HomeMy WebLinkAbout0052 TURTLEBACK ROAD - Health 52 Turtleba_ckRoad
`Marstons.<Mills. P
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AMYROTECHLABORATORIES,INC.
MA CERT.NO.:M-MA 063
449 Rte. 130
Sandvwch, MA 02563
908(888-6460) 1-800-339-6460
FAX(908)888-6446
CLIENT: B. Rangel LOCATION: 52 Turtleback Rd.
ADDRESS: 52 Turtleback Rd. Marstons Mills, MA 02648
Marstons Mills, MA 02648
COLLECTED BY. Meehan Wells SAMPLE DATE: 6/6/2002
SAMPLE TIME: NA
WATER SAMPLE TYPE: New Well/Replace DATE RECEIVED: 6/6/2002
LAB I.D. #. 0206125
WELL SPECS.: NA
RESULTS OF ANALYSIS:
Parameters Units Recommended Results Method Date Analyzed
Limits
Coliform bacteria /100ml 0 0 9222 B 6/6/2002
pH pH units 6.5-8.5 6.47 4500 H+ 6/6/2002
Conductance umhos/cm 500 55 120.1 6/6/2002
Nitrate-N mg/L 10.0 0.12 300.0 6/6/2002
Nitrite-N mg/L 1.00 < 0.004 300.0 6/6/2002
Sodium mg/L 28.0 5.4 200.7 6/6/2002
Iron mg/L 0.3 < 0.1 200.7 6/6/2002
Manganese mg/L 0.05 < 0.008 200.7 6/6/2002
COMMENTS: Low pH indicates high corrosive characteristics.
WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES
FOR PARAMETERS TESTED.
<=less than Date WI It,
>=greater than R nald J. a ri
TNTC=too numerous to count Laborato irector
TOWN OF BARNSTABLE _'� V
LOCATION SEWAGE # 27 4 .S
VILLAGE + �VL:.�I,+� ASSESSOR'S MAP& LOT 0 V 7, O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY- j�C.
LEACHING FACILITY: (type) Li &�,i. (size)
NO.OF BEDROOMS f/ _
BUILDER OR OWNER `. � �t.e. �c
PERMTTDATE: 'Z - 'I - 9-7 COMPLIANCE DATE: PL
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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I
'77 f�
Alb
4.
N c.
J
THE COMMONWEALTH OF MASSACHUSETTS Entered in compJtee!
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for W6pogar *pgtem Congtruction Vermit
Application for a Permit to Construct( )Repair( l'llu"pgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �j V 17(. 'Zpx. Owner's Name,Address and Tel.No.
IMti
Assessor's Map/Parcel
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 Showers( ) Cafeteria( )
Other Fixtures
Design Flow '330 gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 CW �ci S`r� --'�tAu-(.�Type of S.A.S. r -vC-:T
Description of Soil S
Nature of Repairs or Alterations(Answer when a plicable) �Iti'S��- ID Y AK 1=6j,
Uv J Y STvvc,�— Sy Svc
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 bby this Bo_ of He
Signed I Date oZ C
Application Approved b Date
Application Disapproved for the Toowing reasons
Permit No. Date Issued Z4319
_ 7112 t _w
No. Fe1!:1_>
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute.!
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES M�SSACHUSETTS r
ZIpplication for ;igponl *pgtem Congtruction Permit
Application for a Permit to Construct Repair U rade Abandon ❑Complete System ❑Individual Com on"ents
PP ( ) P (�Pg ( ) ( ) P Y P
Location Address or Lot No. ��%V fTLc_ZAC /� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel r'/�
r
In'staller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�I 00�. K�1o�% 5 C �t9,�rc�2p
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3 3o gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1000 Type of S.A.S. r1r
Description of Soil A4 ED S.
Nature of Repairs or Alterations(Answer when applicable)
Gli q STO Z L(
Date last inspected:
Agreement: ./
The undersigned agrees to ensure the construction and maintenance of the'afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo of Health-----,-'
Signed Date a C g7
Application Approved b Date 2
Application Disapproved for the o owing reasons
Permit No. Date Issued Z a
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO C,EjY, t t the Sewage Disposal System Constructed( ) Repaired( )Upgraded(l.�
Abandoned( )by
at !i a-- TJ f T G "Z1 10 C-V-- QQ S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the systernwill function as designed.
Date / Inspector
———————————————————————————————————————
9!1
41
No. — --:?-,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLES MASSACHUSETTS
li5pogar 6pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(grade( ) b ndon( )
System located at -T" v-T-L 73 ri L r
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction mustbe completed within three years of the date of this permit. _
Date: 3 �l Approved by
I
NOTICE: This form is to be used for the repair of failed septic
systems only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, 0 � ,hereby certify that the application for disposal works
construction permit signed by me dated O�? `a-9� , concerning the
property located at 5 J- y/ L� i3 k-�f �� meets all of the
.following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
I .
q:health folder:cert
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COMMONWEALTH.OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AF
DEPARTMENT OF ENVIRONMENTAL PR N e %
ONE WINTER STREET,BOSTON MA 02108 (617)292-55 -Uq /T
FFB CE��EQ
WILLIAM F.WELD �+
Governor T040" 199F E
tary
�lTyOFpSTge
ARGEO PAUL CELLUCCI I1AVID S UHS
Lt. Governor ®� sioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: SZ. Q—ca� Address of Owner: Laves--L c:)
Date of Inspection: .t i 1 S��'i Yn�l1S (If different) Q O•�c5n Name of of Inspector: is � N1t �ct�t 6�►1,1�5 t t�,� o'L-'k b
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_k Fails Inspector's Signature: 1 Date:(!%jt
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.
INSPECTION SUMMARY: ,, g7
Check A, B, C, or D: Z) e3 7 71
A] SYSTEM PASSES: v
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,-
passes inspection.
Indicate 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 exfiltration, 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.
(revised 11/03/95)
A
ii Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
-CERTIFICATION (continued)
6 ��},�1� - • '
Property Address.
Owner:
r,.Mte of Inspection:
161 SYSTEM CONDITIONALLY PASSES (continued)
k. Sewage backup or breakout or high static water level observed in the di ribution box is due to broken or obstructed
-r pipe(s) or due to a broken, settled or uneven distribution box. The sys m 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 du 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] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF H TH:
Conditions exist which require further evaluation by the oard of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH A D SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet o a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD F HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A NNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tan 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 t nk and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic ank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a Sept' tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution rom that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
Ppm-
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: SZ
Owner:
Date of Inspection: k�
D] SYSTEM FAILS:
X I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage iinto facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
T�w
cesspool. AT ,jz of 2r.�d4x���cxv: tx_ .%S �Gvti�►.�L� p�- �4� -c-vt tAa 1 U Ana.Sv.=PY}Cx
PASc,-reu�--,a ANUc— \4 {--
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The 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 health 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 II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 52Tve_\ ADZ i�
Owner: O%S
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
X None 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.
As built plans have been obtained and examined. Note if they are not available with N/A.
S�The facility or dwelling was inspected for signs of sewage back-up.
1( The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The 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: O rSl+er—
Date of Inspection: `` '.5N--,-I
1 FLOW CONDITIONS
RESIDENTIAL:
Design flow: '330 gallons
Number of bedrooms: 0---
Number of current residents:
Garbage grinder(yes or no): iVb
Laundry connected to system (yes or no)>j
Seasonal use (yes or no):_j
Water meter readings, if available: t.s
Last date of occupancy:L.r,�t�,S
COMMERCIAUI NDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
2!h'nod L) rAr N+ - PVoA-
System pumped as part of inspection: (yes or no) t:b
If yes, volume pumped: eallons
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)
Other (explain) �o,�r r ,,.,.r ti� Sic
APPROXIMATE AGE of all components, date installed (if known) and source of information: t 1q-1
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5 Z
Owner: 6 SWec�1—
Date of Inspection: %`
SEPTIC TANK:_kAC.S
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP—other(explain)
Dimensions: IOCX')cip,
Sludge depth: all
Distance from top of sludge to bottom of outlet tee or baffle: 3Z"
Scum thickness:— M
Distance from top of scum to top of outlet tee or baffle: 1 b"
Distance from bottom of scum to bottom of outlet tee or baffle: iZ"
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Nc) C;'Q_evyn�eky' c. T'�{`s �� �Z _ r_N&_\PR-\ csr i..o -Q_u<_k
l
ECA\_� t-_�1 Ole-a_%_x i��y C�2T—�:i� 'Jr: 2 � t n�2; �^J t�Y� G�X] �'-1 1 Of—
GREASE TRAP: *,X)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: eallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float swi hes, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet in
Comments:
(note if level and distribution is a al, evidence of solids carryover; evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working orde :(yes or no
Comments:
(note condition of p p chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: O'S\*t-c—
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): 25
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:-16x6 p,"T—
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
Sx� -�
\v t�
o�- iT G +�
CESSPOOLS: tJ0
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: $2"�'•r�`��yc cL
Owner:
Date of Inspection: �`kS\�,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
1 �"t
N
Z
. y
DEPTH TO GROUNDWATER
Depth to groundwater: 1L117 feet (�
dz
method of determination or approximation: 1,;1,S, C,,t� PL 1 oc:�:Lvti.�,..�
r
(revised 11/03/95) 9
TOWN OF BARNSTABLE
LOCATION S `� 1.��p_ �_ SEWAGE #
VELLAGE of yr 11ll:_ll,y ASSESSOR'S MAP & LOT O • 0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 2
LEACHING FACILITY: t&XN(size)
NO.OF BEDROOMS
BUILDER OR OWNER 1, '
PERMITDATE: - - 1 - 9 7 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
4r*
Qec4
~'No.1 ----------
BOARD OF HEALTH
TOWN OF BARNSTABLE
App[icat ion-for Vell Cootruct ion Permit
Application is herebv made for a perm t to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
Location — Address Assessors Ma and Parcel,���
Owner —Address
Installer — Driller -- Address
Type
Bui
welling
Other -----------_—__ ___ _--____--
- Type of Building----_____ No. of Persons------------------_----_______
Type of Well--Cdit /�E�/ _— Capacity— -----------_ --—
Purpose of Well—
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
ate
Application Approved By `� —_—_—___— 6 (, , ''� —_-___
date
Application Disapproved for the following reasons:
' _— — --— —!! v --_— — date — —
Permit No. `'`J�UD Z_3S Issued--�0 � date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CEROTI,IIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by—_—�q�_e�-1- - ------ -- --- - ----
` Installer \Z
at--- S� �� �°`c-lam <
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tection
Regulation as described in the application for Well Construction Permit No.W-Qff2_=:-E Dated ��---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -- Inspector-------- ----- -- -_-
Fee----
BOARD OF HEALTH
TOWN OFBARNSTABLE
t t. 2pprication for 39dlton5tructioupermit � t�
Application is hereby made fora perm t to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
Location — Address Assessors Ma and Parcel j
Owner Address
Installer ----------------- — --------
Installer — Driller Address
Type of Bu'ld'
Dwelling
�,�m:�,.
Other - Type'of Building----
——_-- No. of Peisons---- _——--— — .— r
Type of Well --- Capacity -------------------
Purpose of Well-
/
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place-the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
Signed — -- —_
\ ate
Application Approved By w `—=—— �0L �G 4
date
Application Disapproved for the following reasons: ----- ------ -- t
a
//-- date
Permit No. W�UO 2 _3 — Issued b G 7-
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate ®f Compliance
THIS IS TO CERTIFY, That"the Individual-Well Constructed ( ), Altered( ); or Repaired (, )
by
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Welt Protection
Regulation as described in the application for Well.Construction Permit No. Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- -- Inspector
i—=�•—. — � �.�-_----.--st r yea.-- ..s----e sr^.r'._...�o'a--n^e �—s—s..-c craw ams —
BOARD OF HEALTH `.
TOWN OF BARNSTABLE
Ivell Con tructton ermit
i�- -- 5'
,r
No. — `- -..f_) "Y� Fee_ --
°Permission is hereby granted
to Construct (`F),.Alter ( ), or Repair.( , ) an Individual Well at:
—^- - _ + .Street
n
as shown on tl`e application for a Well Construction Permit
K
ob
No.- == �f Dated_— _ — -----------------------------
x � I
Board of Health
DATE _
-OW NSOM SUPPLY CO., INC.
195 Broadway- Fall River, MA 02721 -508-675-7433
C.I.T.Avenue 147 Washington St. 1 Freeway Drive
Hyannis, MA 02601 Plainville, MA 02762 Cranston, RI 02920
508-775-4115 508-643-1300 401-467-0200
www.bathsplashsh.owroom.com
----___-_______ _____-----_--------------------------------
----------
-----------_..._._. -___._:__.____.__.-_.--_-_-_-__ - �_._------ _.
__.__--___- ---------------------
--__—_.-__-__.__-____--------------__ —-------___-__-_____________-_____._____
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_---------------------------------- ---- _ ---------------
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--_____-___..... .___.___._._. w___._.__�'--------
_________
The
bath splash
UNIVERSAL-RUNDLE Massachusetts WATS: 1-800-242-3878 UTICA BOILERS
FIXTURES Rhode Island WATS: 1-800-343-3878
TOWN OF BARNSTABLEf
LOCATION SEWAGE # - L/ S
VILLAUE
1- .�----- Jt ' ASSESSOR'S MAP& LOT d • O
INSTALLER'S NAME&PHONE NO. 0
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) `{ ' �� $gib„
t , (size)
NO.OF BEDROOMS'
BUILDER OR OWNER
PERMTTDATE: _COMPLIANCE DATE:_
i
Separation Distance Between the: i
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and LeachingFacility
ty (If any wells exist
on site or within 200 feet of leaching facility.)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by Feet
Y6
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECT_LO�L
FRIECEIVED
a
e
I y
NOV 1 9 2002
TOWN OF BAKIVJ(ABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
"Olt f
Owner's Name:
Owner's Address: — �y
Date of Inspection: I
Name of Inspecfte f C�' 'l MAPCompany NamPARCEL
Mailing AddresIaA �C.p�e LOT
Telephone N � / 9
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant-to Section 15.340 of Title 5(310 CMR MOM). The system',
/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
-- F ils
Inspector's Signature: ,! Date: %fA�Y? -
_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments &tg&
****
. This report only describes condition's at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
' r ,
Page 2 of I I
�J
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: G,�) � �nC
�C A
Owner:
Date of Inspection: �t��P.r f
Inspection Summary: Check A,B;C,D or E/ALWAYS complete all of Section D
A. System Passes:
1/ I have not found any.information which indicates that any.,of the failure criteria.described in 310.CMR
15.303 or in 3.10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
.,_, .
B""System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
"` repaired.The system,upon completion of the replacement or repair;as approved by the Board of Health,will pass.
, Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent.System will pass inspection if the
existing.tank is replaced with'a complying
septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is.leveled or replaced
ND explain:
The system required pumping more than4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1
Owner.
Date of Inspection: J
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 water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic,tank and SAS.and the SAS is.within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a,
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 06-42W24
V
Owner.
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes NoJ
Backup of sewageinto facility or system component dire to overloaded or clogged SAS or cesspool
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
.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 12 day flow
�7 Required_pumping more than 4 times in the'last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface
water supply.
. Any portion of a cesspool or privy is within a Zone 1 of a:public well.
Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. f This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and thepresence.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.)
No-(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,.the.refore 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.
You must indicate either"yes"or"no"to each of the following: -
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a-surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
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.
4
Page 5 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �C1
Owner:
Date of Inspection:
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 F:
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 ?
jZHave large.volumes of water been introduced to the system recently or as part of this inspection?
kZ 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
V Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of thebaffles or tees, material of construction, dimensions, depth of liquid, depth.of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has,been determined based on:
Yes no
Existing information.For example, a plan.at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
i a
Page 6 of 11
OFFICIAL INSPECTION-FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: _
Date:of Inspection: o�
FLOW CONDITIONS
RESIDENTIAL
Number.of bedrooms(design):- Number of bedrooms(actual):
DESIGN flow based on 310 QJR 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no).
Is laundry on a separate sewage system (yes or not yes separate inspection required].
Laundry system inspected(yes or nqh -
Seasonal use: (yes or qoyA4�- J
Water meter readings, if available(last 2 years usage(gpd)): �G ___/v/
Sump pump(yes or Q9>40"
Last date of occupancy:Zl uvx , �i�t�C ✓G ®`'�'�- y
COMMERCIA:LANDUSTRIALL/)�&
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:_
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspects n(yes or 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/Alternative technology.Attach a copy of the.'current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy'of the DEP approval
_Other(describe):
Approximate age.of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 11
OF INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: i VA
BUILDING SEWER(locate on site plan)L.,,/�
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain): _
Distance from private water supply well or suction line:.
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK:��locate o site plan)
Depth below grade:
Material of constructionconcrete_metal_fiberglass_polyethylene
_other(explain).
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth: o /�
Distance from top of sludge to bottom of outlet tee.or baffle:-3
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto,119 of outlet tee or ba fle: 3 /
How were dimensions determined: ,
Comments(on pumping recomme dation , inlet and outlet tee or baffle condition,structural integrity, liquid levels
a�related to outlet invert, evidence of leakage,etc.):
` O7 7�--U.Od
/
GREASE TRAP: ocafe on site plan)
)
Depth below grade:
Material of construction:_concrete _metal_fiberglass___polyethylene_other
(explain):
Dimensions:
Scum.thickness:
Distance from top of scum to top.of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations,inlet and out tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
I
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _7� �-
Owner. Al
Date of Inspection:
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Commerits(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:-,Z(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
kage into or out of box, et ):
PUMP CHAMBER:/)ttt-(locate on site plan)
Pumps in working order(yes or no): .
Alarms in working order.(.yes or no): ,
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: J �(C
Owner. i
Date of Inspection: (�U
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
—leaching chambers,number:
ching 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,
ettw
.) _
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 or no):
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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _7j; MQ01d,W064t%
Owner.
Date of Inspection: . /�� )0C Q
,SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
I�
0
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �
Owner: a% -"'
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
r
Estimated depth to ground water �feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
1]
���`4G� '
C LEVE;Site Lo'ca�;O
�.CiVI�U T ! ICti
Contr•acmr:
SNleasu.i e de Z k7 W2 e".avie
toneare..:. �o _...................... — - _.....__....... .Ja_ / if DZ Z I° �.
S'T•=,° 2 Usinc•V:V.a er-Le.,vei.?ranee -one
znd lriae.X`Weil;:M:a^�loca e
si.�e.and-de:ern-ne
".:ppro.pri2 �-.ndeX wall_..............................._ '�/•-.._..:_.. �iJr�Wae--l.e„e!•,-anee .oil
.......... �—
Using•„onThI-v.r :Jar."GuF a,i
WaLBG I 7of'In•`cX VI/ell
m.or61{yea,
STEP. Usinc. sail .oe-1,41•nZer-lemel Ad i�Strinenis �.
-' Mr index \&ell (S•I Cc ?,< .CLC:'tini d&o'fh' S -
-o wa er•level oj..rode;: wed (S-cP 3-' i
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and-",;-:.er-)e>lel zone (STEP•2B I
deiernr•na•way8, eve• 2diustmjar. ....................
.IIT -P. b =s_Siilai:e'::eptij ic9alicin Water � •.
by sab. -actde .waeY-
:
level adjus_ -an .(STEP i<}
. �iO,T1 ��^•ca5�.i:C4Qe,�.2 iC.V✓cT:.r �
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1
LOCUTION : SEW&C;E PERMIT UO.
-zia ��
VILLAGE
IMSTQLLER•5 M&& AE ADDRESS
BUILDER 5 Q &MF- &,DDRE SS
DNTE PERMIT ISSUED -s
DATE COMPLI &MCE ISSUED ; "
�i � a
� . �
�-
.., �
No........ .......... Fws...,1.✓�...................
THE COMMONWEALTH-OF MASSACHUSETTS
BOARD O I-OEA T
---------OF.......... . . ... .. .............................
Application -for Biopoottl Works Tottotrurtiou ' amit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
------ -------------------------------- -----------.............................. -��/-------------------------------------
A ¢- /{ Location-Address or Lot No.
PSS u_ ir�a YFL'tt1..---------•-------------•----____---••-------------- -----------------------------------------------------------•------_----_-__-__-----____-•----------------------------------------•-
Owner Address
-•--•------------------ ........--------..... ...........................................................................
Installer Address
Q Type of Buildin Size Lot............................Sq. feet a
V Dwelling NO. of Bedrooms.____ ______________________-Expansion Attic ( ) Garbage Grinder A
'4 G4 Other—Type of Building --.� .....---•----•----- No. of persons........................... Showers
( ) — Cafeteria ( )
4a Other fixtures --------------- -----------------------------
W Design Flow..................(3 -- ___..gallons pee person per day. Total daily,flow._._.._..__2 _______ ..----....gallons.
WSeptic Tank/—Liquid capacity/Q_Mgallons Length________________ Width................ Diameter---------------- Depth.-..-----_.--_.
x Disposal Trench—No ................... Widtll____ __ ___ _ __ To al4, 1z,
gth f __ Total leaching area.-.-_..__--_---_-_-_sq. ft.
I fir° v
Seepage Pit No____________________ Diameter_ ________..______ ept et__ __'__ ____.._ Total leaching area.__.__-----......sq. it.
Other Distribution box ( ) Dosing tank ( ) �at 3
Percolation Test Results Performed by------ -------•----- ..................................................... Date............. -------------------------
Test Pit No. 1'_,*_= _____minutes per inch Depth 'of "Pest Pit____________________ Depth to ground water---------------.-_.-___-
,> Test Pit No. 2"'_______________minutes per inch Depth of Test Pit.................... Depth to round water.........
(5V_e---------- -------
O . Description of 1 / '1 iL� ------- 1.t
-- --------------------------
w:: ................ `------------_----------- ---------------------------------------
----------------------------------------------------------------------:---------------- -------
U 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bO..�
ssued by the board of health.
Sig �- / '_`,
-- ----------------------------------------------------------------------- --------------------------------
Date
Application Approved BY------- ,{ --- -�-
Date
Application Disapproved for the following reasons:.:._.__. -----------------•------•--------------................--------- --------•--------- ....--••--•--
..•••••••••..--.••--••---••-....•--••---------------------------••--•••-••---• •••-•-•--•---------•••--•---------------•-----------------------------------------------------------------.........
__,Date
Permit No...........................
.............................. Issued.-------,-_�•......._.
Date
J ,
No....... L_. Fimic ✓�ate.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD EA T
OF.......-.. :.......t.....................
Application -for Di,ipviial orkii"Tnnitrnrtion Vrrnnit
Application is hereby"made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......................
ocation-Address or Lot No.
• ----------------------•-------•--••----------•-----
Owner Address
.. -------- -........0!+:w•+�.tl------------------------ --------------------------------------------------------------------------------------
Installer Address
UType of Buildin - Size Lot............................Sq. feet
,-� DwellingkNo. of Bedrooms_____:_.........................Expansion Attic ( ) Garbage Grinder (0)
Other—Type of Building tip+ No. of persons___________________________ Showers — Cafeteria
a Other fixtures _________________________
d ------------------------- -----------•---
W Design Flow.. .............. � � _gallons;per•petsori per day Total daily,flow....._......._.................._..... ...gallons.
� Septic Tank/-Liquid capacitv�(/ gallons Length_______________ Widt i................ Diameter__---. . _ Depth._ .--___---- .
Disposal Trench—NoyTal# th Total leachin trea____________________s ft'.Pg� qSeepage Pit No. _,_____.J______°'I�Iameter_ iti ......._ ep lie _ .. Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank
aPercolation Test Results Performed bY---------------------..................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.__.-._..-._...--_..__..
�14 Test Pit No 2_______________mmu e ,pe inch Depth of Teat Pit ...._ ...... Depth i g t __.__
x ---- -- f -- ----- �r, r water-----
-..:
O Descri tiowof 1 '"- ----- --- ---Ale - -------------
---
W
UNature of Repairs or Alterations—Answer when. applicable--------------------------------------------------...........................___--____.__..__-..
-•-•-•-----•---------------••----------------------•-------------------------------------------------------------............................•-.----------•--------•--•----=•-------------------------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of-Compliance has be ssued by the board of health.
--- ------ ---
Date
Application Approved By..--- � '' � jI� :.._... `t V- � 7----------
Date
Application Disapproved for the following reasons:.......... ..........+ -------------------- ----------------:---------------------------------------------------
- r
.............................................................................................................__...._..._...._.........._.....---._._.._._...._..------------------..._.-...------....._..
Date
PermitNo......................................................... Issued---------------------------•-------•----------•---•----
Date
THE COMMONWEALTH OF MASSACHUSETTS `
BOARD OF HEALTH
~ df 600
..............O F...........4;6....
fSrrtifirnte of TIMP ianrr
THI TO CERT ,FY at e Ind dual Sewage Disposal System constructed ( or Repaired ( )
y
t
by ' t �r
tal
has been installed in accordance with the provisions of : XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-__-------------- _____________________ ivted.... "14.- _77
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT THE
SYSTEM .WILL FUNCTION SATISFACTORY.
DATE.. -----------
,)THE7 Inspectorg
COMMONWEALTH OF MASSACHUSETTS
OARD HEALTH
- �. ..... . .: ..... ....OF..._... !..':...:. .. ....:...
No. ........ ------•-- FEE---
P' �t�po�ttX � - (�nn�tr at� rrnt
Permission granted:-::. _ ._
to Constru ( ) or Repair ) a I di 1 Se g i os Syste ,'
at No.-- .
-----------
S reet
as shown on the application for Disposal Works Construction P t N ' Dated....
--
.. .... . . . ......00-
..... _..
- ---- ---------------------
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- Board of Healt "
DATE-- ---------------- --------------------------------------•=
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
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f4TJ fF�`=: il��:T!'T E9V 5/£1 �t1 i.s i b •`:i T!•lE 115Y.
OF 04 7 LlANlS i�t _ff--2 h� CrRC.J&A-
S7AWCIF-S 4RE: bE US1t0 FOR I
HEDGES, ETC.
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{ I I I HEREBY CERTIFY THAT THIS FOUNDATION
4 wEca IS LOCATED ON THE WT AS SHOWN AND
LOGA ?"/pN
{ CONFORMS T0 THE TOWN OF 1���NSj'�aL6 y
ZONING REGULATIONS REGAP'L SEYI3A1`,K3
FROM STREET LINES AND LOT LINES.
{ 7- v 7-1- tC h' CS AI .
STAMP:
T - - CHECKLIST WALL FRAMING REQUIREMENTS:
• SHEARWALL CONSTRUCTION
F9,71- PANEL EDGE NAILING SPACING
a-PANEL FIELD NAILING SPACING
• XKXJ- n KINGS 4 a JACKS P DOORS 4 WINDOW OPENINGS.
USE 2K C IJ IF NOT NOTED OTHER WISE
FFIRE ALARM SYMBOLS:
- O SMOKE DETECTOR
COMBINATION SMOKE/CARBON MONOXIDE DETECTORLo F---
Q N ON
# U O O U
Q W co
L. D6
OUo
c � Lr>
c U3
-------------
-------------------- --- ----
LL. w
9 z CI)
w Q ::D
. BEDROOM#2 - z LLJ
LAD (�
TO LOFT CO O
i =2'-I° KNEE WALL OPEN TO t' w Q m
i J BELOW '' z W°
INTERCONNECTING z Z C cJ
STORAGE
E DOOR#S LOPED - 0 �
Sm CEILING ABOVE W CA N Z
ATTIC ACCESS DOOR S (@ SLOPED I O
±7'-3 WALL CEILING ABOVE ccLv
Of O G
_____ _ ___L____=____--------------
a __ _____ o HIGH WINDOWS W
---- --�- '---- ---. ------ STC.7AGE1206
----- -
___-------
LOFT OPEN TOBELOW
- •�
+2'-1" KNEE WALL
LADDER
-t
I i TO LOFT -
7 _ ____ I BEDROOM#3
12'43.11'4• i -
TITLE:
ATTIC&LOFT PLAN
J j DATE ISSUED:
1.6.2014
REVISIONS:
2
FLOOR AREAS(GROSS)_
• BASEMENT (UNFINISHED) -I,OOB gsF
� PROPOSED ATTIC&LOFT FLOOR PLAN i,
° 1 IST FLOOR LIVING AREA =1,115 gsF
95 - Smle:L4'=1'-I.: 2ND FLOOR LIVING AREA .1,005¢sr DRAWN BY:
�E TOTAL LIVING AREA -2,123 gsF TRS
<Z
DRAWING NO.:
E m L�
A1 . 3
L /,+'
-
r
CHECKL-LST WALL FRAMING R l R T� •e.
EQUIREMENTS: -mot-.•�.,-.,f'^" [
SHEARWALL CONSTRUCTION '- - 1 '� •"
R
- �- PANEL EDGE NAILING SPACING
- PANEL FIELD NAILING SPACINGA.I '�
XK.XJ v KINGS= v JACKS P DOORS.WINDOW OPENINGS.
USE 2K c IJ IF NOT NOTED OTHER WISE
FIRE ALARM SYMBOLS:
O SI-IOKE DETECTOR
2 -
COMBINATION SnOKE/CARBON MONOXIDE DETECTOR
~� f '• ; _
.Z O i.
U,p
W O (L t
A3D A3L � 4
N'
42'-O" (EXISTING) '
WOOD FRAM®
DECX BELOW �— —�— —�— — —!— h2L-�
I--�--� t-1--SLOPED CEIUNGKITCHEN AREA BELOW e I 211 210 I 206 N
C ~
r Jl-
_� 0 ..Zc—
��
O y
zl4 ° I 217 206 w w
_ OPEN TO WCHEN v J
--- AREA BELOW OI Y-
OPEN 31° HIGH RAILING LADDER C' .B T
TO LOFT 12 -
G BEDROOM#2
C
12 12'-7' Ib'_1• 12'�=11'<• -. Z .•
I 2s1 WALL t] '
O I CATWALK O I @SLOPED 205 L [n N+Z
O CEILING ABOVE I s Cn _ O
v X
215 MASTER BEDROOM ,..-.. O U/,
@ SLOPED
6'-51/2' 5'-IOj'� I 2a3 O CEILING ABOVE O O a -
I O I BEDROOM-0 3 ry V
J I,. _ _
y_. 2 d FL.HALL I d
OWE LADDER
PV 04
210 UNEN 3,_ - 'r
TO LOCI
' TER CL _ _ O 4' 2"gal 5'-4" 2'-4"1
i
IODS BATH
ow
El TER BATH 3 43/B O o 2a
e-7•=r-It• x' � —
TIRE:
o B zol 9 3 D2 G PROPOSED'.2N�
2 FLOOR PLAN
METAL ROOF BELOW
m MAR tcKENZE
J P FBI I/6�(4
DATE ISSUED: 1A-M-1`
BIER�R
RE�ASIONS: -
FLOOR AREAS(GROSS)_ _
rc BASEMENT (UNFINISHED) •I,cca gsf
E
PROPOSED 2nd FLOOR PLAN BY: ms
1 I57 FLOOR LIVING AREA •I,ITS gsf
S 5cvic:l/4'=1'-0' 2ND FLOOR LIVING AREA -I,OOB gsf DRAWN
v[ TOTAL LIVING AREA -2,123 gsf
mk -
B DRAWN
NO.:
�m 2
Al
e
L'
K,-4
r -
- STAMP:
CHECKLIST WALL FRAMING REQUIREMENTS:
• SHEARWALL CONSTRUCTION
' - - PANEL EDGE NAILING SPACING
O- PANEL FIELD NAILING SPACING
• XK.XJ- C KINGS x a JACKS P DOORS 6 WINDOW OPENINGS.
USE 2K x IJ IF NOT NOTED OTHER WISE
1
. FIRE ALARM SYMBOLS:
SOm SMOKE DETECTOR
• COMBINATION SMOKE/CARBON MONOXIDE DETECTOR
C7
- _ Q N NO
/ U Ol
< 'o
/ w co
/ LCu C6
r v
42'-0' (EXISTING) O o5
c Lr)
/
15' SIDE YARD SETBACK
A3.o N Q
PRgPERTY LINE
// - 12'-�'2 - 312 - B'-42 12'-ryb2°
/ 1�
CABLE RAILS w/ .__......_.............. ...... 3'-IOy4° 3'-IIDy4" 3'-IOj'q' 2'-y4'
MAHOGANY GAP RAIL /
AND PVC POST 114 112
5LEAVES
31 _
I iN m
2
0 5'-Oj'2 312, 116 B' CONTINUOUS BENCH ;y 12 3 3'-B°
SLOPED BACK 4 I09 12
STORAGE BELOW SLOP� IAlG 110 3 -
co
o OVE
117
3K.2J —I O N 1 ------LINE OF VAULT —�� O W
/ >( OPEN TO ABOVE _ _ z VJ
o
118 .,. I' _9�•LONG ISLAND w/BPR____ I z 0 U
w L11 c Q
IL
loe DEN I - �_ Q
3K J I _ .- J O 12'dx 7P�• C!) () Q
KRCHEN AREA OVEN w/ -m C'Q m
/ -
/ 12'_S.2 L—_— 16-1•x 15'S' HOOD z w
__------�--_— 2.6 WALL 3K J O w z c J
2x6 WALL r _- , — 107 = z cc
I S LMNG a00M - _— cz
OPEN 1 T SHELVING.,._.�.... x C CV O
S w O /_ L F-
. STNRUP- WAR DOWN I ?I 109 PANTRY �OPEN
ViNG 312 �i - CL J c
e'a•x ss m O,� �
I _ I i 1 — ,."•••,••, 3'-�. �'} OPEN IT ¢iNNG O 9 COAT
' OSET
I I T_B. g'_ItY2 '2 ._12 7y2°._ IW ` 106 I II
v
Io3 -
I , ? ENTRY FOYER ln2a x b Q HCOATOOKS
p p I T-0R 3n2 O BENCH SEAT /CURRIES in TRUE:
liq
Im
O i I 2_O 101 8_3" O2,_6-2° O3 61.-2 O44
O 3'_B, PROPOSED 1 ST
COVERED PoacH 6 Iz i FLOOR PLAN
�MAR'C A
. _I I MrX6+IItE
-
Fe>/oxAL� DATE ISSUED:
- 1 - EXISTING BOARDWALK REVISIONS:
g - TO DRIVEWAY
1
FLOOR AREAS(GROSS)_
• BASEMENT (UNFINISHED) x-I,OOB 0sf
�� PROPOSED 1ST FLOOR PLAN IST FLOOR LIVING AREA -1,115 gsF
5-1.:1/4'd'-0- 2ND FLOOR LIVING AREA -1 008 gsT DRAWN BY:
E
- ?y TOTAL LIVING AREA -2,123 gsT TRS
R DRAWING NO.:
A ] .
L�
--- - STAMP:
- CHECKLIST WALL FRAMING REQUIREMENTS:
• SHEARWALL CONSTRUCTION
- PANEL EDGE NAILING SPACING
ri - PANEL FIELD NAILING SPACING
I
• XK.XJ. C KINGS 9 0 JACKS P DOORS 6 WINDOW OPENINGS.
U5E 2K t IJ IF NOT NOTED OTHER WISE
FIRE ALARM SYMBOLS:
SQ SMOKE DETECTOR
®/ COMBINATION SMOKE/CARBON MONOXIDE DETECTOR F—
C'7
~ Q C�V �
UcOODo
ol
Q o1,
W O
c7
o U o
Lo
- j QUA
� 04
42--0° (EXISTING) _
EXISTING STEEL rn
(FOUNDATION WINDOWS, ✓ (,ti�
`31,25x13° - TYPICAL OF
5 TO BE CLOSED.IN
AND WATERPROOFED I C
( t
�i C LL ccZ ZD
•� U G 0 U
EX. 10°CONK. I p Z W C Q
FOUNDATION F. W J
WALL - TYP ! _ Q Q O Y
� � m L
cc-1 7-
6 l7 d Z J C/)
�— —' CD NEW 32° PIPE COLUMNS—\' F O - W z ~
_ (4°0.D. 5CH, 40 STEEL eft
3PIPE) AND FOOTINGS w 66 Z G
Z
N I 1 to
- r + i- -i U
E— o 6 L I-i I L-I-J 0 Q
Ifltd)I, 5
I!t
0
EX. 2.5° EX, 1° SWEEP
WASTE ' - WAS 2.5° THROUGH _
ddd EX. 4.5° WASTE FLOOR SLAB
G+YP'd` WASTE ( - C4�Qe�• _ _ TITLE:
APPROX, LOCATION OF
SEPTIC WASTE EXIT -
BELOW SLAB ELEVATION
PROPOSED
BASEMENT FLOOR
PLAN
DATE ISSUED:
1.6.2014
g
REVISIONS:
_ I
2
FLOOR AREAS(GROSS):
s - Q BASEMENT(UNFINISHED) .1,00E gsF
€ 1 PROPOSED BASEMENT FLOOR PLAN IST FLOOR LIVING AREA -I,IIS gsF
5-1.:1/4°=1'-0" 2ND FLOOR LIVING AREA OOe gsF DRAWN BY:
TOTAL LIVING AREA -2,123 gsF TRS
ngg§ 1
by I
"fig E DRAWING NO.:
gym'
o A1 . 0
�5