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0097 WHEELER ROAD - Health
97 WHEELER ROAD, MARSTONS MILLS A= 082. 019 ..rf i i ` O O N Lo 'T O C C7 00cu U C J N LO Q 5 U -C '� O U cu -6 d" O Cc)) M Op � N V N _ J C v`j7 L 10:12 to � ) w c W Cl) y ;ion O N N F N N a O W � A TOWN ;OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION �E� Q� ADDRESS: `t 7 �%.f-r.�t= .� !' j' �` � MAP NO. PARCEL NO. r7> OWNER NAME: L/ ,{ f: if �f�. ,I�,t." !✓5 der VILLAGE: INSTALLATION DATE: MY / q _ BY: - r ADDRESS: CERT. NO.' r L� 9 TANK INFORMATION fvv LOCATION OF TANK: �J/l�`� lJ U S,f' ' �C ,�"'I' CAPACITY /0 0 0 6AJ-TYPE 116-iJf w 6.4 AGE f k Y-e FUEL/CHEMICAL - S a/.f 1 TESTING CERTIFICATION C, ] PASS C ] FAIL DATE LEAK DETECTION 43 CHECK IF N/A TYPE/BRAND 'AoqZONE OF CONTRIBUTION C .] YES II NO ; DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE Joko CUNSERVATION C ] CHECK IF N/A DATE BOARD OF HEALTH TAG NO ]C ]C ]C f ] DATE Gy PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD p � • '� i , ���`� i Iv �1� ��% G � OV �` �� . � k CENTERVILLE - OSTERVILLE FIRE DEPARTMENT PERMIT FOR STORAGE OF FUEL OIL In accordance with provisions of Chapter 148, G.L., and Regulations ' made under authority thereof. Name ...Thomas..Menchi ............... Name .$ernard...01 Re.illv.......... (owner or occupant) (Installer) Address .9.7...Yhee).er..Rd............. Address .24..MY-r le...TJ. --*...BYAnnis Burner Storage Make ...BeRk-ett.................................. Type of Tank RQI=d.......................... Manufacturer . Q.Q39e-tt....................... Capacity 1000 gals. (or) Size............ Model No. or Size Location 21d2rgTOLiIld .................................. ....... . Type....Gim............ Mass. Approval No. ..9.69........ Permit issued .. .' .�k..tQ...-f-....................�TQ ..MF...�'' fix' r gtpn Chief.. (Head f •ite De ar ment ...... By (THIS PERMIT MUST BE CONSPICUOUSLY POSTED UPO HE PREMISES) TOWN OF BARNSTABLE �� ✓ LOC 11ON g 7 SEWAGE # 11ILLAGE '" fy�",YT��S /�/5�g ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. G�� � !C��v 77/` SEPTIC TANK CAPACITY LEACHING FACILITY: (type),�l 41 ICJ (size) NO.OF BEDROOMS BUILDER ORWNER 25 ,1 / PERMIT DATE: 6 —Z/' / COMPLIANCE DATE: 7 —/7 —100/ 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) /S6 f Feet Edge'of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished byCZ �I� �B' �. e �S � ae� . , �� � -►o ,' � . , �I i a, t AsBuilt Page 1 of 1 / TOWN OF,BA/RNSTABLE �Cr LTION SEWAGE # VILLAGE '�Sns ✓���s ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. T/ SEPTIC TANK CAPACM /1"d c> Cc LEACHING FACILITY: (type) l;� 4 (size) NO.OF BEDROOMS BUILDER O WNER 622 o -J PERMITDATE: 6 Z I'ZP / COMPLIANCE DATE: 7 —/7 —Zoa Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 5~ 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 �CZ Fa=: ;c o y http://issgl2/intranet/propdata/prebuilt.aspx?mappar=082019&seq=1 8/13/2012 CERTIFICATE OF ANALYSIS Page: Barnstable County Health Laboratory 9shCln} "fi Report Prepared For: Report Dated: 10/24/2007 Lauren Kleinas Order No.: G0743873 97 Wheeler Road Marstons Mills, MA 02648 Laboratory ID#: ----� 0743873-01 Description: Water-Drinking Water Sample P: Sampling Location 97 Wheeler Rd.Marstons Mills,MA Collected: 10/2.2/2007 Collected by: L.Kleinas Received: 10/22/2007 Routine ITEM RESULT UNITS RL MCL' Method# Tested Nitrate as Nitrogen 0.56 mg/L 0.10 10 EPA 300.0 ` 10/:2/2007 5 Copper 0.10 mg/L 0.10 1.3 SM 311113° h aOrre 1007 ! Iron ND mg/L 0.10 0.3 SM3111B 10/24;2Q 7 Sodium 47 mg/L 1.0 20 SM 311113 10/24/2007 Total Coliform Absent P/A 0 0 SM9223 10/22/2007 Conductance 370 umohs/cm 2.0 EPA 120.1 10/22/2007 PH 7.3 pH-units 0 SM 4500 H-B 10/22/2007 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physici n. Approved By- (Lab rector) i I �y, 1 - N) ND—None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 0$Z,-elf 44 No. Fee L• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 7V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application for Misspool *p6tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade/Abandon( ) ❑Complete System e Individual Components Location Address or Lot No. Q 7 u ee 1, r Owner's Name,A dress and Tel.No. Assessor's Map/Parcel l n vv wj lql/ls Installer's Name,Address,and Tel.No. �L lfi" Designer's Name,Address and Tel.No. B�✓`r�loC��ST" Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder Other Type of Building &Vwce No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ml2 gallons per day. Calculated daily flow 3369 gallons. Plan Date Number of sheets Revision Date Title .� Size of Septic Tank 4 X Type of S.A.S. 91` Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t 's B and ea _ Signed Date Application Approved by _ Date Application Disapproved for the following reasons Permit No. •?zl rl�/ 46!!!� V ? Date Issued No. !'i' ���^" �.'L../ Fee THE COMMONWEALTH;OF MASSACHUSETTS Entered in computer: Y/e PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01 pplication for Migaar *pgtem Congtructton Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) ElComplete System ©/Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. - Assessor'sMap/Pazcel �n f9 y�a�y ,�,/ 1 j ��e/oa YVW Installer's Name,Address,and Tel.No. Designer's?Name,Address and Tel.No. Bdrrza�• �'d7sT Type of Building: ;� ' Dwelling No.of Bedrooms Lot Size 't sq.ft. Garbage Grinder(Ato Other Type of Building `�lrlp No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow &2 gallons per day. Calculated daily flow .3349 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. l > Description of Soil ho .f11 Rye? 4 Nature of Repairs or Alterations(Answer when applicable) /1,>- 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 B and f- / Signed Date 6121_/ 4 Application Approved by Date A` Application Disapproved for the following reasons Permit No. 2,o30 A- E7,If Date Issued '< "l-�.-odd ——————— —-------- -------------q-----— -- -- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificated Conmpliance THIS IS TO CERTI�j that the O/n-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned )by . eJW 7D�o �� 5 "• at Al e& r r A S O 5 /f9J/s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction PermiaAk( /r` ated Installer Designer The issuance of this permit a)1 no a construed as a guarantee that the syste 1 fun On a. �signed'.'_ t� Date 7 0 Inspector fiNj ——————————————— — ——————ems^ ----- NO. Fee gn THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogar *pgtem Congtructionermcit Permission is hereby granted to Co truct( )Repair( J Upgrade(✓)Abandon( ) System located at 7 kll7e and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thi's�'�" Date: !� Approved .ytty,!n— D I Y Q �x� 0 w�e,elle, NOTICE: This dorm Is To.Be" sed For the Repair Of wiled Se & Systems.Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT fWETHOUT DESIGNED PLANS certify that the application for disposal works c0ns7uction oermit stoned by me dated !2./ concerninz d�e propetY located:atmeets all or the fpllo--ins citena:. �Tne fziled s,item is connected to a residracal dwe=!z oniv. 7here are no cornme:�:al or business rss=ated vvith the dw it nv, �' ae soil.is class ItCLASS '!and.as i nd he^c oiation ats is :^ss tna*t or eqtui 17=-ut.a Vlzr _ C:L W =ae e are no wedanns .✓i-thln 1o0 of he iloesed s.-oec;.stem v i ne:s are no wt2s-Aithin.140 :of ns promised s=tic ::: • nerds nc inc: se in low and/or c:Lazge in use proposed V =ne:_--re no or Ti=, �The bonom.of the proposed leaching will not be located less than nve= :ai cve tne :.mxdmum adjus�,�ounavater taoie elearion. (Adjust the --oundwater.tab!- using the i=:imptor method when applicable]. �if:the S.a S.will be located with._50 lest of a-iv veseated we:lancss. the ooaom of the propesea ill leaching facility w not be located less than four�e�a(14) fe_t above the nta urturn adfusted g-mundwater table elevation, Pie=MmPiete the foilowin—, A) Top of Ground Sm a=-Zlv,adon(using GIS information) 3) Cz:W.IIcvarion L`S -the?viAX rit;ii G.�.A,d�t=s�meat � _ � Z', D&-FFEI�NCZ- 3E N A and 3 SIGNED : DATE: (Sketch Proposed pLan.of symcm on back]. g hahh Saida:cat vR COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION � y`W � See TITLE 5 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:.7�7 Aaf Owner's Name: ft . Owner's Address: !2 'r z g eg L 0a n U Ve Date of Inspection RECEIVED Name of Inspector: lease print) Company Name: i .. Mailing Address: .U qoV APR 13 2001 Z22a/.0, Ao /�Zt °;./�� �P � TOWN OF BARNSTABLE Telephone Number: ,�;(� '. `771— 9,395 HEALTH DEPT. 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 c.omplete.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(MO CMR 15.000). The system: Passes Conditionally Passes . Need urt er Evaluation by the Local,Approving Authority Ea' Inspector's Signature: Date: 4 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 ofthe DEP.The original should be sent.to the system owner and copies sent to the buyer,.if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTWINSPECTION FORM .PART A CERTIFICATION (continued) Property Address! _9q '(dju &L eCwI"ve Owner:'W1,no Date of Inspection: J,0 WO/ Inspection Summary:)Check A,B,C,D or E'/ALWAYS complete all of section D A. System Passes: JI have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluatedare 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"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or 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 than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: , 2 Page 3 of 1.1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY`ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9�2 Legrla.Z224 ,02aA,: AAA Owner: Date of Inspection: 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.Avopy of the analysis must be.attached to this..form. 3. Other: 3 1 Page 4 of]] OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM'INSPECTION,FORM' PART A CERTIFICATION'(eontinued) Property Address: �z 4 Owner:?/Le�%Yl�_. PtYc.. Date of Inspection: A0.7161 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes ' Nc� _ J Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding'of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 ''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. J Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or;privy is within.a Zone 1 of a public*well. Any portion of a cesspool or privy is within 50.feet of a private water supply well Any portion of a cesspool or.privy is less than 100 feet but.greater than 50 feet from a private water supply well-with no acceptable water quality analysis. [This system.passes.if the well water analysis, performed at a DEP certified laboratory,for coliform.bacteria and volatile organic compounds indicates that the well is freefrom 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'mustbe attached to this form.] (Yes/No)The system fails. I have determined that one or.more of the above failure criteria exist as described in 310 CMR 15.303 therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large'system:the system must serve a facility with aAesignflow'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 i.s.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 questibn 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 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:g1/ a' _kf Owner: s a e� - Date of Inspection: -710 Z Check if the following have been done. You:must indicate"yes"or"no"as to each of the following: Yes No _ Pumping.information was provided by the owner,.occupant,or Board of Health. Were,any of the system.components pumped out in the previous two weeks _ Has the system received normal flows in the previous two week period? Have large.volumes of water.been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break.out? _ Were all system components,excluding the SAS, located on site? _�_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of-liquid,depth.of sludge and depth.of.scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 Page 6 of l l OFFICIAL.INSPECTION`FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL' SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �� �/, f1��,t Ac ' Owner: Date.of Inspection: �,77/U.I FLOW CONDITIONS RESIDENTIAL(/ Number of bedrooms(design);, . Number of bedrooms.(actual): !. DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 116 Number of current residents: rsPrn1� Does residence have.a garbage grinder(yes or no): U' Is laundry on a separate sewage system(yes or no): if yes separate inspection required] Laundry system inspected(yes or no):/;f`' O Seasonal use:(yes or no): Water meter readings, if a isa table(last 2 years usage(gpd)): Sump pump(yes or no):/71,a- _ Last date of occupancyfk .-XaAA GWzd A41�. ' COMMERCIAL/INDUSTRIAL/7..6— 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: �0 (�°� Was system pumped as part of the inspection(yes or n If.yes, volume pumped: gallons--How was qua irt�ty pumped determined? Reason-'for pumping: TYPE OF SYSTEM ptic 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):`7� 6 r •' Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9� /,tJh�u, Date of Inspection: BUILDING SEWER(locate.on site plan)/JU)- Depth.below. grade: Materials of construction:_cast iron 40 PVC_other(explain):- Distance from private water supply well or suction liner Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: je"� (locate on site plan) Depth below grade: Material of construction: voncrete_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: '� ,✓ Distance from top of sludge.to bottom of outlet tee or baffle: 39 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: How were dimensions determined: x2zuJaLliAz 0 Comments(on pumping recommendations"inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc. : ' a- I 000 Air` i GREASE TRAP• ocate 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 outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11. OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS `SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONTORM PART`C -SYSTEM INFORM 'TMON(continued) Property Address: Date of Inspection: --341-7,/Q / 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: Comments(condition of alarm and:float.switches, etc.): DISTRIBUTION BOX: V�'(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:( 2iP Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of ,1 akage into or out of box, etc.): PUMP CHAMBER "rfoCate 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 r Page 9 of 11 .OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACK SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATI.ON(continued) Property Address: `'7 12,6& 6, r � Owner: QJ4_311 t_ Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):—.1-rocate on site plan,excavation not required) If SAS not located explain why: Type leaching.pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool;number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, c.)� a`)v CESSPOOLS (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVYy2&1—Tlocate.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 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C .SYSTEM INFORMATION(continued) Property Address: 9,7 C0,124t Owner:"-` ,Old Date of Inspection: ;:/-3 7/13/ SKETtIlOF 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.. oe a o IU a� 10 r Page 1 I of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: / fit!/ /t'1�z'eo✓- � L�'� ----------- Owner: Q pip �iti ofa�_ Date of Inspection: SITE EXAM. Slope Surface water Check cellar. Shallow wells 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: JChecked with local excavators,installers-(attach documentation) Accessed USGS database:-explain: You must describe how you established the high ground water elevation: . /,ter e caz - 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. " Owner's Name: 17—h.P1h? �. Owner's Address: 417 Gel, ZU-Llt. Lv_azl Date of Inspection: Name of Inspector:1please print) -7t3U/17b/0►4` Company Name: rE;f ,th�c Mailing Address: A.0-4� 17a Z' Off ® Telephone Number: iSOC--77i— 9324 APRCERTIFICATION STATEMENTI certify that I have personally inspected the sewage disposal system at this address areport d. below is true, accurate and c.omplete.as of the time of.the inspection. The inspection. iy 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(MO CMR 15.00.0). The system: Passes Conditionally Passes Needs.Further Evaluation by the Local Approving Authority iIs Inspector's Signature: - Date: 0 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 ofthe. DEP.The original should be sent to the system owner and copies sent to the buyer,,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I r 4 Page 2'of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9`zW2_01,64 WoA- ,a� Date of Inspection: 1,2 7/0) Inspection Simmaryi Check`'A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or.more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 over 20 years old* or the septic tank(whether metal or not) is structurally unsound,lexhibits 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 than 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain:. 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9,/ wag&, a-dc/— Owner: Date of Inspection: a� o C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation 6y;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 aseptic tank and.SA.S 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 i Page 4of 11 OFFICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION,FORM' PART A CERTIFICATION(continued) Property Address: i!G1ll AALe!j� 171nel"10 ILIA O.wner:'Z��_ d./,x_ Date of Inspection: 3Jz) D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the:following`for all inspections: Yet No 1/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding'of effluent to the.surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded_or clogged SAS or / cesspool y/ Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ ✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: _ Any portion of a cesspool or privy is within a Zone 1 of a public.well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. _ Any portion of a cesspool or.privy is less than 100 feet but:greater than 50 feet from a private water — supply well with no acceptable water.quality analysis. [This:sys'teni.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.kcopy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303 therefore the system fail's..The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. E. Urge'Systems: To be considered a large'system:the system must serve a facility,with a-design flow of 10,000 gpd to.15,000 gpa• 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 questibn 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 15304.The-system owner should contact the appropriate regional office of the Department. '4 Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST:' Property Address: " tee/- Owner:WU-/,4 �e y` Date of Inspection: 3/-J —7/6 J 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 4—Were.any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built-plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of breakout? Were all system components,excluding the SAS, located on site.? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth.of sludge and depth.of scum? _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no 1/_ 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 Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL`SYSTEM INSPECTION FO RM PART C SYSTEM INFORMATION Property Address: 0 2 � —: J 14 � , Z?2 Al', Owner• dY�1,t, Date of Inspection: 23h h10 ✓ . . FLOW CONDITIONS RESIDENTIAL ✓ Number of bedrooms(design):,3. .. Number of bedrooms:(actual): _,:, DESIGN flow based on 310,CMR 15.203 (for example: 11.0 gpd x 4 of bedrooms): ,3Q Number of current residents: Does residence have.a garbage grinder(yes or no): Is laundry on a separate.sewage`system (yes or no .f if'yes separate inspection.required] Laundry system inspected(yes or no):� Seasonal use:(yes or no)�� , Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy• eu -(W&v/L. 141d luao&&W - COMMERCIAL/INDUSTRIAL./✓1 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 _ tt P �� �'4E✓a /O Source of information: i t.,, Was system pumped as part of the inspe ion(yes or n :.� If yes, volume pumped: gallons--How was quantity pumped determined? Reason or puniping: 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 copyof the DEP approval /Other'(describe Approximate age of all com onents, date installed(if nown)and source of informationor Were:sewage odors detected when arriving at the site(yes or no): 6 ' Page 7 of 11 OFFICIAL INSPECTION FORM—NOT•FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9V /.y�fD��°/L� � 1 4GLt/dlJ 7`a,oz ZT,jjill16l7f0 ly'A Owner: %411"A Date of inspection: 3J� BUILDING SEWER(locate.on site plan) 126— 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 on site plan) !1 Depth below grade:_ Material of construction: ✓oncrete_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: JD� Xb Sludge depth: Distance from top of sludge to bottom of outlet.tee or baffle: Scum thickness: ty i-' Distance from top of scum to top of outlet tee or baffle: ! �, Distance from bottom of scum to bottom of outlet tee or baffle' �J How were dimensions determined:� �^ _��, Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,yvidence of leakage, tc.): n GREASE TRI�cate 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 outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM . NOT FOR VOLUNTARYASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C ..SYSTEM INFORMATION(continued) Property Address:97 t y - G�Jifi� Date of Inspection: 24, 2-1/0 TIGHT or HOLDING TANKV21-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: JJ 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 fast'pumping: Comments(condition of alarm and switches, etc.): DISTRIBUTION BOX: (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 leaka-e into or out gf box,.etc.): Q 4LQaZ QV-Ayl Q? PUMP CHAMBE�ocate 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.): I 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q!Z�V A I'Al. - fizaclZ (A01'6 Owner:wp j�� Wp1it . Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required) If SAS not located explain why: Type aching.pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool;number: innovative/alternative system Type/name of tecluiology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, tc.. d 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 I 1 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE�'SEW.AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INPO'k VMATIO.N(continued) Property Address: GGJ Owner: .0 Q!Z'1�l � O�✓n,,o Date of Inspection:-- Z.IQ ZZ'n SKETC14 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. t9l d a 10 r • Page l l of I I OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 9 p, , A20V - Owner: / 1_11)-ml Date of Inspection: ,q --I lei I SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to ground water N 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: hecked with local excavators,installers-(attach documentation) Accessed USGS database:-explain: You must describe how you established the high ground water elevation: / ter 5; 11 I12-03-1997 12:0OPM CENT DST FIREDEPT 5087902385 P.02 MaKe application to local fire Uepartment /^ n Fire Department retains original application and issues duplicate as Permit. ,�' ��/ �V'U/�P V'r%/Xr11lCES — ✓�JQ4lX�4��� �J494rQ�►LC,pO,L ji F? ��lJ�/�-� ' ' APPLICATION and PERMIT Fee: 1 T4: ; for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: Benson Tank Owner Name(please print) x o Address 97 Wheeler Road, Marstons Mills, MA agnera+e 0M9 rpsinq sneer city SUN ZIP tL Company Name Enviro—Safe Corp. Co.or Individual Enviro—Safe Corp. Rini Rim Address P-0- Box 304, Sagamore Beach,MA Address prmt Pro( Signature i g f it) Signature(if applying for permit) ;L,J.FCI Certified Other C IFCI Certified = LSP# Other F-711 MR Tank Location 97 Wheeler Road, Marstons Mills, MA 02648 sreer adaress �, Tank Capacity(gallons) 1,000 Substance Last Stored ��2 del Oil Tank Dimensions s(n (d'iameterx length) st Remarks: C" — A �912 5 • • IT 4T. Firm transporting waste Enviro—Safe Corp. State Uc. # MA-329 Hazardous waste mantles-,", E.P,A.# Approved tank disposal vzrd Turner Salvage Tank yard# 002 Type of inert gas Tank yard address Lynn, MA City or Town Cencerville 01920 FDID# Permit# Date of issue December- 3, 1997 December 17, 1997 Date of expiration Dig safe approval number. 974801872 Dig Safe Toll Free Tel.Number-800-322-4844 Signature/Title of Officer granting permit After removal(s) send Form=?-290R signed by Local Fire Dept. to UST Regulatory Compliance Unit, One Ashburton Place, Room 1310, Boston, MA 02108-161S. FP•292(revised V96) TOTAL P.02 I__ 10 TION SEW mEPERMIT NO. V I L L A C E INSTALL It's ME ADDRESS OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED .00 . % r, 177, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V ...................... ...................OF.................... ...... ...... �~°r � ~ �����o�w��u �� �����^ �� 4����� ��u���������� ���utit � Application is 6err6v made for u Permit to Construct ( ) or Repair (1~1-uo Individual Sewage Disposal System at: ....___-------____-----__-'__'-'-'-'--_-_--___' _-'---------_'-'---'__-_----__-__-_--___'---- ��" ��� IL 4e Owner � --_'_--------------'�---------------'----'--'-----' ---'_-__'-'__-'-~�'`~-'_.... i'~'°~~~~------------------------------- Address Type c6Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Pq Other—Typeof Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) PLI Other fixtures ---------_'-.---'------_-_---_--___.__._.____________________________. Design Flow............................................gallons per person per day. Total daily flow............................................ . Septic Tank—' Liquid ............gukmu Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.---------.sg. ft. Seepage Pb lVo'-__.---.. Diameter.................... Depth bdmviuloL---------' Iota leaching area--_---_'sq. ft. (}t6orD��z��odoobus / ) Dosing tuo� ( ) �� ` ' 000�� ` ' '- Percolation Test Results Performed bv.......................................................................... Date........................................ Test Pit No. ]................minutcoycrinc6 Depth of Test I`d---'----... Depth to ground water......................... �Zq Test Pit No. 3................minutes per inch Depth of Test Pit.................... Depth to ground water........................ � .- _ -__-__-_-.---'-.-_.-_-__-____'---'----'---'-----------------.-----_--'-- 0 � --_`,-_' � S��-__--__---_____'__----'----_-'------.-.-----------..--'_-----_-------------'--- � __--'--_-'_-____-'-__'-_'______--_----_-_-_-----_---'____--_-.-------------_--.------- ----------'-------'---'---'-----'''----------------' U Nature of jZepairs or Alterations—Answer when pplic;�bll ....tyun I, le!WS4 . ' ? .......-�... ''"'-_-_-. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'JITL LE 5 of theStateSanitary [ode— The undersigned further agrees not to place the system in � operation until a Certificate of Compliance has bWissud~ ----- --.---- ��� ------ -- y�z V�Ak� % No.:4................... ............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...._." ..........................................OF....................................... Appliration for Disposal WoUll Towitrurtion Prrutit J_ Application is hereby made for a Permit to Construct Individual Sewage Disposal or Repair ( 414 System at: ... ...1.7.....��_. ...... ..... .................................... ........... . ................... . ........ ........... Location-A Address No. ---- ....................... e ........................................ . . I ................. ................................... . ..... ............... ........ Installer Address ..... Type of Building Size Lot.............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid'capacity............gallons',. Length................ Width...___...._..... Diameter_---_________-_- Depth....._...._..... 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 ( ) I" aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_.__._____.._........... gr G14 Test Pit No. 2................minutes per inch Depth of Test Pit..._.__........._... Depth to ground water........................ 04 .. ............................................................**--------------------- ......"------------------------------- --------............ 0 Description of Soil....................................................................................................................................................................... U ........................................................................................................................................................................................................ .....................................................................................................................................k...................... . . I 7..... ... ......... U Nature of Repairs or Altcrations—Answer when applicab _._IAD -4.UtZ&----AP-A25. .. ... ...... . 400..... ... ............................................................................................... Agree ent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TlTIZ 5 of the State Sanitar Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ,....n Wised b q4te+oard ofbealtW ........... ............................................................. .!F/ ApplicationApproved By.............................................. ..................................... ........................................ Date Application Disapproved for the folloiving reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tomphaurr THIS I CERTIFY, That the Individual'Sewage Disposal System constructed or Repaired by-------------------- -------- ........................... ..................................................................................... ....... .. �............ Installer at........................ . . A- kw... Ao . - ,- has ..Y..4.......................................................................... been installed in accordance with the provisions of TITTR,a State Sanitary Code as described in the e 1-1—0�_ application for Disposal Works Construction Permit No......................................... dated_...._.-__................_..._.__.............. THE ISSU lc I OF THIS CERTIFICATE SHALL NOT BE CO �AS A GUARANTEE THAT THE F SYSTEM Wj" ON SATISFACTORY. DATE.... 1...................................................... Inspep ......... .......... ............... ......7...... to ---------------------------------------- • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... No........................ FEE........................ Ravolial IV" boa tr rrmit ........................ Permission is hereby granted__... ---- -- ---------- ........... ......... .................. ........ ....... to Construct (?)�pr Repair ap Individu wage gwoSystem_/al je D' atNo....................................................................... ................ )2 4....................................................... .... ................ Street as shown on the application for Disposal Works Construction- Per 0. .0-0--------- Dated......................................... ................................. ........... ----------------------------------------- (� /,//� DATE..................... .... Board of Health ..... ........... ............ FORM 12$5 A. M. SULKIN, INC., BOSTON F ........-------------- 1� THE COMMONWEALTH OF MASSACHUSETTS BOAR F H .......*... ..... OF. ....... . . . ... . ..................... ...... Appliration for Disposal Works Tonstrurtion r 3n Application is hereby made for a Permit to Construct (V�or Repair (v� an Individual Sewage Disposaf AIS at: Location-Adifress' r I o. ............ ............... .... ................. ............................................. ......... Owner A r4 5d 4(.'j. �s... . . ....... .......... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedroom ........Expansion Attic Garbage Grinder (t.-r Other—Type of Building a-------;11-'T......No. of persons.......3.................. Showers Cafeteria yp P4 Other fixtures ------------------------------------------------------------------- ............................... ----------- ----------------- Design Flow;,...............��Vc...............gallons per person per day. Total ......................gallons. Y/ p ....... W. Septic Tank Liquid capacity .... gallons Length................ Width................ Diameter._..._........_. Depth................ Disposal Trench—No..................... Width............._...... Total Length" ... Total leaching area...................sq. ft. Seepage Pit No...........j ........ Diameter.......... Depth below inletTotal ching area.................sq. ft. Z Other Distribution box Dosing tn� Percolation Test Results Performed im. ......................... Date... Test Pit No. I................minutes per inch Depth of Test Pit._.................. Depth to grou2w7ar....... G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................._. Depth to ground water._...................... 9 :.................................. 0 ------- ...... ...........*......**..../2 Description of Soil................. ................. S.7 'ek-----------......... ................. ..... U ............................. ......................................... ...... .. ............. ............ ... .... ........................... ...Tf,------ 07 '6-1 t4-_: 1P Ic U Nature of Repairs or Alterations—Answer when ap, icable......................................................... ... ..................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL IT,LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signe,,b7 ....... ----------------------------------------------------------------- -------------------------------- Date % Application Approved By----- .0... ....2.9,....... Date Application Disapproved for the following reasons:.................................................I.............................................................. ......................................................................................................................................................................................................... Permit No._._..................................................... Issued.....I .......7q......• Date.............. ...... Date _.............. TH ALTHCOF`MASSACHUSETTS BO ^ RD Aptiration for Disposal Works Coustrur#ion ramit r Application is hereby made for a Permit,to Construct (I/J®ar Repair ( an Individual Sewage Disposal i System at �`w 1 • . , . , Location.-Aores9z t o.. ................•.- -�_. 2...: `' / lCra el ./Sx4R..!. d 9., ......... Owner /ss W - ` ' (,e/ © Installer Address :Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedroom _.. ...........Expansion Attic ( ) Garbage Grinder ( _r a` Other—T e of Building l� —Type g __.___ ._.. No. of persons_____ ___________________ Showers O — Cafeteria ( ) Otherfixtures __- -•---'----- --------- •-- ---- -•-- -•-------------...._..---• ---------------•-• . W Design Flow_______________J711..___.._.___. gallons per person per day. Total daily flow..__. -�►7_-�.�-i_--- WSeptic Tank -Liquid capacity�i gallons Length................ Width................ Diameter................ Depth................ 2 q. x Disposal — o..................... Width_...-•-•-.......... Total Length ... Total leaching area...................sq. ft: _____ Diameter____.. Depth below inlet_.__..._ Atall�aching area__________________sq. ft. Seepage Prt 1No. 1 `�-- - ....Other.Distribution box ( ) Dosing to , .. .�s'i3.� t _ Date--4"�� /= a Percolation Test Results -Performed by.-�_. Gq _________________________ ....... Test Pit No. 1................minutes per inch. Depth of Test Pit.................... Depth to ground wat&_.__._��____..I ..__. G4 Test Pit No. 2................minutes per inch ' Depth of Test Pit.................... Depth to ground water.___________=_._.___._.. �..._.. fi•- -•--n ---• - -•----- O Description of Soil........... tel:n-- ••• ' •• �,-------''� ' f�`i,'�` ---------•-- -•-- -- - ------•------- V Nature of Repairs or Alterations—Answer when a i' able........................................................................1_..................... . •------...-•---------•-•----•--------------------•-•----••---------•----------------.....--•-•--------••--•--•------------------------•-------•---•----=---........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal.System in accordance with the provisions of TITLE 5 of thejState Sanitary Code—The undersigned further agrees not to place,the system in operation until a Certificate of Compliance has been issued by the board of Health. - 5 Sign __ -------------•--•-•---•------------- ....._-- 'f Application Approved B f. .._ ` Date Date .._ Application Disapproved for the following.reasons_______________________________________________________________.----•----••---------------• ----.._. . Date PermitNo.......................................................... Issued...................................................... i` Date { THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT jGi+!.Z..........0F..... .ZA.'. ............................ (Intifiratr of Toutplianrr THI S TO CERTIFY Ahat the ndividual Sewage Disposal System constructed ("' ) or Repaired ( ) sta T ,�7 / '64 /. has been installed in accordance with the provisions of TITT j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:_____________� j+ __...______.____ dated__.. _ _ . _ -___7. . `� , THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE.THAT THE SYSTEM WILL FUNCTION }•SATISFACTORY. . k DATE......... l ��. . .._ Inspector......... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH ,r o CIX)..1. ................ oF._........................_.....-------•--- -NoFEE....... ........ Mops l quorks TonA r n prrutit Permission is hereby granted........ ---- .. ..................... x •---••----�•-=-.....-------._......_.._......._.....-••-•.. ... to Constr /� or Repai ) an In 'vldual Sewage Disposal Syst4 at No.arldss , - j% IZ -- g r'r� 'C/--.... �:_ .._ Street / as shown on the application for Disposal Works Construction Permit Nol"_________ ____ Dated... `. %�' ............................. ................................._ Board of Fugal DATE........ -Z! Z. (/ FORM 1255 -HOBBS & WARREN,INC.. PUBLISHERS - ,: t i L*T A as i ol P ex. ' Well �. to g5D �D WALTER ` E. Q Vet Kj SMITH,JR+ DY�t 5 ��/ �` #15.128 �� �C.�/� � ���+ A�o,� `�FGIS1f.R�����``� opt AP A AMoto QA,-re Mi 10 loll A I l" •t A '� •r 4-d 1'GS a ` ,, d 06 mew. :MAY , �sr •gib ,) _ �t 33p'aVol r t ,`� 4-�------ t — t s Teat ,�•6 - t o-4-�=p PING{ � ,�C�G 4 �' •r 'a 415 to ;* r .. .. - �' +' 'ram ,. .}. � � • '37. 0,--- -1 - 7 fir=---`' �r ,�iO�Hr13. C► R , i No. Fee----2---�---- BOARD OF HEALTH TOWN OF BARNSTABLE 0ppfication forlVell Congtructionpermit Application is hereby made for a p rm to Construct ( ), Alter ( ), or Repai ( n in4idual Well at: --------- d _ - --- -------------- Location — Address Assessor Map and Parcel ------------------ ------------------------------------------------------------------------------------------ Owner Address -��--� --- --. _---------�.- -lam ------ -��----- �./c/ --- - -------------------------------------------------------------------------------------------------- Installer — Driller Address Type of Building Dwelling---------------------------------------------------------- Other - Type of Building ---------- No. of Persons--------------------------------------------------- Type of.Well- -�' _r r- Gv — - Capacity Purpose of Well---- r =1= = ------------------------ 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 rtificate of Compliance has been issued by the Board of Health. Signed-----M.... -- --------------- --------------------------------- c� date Application Approved By------ -• - ------------- ash__- � Irn- 1 Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------------------------- -- --- - ------------------------------------------------------------------------------------------------------------------------------ date Permit No.__ Issued -------------------------- - date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired) _ ------------------------- --------------------------------------------------------------------------------------------------- Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No!lk'% -=--- Dated---------------_-________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -- — ----- - --- -- - --- -- - Inspector------------------------------------------------------------------------- II �'---- BOARD OF HEALTH TOWN OF BARNSTABLE Zipplftat ion-*r V ell Con5truct ion 3permft rtL Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: In -- 1 -- - - i --------- �—P Locatio '— Address Assessors Ma and Parcel �V------------------ - - --------------- ---- Owner � Address ''Installer — Driller Address Type of Building Dwelling ' Other - Type of Building--------------------------------- f No. of Persons------------------------ Type of Well-------! ------ Capacity ---------------------- ------ Purpose of 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. - -- 1 —___—----- — Signed- -- 6 date Application Approved BY---------- ---�-�-- ---------------------- ----c ----ae '-�j .� f Application Disapproved for the following reasons: ------------------------------------------- - date Permit No.-__ ;�; _� `�� - - --- Issued-------------------------------- - ----- date BOARD OF HEALTH, TOWN Of 'BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) -'ty t --- �' -----------in---------------------------------------------------- - - C-"�xf `v G "X�"v�v� Installer � at----------7-------------' r n - - - --------------------------------------- ---- has - - - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit Dated------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------------------------------------------------- Inspector---------------------------------------------------—-------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Vell CootructfonVermft �y Fee----vv Q-'=__ No. L A=- �— f= Q� Permission is hereby granted------ — 1�t ---------- ------------------------------------_— --- to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: No. -n — j — 1 ------------------------------------------------------ -- ----------------------------- v "t lX�['r — l�C /W •—�tre t as shown on the application for a Well Construction Permit No.-------------------------------------------------------------------------------------- Dated--------------------------------------------------------------------- -- --- B aro d of Health DATE-------------9=--�—�—�-�-��-�---------------------- rn o ti E ti � N a) UO CLO M 00 U NCOa a � J N L0 0- OF ICE O x �('U♦ M �965 IS = CU l^may`/LLJ u —1 V) O � 2 � U0c) J N .- cb E O N LO a � a a� GARAGE I / 21-2— Q 6]6 SO FT g KITCHEN a V, —X- 955�F! /�/��� N r ——————1 !——————————1 ♦V FAMIL — FAMILY ttPORC1Hq I I 661WF t1—FT 1J1 SOR I I I _• I I I W I I Q I I I I Q ---------- --------- LIVING ca $ 15-SX tY-1P � �7 2Ca 5o Ff k r _ BEDROOM usXlnm teT so Fr •� 1 — V 00 r-I 0 N M " LIVING AREA N t J625o� Existing 1 st Floor p. a H b Q � 3 5'-6 5/16" 5-4 1/2" cy) O N E w N OV ------------------------� a) LO d -—- -— _ C M CID U ,C cD co O N I J ON LO C I I 5 Q M �UU``m Y " V Future D or Frame 00 LI. / r 0 O La ~ OPEN BELOW O O j M O cp (6 2 x LAUNDRY/CLOSET I r- U CJ -_ J 211 11 SO FT FT 10'-9"X 13'-1" I 1-4- M 129 SO FT I O Q ry L0 I I I I I I Shelf and Rod for Clothing I CLOSET 17'-11"X 3'-11" 5-11"X T-11" 71 SO FT 23 SO FT HALL � I 0 All ( I N lW9 <OfiB I O I I I � N I I I New 4 uble oor I o ft. I� I I W I I I I $ --------- ---------J--------------- P O I I 0 BEDROOM i BEDROOM 15'-7°x1r-11' 13'-0"X 11'-11" i 185 SO FT CC� 154 SO FT G i U) cu I •W I Y I - I I I', I I —- ------------ ---------------------------- ------------------ ---------------------- 3&90H ]W9g1 '8;;D; 38i9�V1 Ifi49O1� 00 r-1 O N 36' clj N Existing 2nd FloorCIO Q „ rn 4 r— W� r` aD E N U N Lo 7 O O j I I c 6( (D O 00 � 2 sl I I JNLr) CL I I O X M m I I I � O I I I Y I I I (U + 0.) O J- '— O U CU Proposed Mudroom Expansio - i i i F- o � 0) ° Ipg�, I ao — I€ � V N — J I I 'T t6 I I pp E I � I 3 N I I I IO I I I FD I I I \ I I o f I \ I I I I \ I I I 1 \ I I MU ROOM EXPANSION I I I 1108 SQ FT I \ I I S \ q l m l \ I I C e,, o„ I I O r--------------------------� _ I ' - I fn 7T.... GAi�4GEcaKC11 " \\ --” r-------- I w FAMIL FAMILY II I 'WING UDRO A 11' 32 32 a FT FT O Q = X a I (u a I LIVING •//���� —————————————— -- --------J ,¢-s'x i=-,v W BEDROOM °��� S q CIDvs aun w ana� am.. O N Cl) N LIVING AREA taeSw Fr � Y rn� CO V � H Q U) i I Proposed Mudroom Expansi® � I I I - I 10) I ~ E I N O O I I O Lo p ST I C (coo M U JNLO ❑' O 5 O x U m 12'-4" � V O m ti O C � _r O U 2'-91/2"�3'_1,�- �I-j2". —3�_1��- EE 3'-21/2„ �-- +�' �' 0) 0) zseso" 'II_ zsasw� I - — ————— -- U M — J N •_ I I \ 00 E I I \ 0 O I \ I I \ u> I I \ O � I \ I I \ I I \ o \ m I I MU ROOM EXPANSION \ 11'-5"X 9'-6" i \ 108 SQ FT io I \ I , \ C sus c O ------------------I I I _ v C i � , i eza sae eza e3s \\ �/_-----1---/__ L� Raise Floor to W �r �/ I House Level \\� \ f I \\ E I \\ \\ O \I , KITCHEN 13/16" 11'-111/2" \\ I 181-9"X 9'-8" L----- 195 SQ FT rr ::3 I , EXISTING MUDROOM 11'-8" 11'-4" I m 132 Q FT �_ 00 zxse I - I I ----------- I I 36C9DN CI I m � I co j I N v] Q �