching Facility_ Feet Private Water Supply Well..and Leaching Facility.:,(If any,wells eusi , on site or within 200 feet of leaching,facility) Feet ,yr Edge of Wetland and Leaching Facility(If any wetlands exist within 1300 feet of leaching facility) Feei )."shed by d 4 Hn s i _ f . Fr 21 23 ji , �3 No, i�c:="w "'' y Fee i / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. ./ Yes PUBLIC HEALTHwDIVISION�- TOWN OF BARNSTABLEi MASSACHUSETTS ZIppYication for Miopoar *p!tem Congtruction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System UeI vidual'Components Location Address or Lot No. Owner's Name,Address and Tel.No. �0 �l�Ndr�n.� Rb FFCr An // Assessor's Map/Razcel �V1 �� 061 L V 1(.� A 1C 7t `&1 i- FDA �11Z0. -®b s �,��rt Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons ,yi Showers( ) Cafeteria( ) Other Fixtures Design Flow �f Tr gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank F_ �rls/ i,�.n ii�nM:" a ia� Type of S.A.S. X 30 try ""�/h>:� T13 A nC,s Description of Soil k� c1 grr Nature of Repairs or Alterations(Answer when applicable) I M_< f-,nLL t� Ian a- 2 2 o S D —to r-I L f-&4 f-n x < :2- C '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 this rlexc ealth. Signed Date 424-2 C- Application Approved bye`` Date 6- Z<n-C// Application Disapproved for�the.-following reasons Permit No. 7,dy -.0 Zr] Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS i Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( L Abandoned( )by Z:;-,4;"Fc at 1'e, 6 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. y Z 7 dated (y - Installer �'�w,Ec WI3L k irk Designer The issuance of this pe t shall not be construed as a guarantee that the system 1P uncf pas signed �} raj t Date f_ l � Inspector fit/ P't f --- ----- f - Q No. W u/."'- 7 C Q G U" - Fee � V THE COMMONWEALTH OF MASSACHUSETTS -PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS _Mi2;po0ar *p5tem Cotn5truction Permit _ Permission is hereby granted to Construct( )Repair( g'Upgrade( )Abandon( ) �'7 System located at L O T a)11X n A k. n n. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to t comply with Title 5 and the following local provisions or special conditions. Provided:Construction must Pe completed within three years of the date of this it. Date: 6/7 6 a/ Approved by U6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTI;iICATION OF SKETCH .�YD .kPPLICA—EON FORA DISPOSAL WORKS CONSTRUCTION PE ,'YEIT (WITHOUT DESIGYED,,PLANS) �`~I at"?F't WALkCA hereby cz--mfy that the anplicauon for disuosal worts coa=caon pernit signed by me dated 2 C_D/ concerning the property located at (eO -TACK m K I•v�_���/c meets all of the following criteria: • The failed sysent is conne-c—zed to a residential dweling only. i net e are no comme-c:a1 or business uses assocatcd with the ciwellins. • The soil is classined as CLASS I and the pe-calation rate is less than or eoual to 5 minutes per inca. • T here are no wetlands within l00 fe=of the ororased septic s�se. i ne:c are no orivate wets within 1d0 feet of the oronosed septic s�sce rt • The-c is no incise in flow and/or change in use proposed • Tne-e are no varianc=.requesed or needed. • Tne boaom of the pooposcd leacaing faqir.will not be located less than five feet above the madm=adjured-oundwater table elevation. (Adjur the groundwater table using the r-cmptor method when applicable] U the S._-�.S. will be located with_fo tee:of any ve=ated wetlands, the bottom of the proposed leaL ung facliry will net be lccatcd !ess than our-zeta(I,) feet above the rnacimum adiused groundwater table e!evatiort, 'p e=e complete the following: A) Too of Ground sur:ace ='cwi ion(using GIs inior;rtati.on) / B) G.W. Elcvadon the:NL-`(. Fiah usmea G.`N. .�dl t = T. A and B 2 SIGNED : D A i (si<etch p ocosed plan of s.stem on badt1 W F�®Z 4 O 1` O + oZ via }� a m?jilAlztu4 D°J Commonwealth of Massachusetts Executive Office of Environmental Affairs :� � `le r Department of y, • Environmental Protection' Wham F.Weld Trudhry Oovrrrnor r-` Argeo Paul Colluccl � h,� u.Oowmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r V PART A y �L s !L/ CERTIFICATION Property Address: h� / S Address of Owner. Date of Inspection: ! (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5—8 7 7,6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site 7Pae, disposal systems• The system: _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails , Inspector's Signature: Date: F— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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. r~ INSPECTION SUMMARY: Check A,B,C,or D: A] SYS PASSES: 7a any of the failure criteria ea de ve not found any information which indicates that the system violates fined in 310 CMA 15.303. Any failure criteria not evaluated are indicated below. B] STEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. to yes,no,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 enfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r v sed 11/03/95) 1 One Winter Street a Boston,Massachusetts 02106 a FAX(617)5WID49 a TNaphons(617)292-SM i Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: Bl CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are 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(s)are replaced obstruction is removed C) FUR EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Con 'tions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pub li health,safety and the environment. 1) SYS WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A 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) SYS WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) D INES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND S 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 within 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,unleae a well water analysis 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 Im than b ppm. 3) (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: Owner. Date of Inspection: D) TEM FAILS: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an 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 dogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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(a). Number of times pumped 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. El LARGE YSTEM FAILS: following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: 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 U of a public water supply well) The owner r operator of any such system shall bring the system and facility into Rill compliance with the groundwater treatment program requiremen of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: Q G Check if the following have been done: /Pumping information was requested of the owner,occupant, and Board of Health. uNone of the system components have been pumped for at least 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. _ .bat plans have been obtained and examined. Note if they are not available with N/A. t �►ty or dwelling was inspected for signs of sewage back-up. stem does not receive non-sanitary or industrial waste flow 141e site was inspected for signs of breakout. 11 system components, excluding the Soil Absorption System, have been located on the site. _Ugfhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or /The tees,material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or a roximated by non-intrusive methods. facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection: o 9 tf FLOW CONDITIONS RESIDENTIAL.• Design fbw:• j,� na Number of bedrooms: L Number of current residents: Garbage grinder(yes or no):/L D - Laundry connected to system(yes or no Seasonal use(yes or no):Al D Water meter reach ,if available: Last date of occupancy: COMMERCIALL INDUSTRIAL• Type o stablishment: Design►fl w:_gallons/day Graeae present: (yes or no)_ Industrial rite Holding Tank present: (yes or no)— Non- waste discharged to the Title 5 system: (yea or no)_ Water r readings, if available: Last of occupancy: OTH (Describe) Last of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of' ormation: jq System pumped as part of inspection: (yes or no)� If yes,volume pumped: gallons Reason for pumping: TYPE O YSTEM 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) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: J 2 Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: C?„�►_ SSPTIC TANK1�l (locate on site plan) t Depth below grade: Material of construction:_oonce+ete_metal_FRP other(e:plain) s Dimensions: ..t• ., —' o✓ L ✓Z .. , C/ �' 6 t 6 6 R Sludge depth: , Distance from top of shuige ljo bottom of outlet tee or baffle: �z D Scum thickness: O—/ , Distance from top of scum to top of outlet tee or baffle:__ Distance from bottom of scum to bottom of outlet tee or baffle:- Comments: (recommendation for pumping,condition of inlet and outlet tees or depth�of liquid level in relatio to outlet Invert,structural integrity, evidence of leakage,etc.) p o C p v I A- 1,04 L:- G E TRAP:_ (locate n site plan) +D, grade: construction:_concrete_metal_FRP_other(e:plam) : m top of scum to top of outlet tee or baffle: m bottom of scum to bottom of outlet tee or baffle: ation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, eakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: ^� TI OR HOLDING TANK_ (locate site plan) Depth grade: material of _comets_metal_FRP_other(explain) Dimensions: capacity ns Design flrtame, y Alarm le Comment on of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)_ PUMP C ER (locate on plan) Pumps in ]ciag order:(yes or no) Com:mm ts: (note n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: Q—5,_Q (4 / SOIL ABSORPTION SYSTEM(SAS):V (locate cn ad*plan,if posnbls;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: 7�rPe: leach, g Pam,number: leaching chambere,number._ leschin8 galleries,number: latching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: / Commel�ys: (note condition soil, ��8+_�9�hydraulic fail level of ponding,condiy'on of veB�J�twn,etc.) O G d S 7 6� �l G O A-Gl CESS LS:_ (locate site plan) Number configuration: Depth'top f liquid to inlet invert: of lids layer. Depth of layer: Dimensio of cesspool: of construction: of groundwater: inflow(cesspool must be pumped as part of inspection) Comma tic: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: (locate site plan) of--Marl.site Dimensions: Depth iolids: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. Date o!Inspection: S10TCH OF SEWAGE DISPOSAL SYSTEM: inch>tds ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I / DEPTH TO GROUNDWATER Depth to Woundwater. )2 4 feet method of'determination or approximation: .O c v (revised 11/03/95) 9 . 6o TOWN OF BARNSTABLE L.aCATIO ('L--[) /4�5 1�nC Q,4,-j Py-Q SEWAGE # IR-0i VILLAGE f & ASSESSOR'S MAP & LOT iNSTALLER'S NAME & PHONE NTO. --j-ut i-, l y�- '4/b S<p SEPTIC TANK CAPACITY 160o - LEACHING (size) /6-o NO. OF BEDROOMS PRIVATE WELL ORTPUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 1 3 / R q DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No v a- - �._ .� . .�� ,. O . s �` .. � � �� �� � � � , `� ,,� � � �+ /�s ���� �.� P,. — No.--- ':.,17.... -FEB...7.k..i THE COMMONWEALTH OF MASSACHUSETTS BOARD)F HEALTH Appliratinn for Uiopoiial Wor ii Tonstrnrtion Ifumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: I ' j LC Location-Address / or Lo o. _...._................................. ...... ...•......._ ........__... P /a /Zs 7 �-•iC/ �6A/ Address------nstail-er......................................... ............................................. Addresss•........................................... UType of Building Size Lot__id----�_-----.-_Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (y ) Garbage Grinder (A/) PLO Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .----•-•--•----•-•---...---•-------•--------•--------•••-------•-----•-------•-•----.......----------------------- W Design Flow...............55.....................gallons per person per day. Total daily flow........_._.�...............____.._.___._gallons. WSeptic Tank—Liquid capacity-—gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by.. ._t..EC'---Z E--- ---- Date...................................... „a Test Pit No. l.._.4:� ...minutes per inch Depth of Test Pit---- __'_''� Depth to ground water_l"'Y( _ (i Test Pit No. 2................minutes per inch Depth of Test Pit.............___._.. Depth to ground water-._____--_-____--.._---. .................................. --------- --........- O Description of Soil_ C-01uM.. 5-nre� c. p���3 ce3 x .......................I . ---------------------------------------------------------------------•-------------------- U ----•-•-------••--------------------------------•--••--•••••---------•---------------•--•--•...----------------•----•------------------•----•-----•-----•-------•-•-•--•----•----------••--------•------ w UNature of Repairs or Alterations—Answer when applicable_____________________________________________________________________________•_____•-----_.-_-. --------------------------------------------------------------------------•----------------•.......•-----------•-••----••--•-----••----•-•-••-•--------••••----•••-•-•-•-••------•----•._...........--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with '1a^ the provisions of TT��: .:E 5 of the State Sanita Code— The dersigned further agrees not to place the system in operation until a Certificate of Compliance ha be n issu y th board o iealth. Signed. - . .�......../.� - - ------------------ao �a.l-. �.._.... Date Application Approved BY ------��- .. --- � �-------------••-----------.-----•-- +C �-�., ff�f Date Application Disapproved for the following reasons--------------------------------•------------------------------------------..................................... --------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- =-------- Date PermitNo........... = ......................... Issued....................................................... \ . Date No..11:..�2.... Fms.... ...... -... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ell Appliration for Disposal Wor u Tonutratrtion rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at --at �-£---------. f--- ----------------------------- -------- Location-Ad s or Lo o. ter. r ✓C 0, I6 o- N rti�OT vJtC .....__ - ...... -------•-- ...... 'f' Owe Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ............... .......•----... - W Design Flow...............�"`__�....................gallons per person per day. Total daily flow--__.-__-___-- .............--......gallons. WSeptic Tank—Liquid*capacitylk...--_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dying tank ( ¢) / / Percolation Test Results Performed b ..�_ _._d.____ ° '� _ .. '........................ 1Date.! __ (_. _ .....____.._..._.. ,aa-1 Test Pit No. 1...e. --_--minutes per inch Depth of Test Pit.... ! _._. . Depth to ground water_"O lv .'....___--_-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......................................... /------•-- O Description of Soil_ _t'a v'w--------•--..-��.............. {-C - -- - -- - - -- - x UW --------------------------------------------------------------------••--•--------------------•-•-------------------------------------------------------•----------------------•---•--• ............... Nature of Repairs or Alterations—Answer when applicable.________________________________________________________________________________•-•---------_-. --------•---------------------------•--•--------------•------•----------•--------•-------------•---------------•------------••-•----------------•------------•----•.•-•-••-••-••--••-----....•••----•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTLE 5 of the State Sanitary —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued`Py the board ofAhealth. Signed +.'=- ? Date � Application Approved By............. ! � •-"5 Date Application Disapproved for the following reasons: .................... ....................................................-..............._.......=............................................................................................................................ Date PermitNo.........5''r----3-7---------•--------------- Issued-----------•-------------------------------•------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .. .. . Tntif iratr of TompliFaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by_....:-•......-=................... ._�"a-t......----�'......./........--------------------------------...------------.......----------------•-... Italy n at (. f r`9 :� 1 n 3.? a. /Z ---------------•-----------------...-------------•------•----a---•-------- -----•------------------------ has been installed in accordance with the provisions of TIT7_E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------- --- i............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..•-•..................y:'.5_..S...--•--.............•...-••---•-•_.. .....................W'5D------- ----------------------------------------- THE THE COMMONWEALTH OF MASSACHUSETTS BOAR-D-�OF HEALTH _ /� ......... ... '.......................O F..... .,,.........'.`..y t.r.9 E. .....-----.................................... FEE..'2-} ` 2:.'':... Disposal Works Tonutra$rtloat rranit = s t�t. t PermissionJi) hereby granted = = ' ._..... �w --------------------•---- --•-----...----••--•-•••--•-•---•-•-•--............._•••••-••••. to Construct ( or Repair ( ) an Individual Sewage Disposal System --------�-t S........... N ........ �. .?1 �". .--•-----------------•---•---•---------------•--..... ............. Street as shown on the application for Disposal Works Constructio mit NZM . _Date_ _/.................. lBoard of Health DATE_ -------------........................... FORM 1255 HOBBS & WARR INC., PUBLISHERS 9�T 1A OF J W an w!w w rtAA _ Lem r V•t 1r0MrwtAft r =M m A�•tw Wow ON tw 73 i VM1AMTr MARSMS MILLS to�!p ♦�.® art 1 A I ® DESIGN CALCULATIONS: ® MIMOa or Aulmem 3a TOTAL O " 11a• 11/tw �� OAIYOL�0/K WT Ipr W R t A01 Pw tR 1oaA11olV Vuw �� IMt wlaA t/►W R s Vs/�Pw w! GULL oA.AZAAY x 3 NO M 110L PAY e..IAM r tAtw o �17S slLWML AtrA�pAL/ar. r4 ItAOM G► (eoT10Yf0lW1Ly pA. M Y{W1Lo) lY011st1 ) 1� -t•q/r LOP[1fAOM GPAQTT SAL ow OISiRIlU11pN • �M !OX NOTES: am ® I. ALL AMMwAwW me m1wAs On1L aateOlw A ILLML Hitt s MID MM 10w1 Of IIAEWAMr DIAO Mq �sATIDM!rl 11t 9=AL!MPOS&W=WAQ /000 GALLON SEPTIC TANK I r I • I r I ! mttarxa rw wu D!wouoMr To w I ` a ANY Wtt01RT WTA UMTD w 0W=8 TO gLIK SEPTIC SYSTEM PROFIT F OVAL m kIMMID 0 PLACL ♦ ALL OO POW1Ts OF T1M&WTMT 5VVW OVML IN fXM IX wn is AVru BOTTOM OF TEST HOLE OF ODwTA M*-I*tOAOAw Wos 11MT AM U0t OR WNW 10 FT.W wt0 Olt PMA W4 AFAM INM WAS M LEACHING PIT biftL w MID m m v to rT OF w D• a 01mlZMAL Me twlweAL CowmaL sa uw.ll w LNO. ELEVATIONS LEGEND: Fax saw KL M IM106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 www TAM uumm BOX o O.FOUND. im twtACHMM Frr PPff O- A 10.5 7s.0 760 -k,0 7b o 110 0.* 1W.0 760 70•9 '.,G 77.0 10.9 00.0 40•5 tt4 bL• Me 01,8 90. - 01•0 %D 10.0 91.0 74•f 7f.4 Imo 74.0 AIw ML AT1M1 Tar 7#.t 74.7 71e do 71.0 7r.o 7s.S lb•f 79.0 7f ii 73a 11T.o 71•3 7�1. 71f1 A wo em a��Vt VVsI� 8 7b•3 Ko H•o iN Lid 00.0 ►1s 7►6 lt.o 7}• 7).v 7*v 76,0 n.f 71.3 7ls w 70.1 764 76.5 - 7s.0 760 7S.G 7tf t f a.► 71A 71•i 1os 7t.o lss 7`4 7f.5 744 7i•'I 7s.9 77A 7►4 NA K.3 if4 ►4.0 74e B C 1b•1 6 .♦ if.l ►sb i �7 i4t 7L3 7L1 7l.7 7f.7 74.1 7l.7 7►•t l7• 17.7 7r. 71•e 7t.b •w•y _ 77.7 7E1 US 74 -?I•b 124 71.11 70•+• }.t 7f.7 1 i 1 7>s 73J• 7f.s 4 77�fr 1s.Y 7t.f 71. I Ha M• o'fs 610.7 '*.1 C D 700 NA Ls.� ►u ►f•1r p.f itt 7L• T.f lib 7tf 1,•0 7e.f 7r0 0 77.e 7b.o 7+IO 77 7►0 - 77.5 7Ef 7f.t o 71•I /i.4 71.E 71e.o 70.0 7bf 7}0 774 7f.o 74.4 7S9 7s.9 71•4 70. N•1 1rro 1/fo ►4.f 7ks D E 6t% 69.0 ►33 ►s,4 KA W) &$-*I bol 71.3 I 1L► 73..$ 7s.9 7l.3 7f•s r6,.s A.S 7/1 7,r.s n3 3 77.3 1 7 b.1 7•A 75•9. 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LOT 131 LOT 149 LOT 746 MARSTONS MILLS WOODLANDS w trmovo w/uq r AtAMa tAP'w eAAa >•w mm. w w m0a - BARNSTABLE, MASSACHUSETTS rw WARM w1uM•WAIL A1Mt - eve WARM ` e'M �eme ww.M w.A.Wa tA.M WOODLANDS ASSOCIATES REALTY TRUST or WrwAIO AAe t�AAIA WSRM tl11AAAl Alte owsrM 1AI�w 4ArM t AAe Au WMt fluffVAM Ane ww•nwOr tsAm emstAOAm Vw SCALE I" >• 40 JOB N0. 133e/sDa .n a w ow w/OrI w s w w w/AND * PAuc `! DAR v!m 7W 29! 1 OAR Dr W L 1aT� CAR O st 1aTA DAM W WIL WIFUll" •AR Q SIR TOT MSM w o b w W11-m DT AM�L w11107m BY A.� Is110�0Y weOm 0T A.MR� t r r POOO AIM DATE 1L_wL0"m PDtI4ATxw LIAR SLIMLA1m Pw74AWN DAR si1OLAVo1 pulmAUm DATE"L-19LAW PDX*AumnMR AA IML/wDl •n .�O.0 PERCOLATION SOIL TESTS Lm zw=GB & 1iAGFi&R mocuts INC. umm t "m uIB>Lmne seta I= hunt smaw czpmmv= KA OR= rMARSMNS SHEET 7 OF 7`—lOT 130 MAN s �'CP LOT 129 !LOCATION MAP / \ 1�1 LOT 12t OT}32 4�7 � dlla try. *4 tens s GNt� tee s � g• J / ��� \ Val--'CQTi'1T. � LOT 31 137 �1i ��` s 1S LOT 124--141,7611 SF , eP LOT 106 I 1 M>j V o¢ ^j ^V r >ua> S} 1 1 \`� `�� -�1011t23'' ` '�e+°0 LOT 123 ►off ` K �\ LOT 126 tt 1p s �40 g .. ran°tt ' h ' -'�'' p � 15 I [ TAA �a �}l_ >�x' < �1,.b �yd I.I 1• LOT \\ LOT 149 I�.'L LOT 136 -.9 �%' p•� tt.w41 V, 14, 3 \ • i �49 I 1 y ,1 ���� �'/P S LOT 122 LOT 134 \ 1 �I ,� i rasa/► aW= .. LOT 121 1 l J I ly Ily, �1*dY 1Mo0 s s \ COT 107 LOT 148 �?� i' / .� l � N \ !$ .t - �j !°6 I tewe V ° - ,, �� M �*b > '\�R� `i I r �• y elA A&OT 147 40 ��I i ^ Ll ¢ �oM _ Y. \ �� LOT 119 t I° y �� .. ly.y ���� 'LOT 141 1\ \� ° t1� q temo: ~14 < e°.S r T. dt \ ♦ ,Dame ��''�, rt < epv \ �971 SOT I*1 ��(. •i •• '�,� L s2 \/ 1 1P�s �y� .IL • LOT 120Ir ! / \ >.l' s. '' 4 LOT 117 LOT/143\\' �' .�� \ }\v�t°moo u \t -$ < *.4 I I `f I 1 . 1• 44 A mub - RK Y < ° o�. ttl P-m 'LI j 1t• ���'' ° ,°rioand �' I.5Et !MEET 7A orI WIC soft, II6S O..4b i x • ,. \� 6 LOT 115_ is a 1't1El:Lvt•AT°t•1 -Misr. Ac"I.O►s.. t1 '$toxo s $ _ _ �Q !.%as twmgr 7A OI7 /VP -"LA&IIIN , i I.1 COT 146 hna s/� ��' ./ ' P+ < I LOT toe ? „aapr 1 -' r,g Y < T LOT 118 \ 'r \. LOT 11� ,F a $ totoo s st e� f • ,J''�' \* LOT Ili V. +4mt1g tad ". 4' $LO 114 1e1 b t1 $ I g. 11 O •b .O.ri.Mt° e.{ RLAO E Y4.6.IT11o.db r < 91 6 tat 3 11 29 88 FINAL BLDG. AND SEPTIC LOCATIONS PALIt I ! N .--Z- 11/a/sa BUILDING LOCATION PLAN tOp INITIAL ELK 0 \\ IV �� }� }D•6 \1�� DESCRIPTI BY BUILDIN ON PLAN .. •.w,s `'�' ` I MARS TONS MIOLLSTIWOODLANDS \ LOT 110 M \ LOT 109 tt.eo 17 1 BARNSTABLE, MASS CHUSETTS fall \\\ WOODLANDS ASSOCIATES \` SCALE: 1' a 50' JOe NO. 1338 Ant-to b o b too \^�;� im mum irAGNER Assomit INC. o®s Lmn mm= rim IN» ee9 vast )tutu 37RM COTERVIUX to 02M