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Home My WebLink About0258 WILLIMANTIC DRIVE - Health 258 WILAMANTIC QidC, - _ MARSTONS MILLS A = 103 080 —� TOWN OF BARNSTABLE l LOCATION 'a ��,_� �,�'�\� v..� �2 SEWAGE 94'y VILLAGEja ASSESSOR'S MAP&PARCEL 0%70 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (size)- Y k 4t4t NO.OF BEDROOMS o� Y OWNER PERMIT DATE: /0 e-,62C� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 3 S Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) X Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) X Feet FURNISHED BY7:CS�t�� „ ,t, Qa= 3r"7" t3a= Dal 3„ • � .J. 3�� g3; 33,,E �. S � � Li 716 4 S �8 ,I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is ry Marstons Mills MA 02648 Janus 13 2009 required for , every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not IName of Inspector use the return key. Ready Rooter, Inc. ' Company Name PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 City/Town state Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority . / -4 � January 14, 2009 Inspec or s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Lb I I m Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13 2009 required for ry , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 Conditional! Passes: Y Y ❑ One or more system components as described in the"Co ditional Pass"section need to be replaced or repaired. The system, upon completion of t 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 yea old* or the septic tank(whether metal or not) is structurally unsound, exhibits substanti infiltration or exhitration or tank failure is imminent. System will pass inspection if the exi ng tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass in pection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that th tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high atic water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, ettled or uneven distribution box. System will pass inspection if(with approval of Board of Hea ): ❑ broken pipe(s) are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13, 2009 ' required for ry every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or placed ND Explain: ❑ The system required mping more than 4 times a year due to broken or obstructed pipe(s). The system will pass ins ction if(with approval of the Board of Health): ❑ broken pi e(s) are replaced ❑ obst ion is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or t e environment. 1. System will pass unless Board of Health det Ines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning n a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 50 fe of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Boar of Health (and Public Water Supplier, if any) determines that the system is fu tioning in a manner that protects the public health, safety and environment: ❑ The system has a septi tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface ter supply or tributary to a surface water supply. ❑ The system has a se is tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a ptic tank and SAS and the SAS is within 50 feet of a private water supply well. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13, 2009 required for ry every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS. 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 /alysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the mmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that nocriteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or 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. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u, 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marston Mills MA 02648 January 13 2009 required for ry every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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, perforated at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no' o each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 f et of a surface drinking water supply ❑ ❑ the system is within 2 feet of a tributary to a surface drinking water supply ❑ ❑ the system is locat in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or mapped Zone II of a public water supply well If you have answered "yes"to any q stion in Section E the system is considered a significant threat, or answered "yes" in Section D abo a the large system has failed. The owner or operator of any large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 MR 15.304. The system owner should contact the appropriate regional office of the Departm t. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r•'`� 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13, 2009 squired for ry every page. Cityl-rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13 2009 required for ry every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 349 GPD Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected. Yes ® ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage 2007= 98 GPD g ( y g (gpd)): 2008= 76 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc. . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to th itle 5 system? ❑ Yes ❑ No Water meter readings, if availabl Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '<0 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13 2009 required for ry every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No records found Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Septic tank and leach pit aprrox. 20 years old. Soil Absorbtion System Upgraded April 2000. As built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name rti is Marstons Mills MA 02648 January 13, 2009 reequirequire fo d for ry every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below 1,4" p w grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8 X 4.5 X 4.5 1000 gallons Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle g., Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure and dip tube. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name reformation is ry Marstons Mills MA 02648 January 13 2009 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal fiberglass ❑ polyethylene y ❑ 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at tim of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ iberglass ❑ polyethylene ❑ other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13, 2009 required for ry every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons . Design Flow: gall s per day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float s itches, etc.): Attach copy of current pumpi 4ontract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two outlets with equal flow. No sign of solids carryover. No sign of high water staining over outlet inverts. Riser brings cover within 6"of grade. PumpChamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13, 2009 required for ry every page. City(Town State Zip Code Date of Inspection D. System Information y at on (cunt.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6'X 6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: to innovative/alternative system Type/name of technology: 4 High Capacity Infiltrators w/4'stone. Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit liquid level 3' below invert. No sign of past hyadraulic failure. Infiltrators located and inspected with video camera. Empty at time of inspection. No sign of past hydraulic failure Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills MA 02648 January 13 2009 required for ry every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part 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 groundwat r inflow ❑ Yes ❑ No Comments(note con ition 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, sign of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is required for Marstons Mills MA 02648 January 13, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 '�!-eVC4 I 3`(,Ir 3 1�3 ' 38 1 63� 33 ` 7" 1J I .1' 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 258 Willimantic Drive Property Address John Butler, Trustee Owner Owner's Name information is Marstons Mills required uired for MA 02648 January 13, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 35+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: April 28, 2000 Date ❑ 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Base elevation of property is elv= 87.2. Max ground water elevation is elv=38.7. (2000)Accessed local ground water contour and topo mapping. TOWN OF BARNSTABLE �� °r .w, a Lf CA'I V N t 1� (�/ll i/J'I�/�T��G SEWAGE # 000 VII.LAGE_ /l : /rI%�Z S ASSESSOR'S MAP & LOT a ®� INSTALLER'S NAME&PHONE NO. M i hc4a mot' LC _ SEPTIC TANK CAPACITY %"a J LEACHING FACILITY: (type) (size) j X NO.OF BEDROOMS BUILDER OR OWNER PERMI UDATE: 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 P � a� I' V Ar 131IL a2 7 Li 3 � C� i, No. Ke THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplicatiou for Migoml *p6tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(t✓TAbandon( ) ❑Complete System individual Components Location Address or Lot No. =Lt5& Owner's Name,Address and Tel.No. Assessor's Map/Parcel 'a.3._.O FO Installer's Name,Address,and Tel.No. 0o 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 gallons per day. Calculated daily flow cZ gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �'b A : Type of S.A.S. I/�i,c�� Description of Soil Nature of Repairs or Alterations(Answer when applicable) �� crt 5C� rt1C/ Cr c- -. 1 1 � P 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 ha een issued by this H th, Signe Date " o D Application Approved by Date Application Disapproved or the following reasons Permit No. Date Issued No. Flee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE., MASSACHUSETTS Rppricatiou for Migpogar *pztem Conmruction Permit Application for a Permit to Construct( )Repair( )Upgrade( V)Abandon( ) O Complete System N�Uidividual Components Location Address or Lot No. c gv\eL T-a ,, Owner's Name,Address and Tel.No. Assessor's Map/Parcel t D 3 O O 09 x Installer's Name,Address,and Tel.No. ;'fir 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 gallons per day. Calculated daily flow �`"1 gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank 4 } ti �Cx�� 1� � Type of S.A.S. `r C_,t,,0,c Description of Soil V V CC)A Nat re 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 provisl of Title 5 of the End onmen Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by this Bo— th. Signed a.. 0 Date — g�'�� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued —L406FO ------------------�-------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS . � Certificate of Compliance THIS IS TO CERTIFY,that the On-site.Sewage Disposal System Conistr7cted(r—,3RepaVed( )Upgraded Abandoned( )by at VAJ ha nstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer C Designer i The issuance of this permits a 1 t b construed as a guarantee that the system i11 function as designed. �� t C, Date OP Inspector ��f �N _�� ,4.;1! %'�/l i� f '� - -- ------------------------ No. r THE COMMONWEALTH OF MASSACHUSETTS Fee ' ` f PUBLIC HEALTH DIVISION•i BARNSTABLE., MASSACHUSETTS Mig;pooar *pgtem Cougtruction Permit Permission is hereby granted to Construct( )Repair( )U grade(V Abandon( ) System located at S ` V1/l�oti i d C__ Q �! 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. e' Provided:Cons tion mushe co pleted within three years of the date of permit. � Date: � Approved by y � 1 a'3 Wya 1/6/99 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 PERNM (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at (.,1,J1 wt c-.-'\ F o,,� meets all of the vu,�vk, 1 S following criteria: u The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. v The soil is classified as CLASS I and the percolation rate is less s than or equal to 5 minutes per inch. VThere are no wetlands within 100 feet of the proposed septic system C1 There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] e_ If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 77, B) G.W. Elevation°y+the MA.`(. High G.W. Adjustment .3°7 = DIFFERENCE BETWEEN A and B SIGNED : DATE.- (Sketch proposed plan of system on back]. q:health folder.cev d% U011 SAlL (( O �J TOWN OF BARNSTABLE ti LOCATION SEWAGE lt VILLAGE - �%1� ASSESSOR'S MAP & LOT __ D INSTALLER'S NAME&PHONE NO. C SEPTIC TANK CAPACITY %eo J LEACHING FACILITY: (ty ) �1��/r�.�7d (Size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 f. Furnished by I 771 y, [r) V G }j A I I I. I ra j y LOCATION, ',W SEWAGE PERMIT NO. Xo� 91 VILLAGE ✓27)0�2A&W J �0 INSTALLER'S NAME&ADDRESS )(3 . ,tt� ate. BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED • z 4 No.�..� Fxs......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF......................................................................................... Alip ira#iou for Rspuutti Works Tonutrnr#iun Vernat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: a3 Lo i Address or Lot ^� Owner �� a�ddress Cf2. ........... .......... .. ..._........ .�. �ey�......- ........-•�•1_,��.CJ3�y. Installer Address d Type of Building Size Lot...Zekki* '_'___Sq. feet U Dwelling—No. of Bedrooms.........:&.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria aOther fixtures ............................................... •-• - W Design Flow..... .0...........................gallons per,person g erff ay. Total daily flow...-.�3__�_.._.__...._.....___.__.gallons. W Septic Tank—Liquid capacity/�'�?.gallons LengthA!.__&.__. Width.41.,_!_v.. Diameter................ Depth...... :.--..iY x Disposal Trench—No._./.............. Width.................... Total Length..... .___._..____ Total leaching area_._.._.._._.•.__ -sq. ft. Seepage Pit No..................... Diameter -.�.._ Depth below inlet_ ._.__.__.. Total leaching area_ � (�,sq. ft. Z Other Distribution box ( ) Dosin�a�(, )Percolation Test Results Performed,by. 2 .-•----•••---•---.. Date.- —�,�!�j Test Pit No. 1................minutes per.'inch Depth of Test Pit.................... Depth to groun water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - ..--• ..................................................� 1 tion of Soil•-.___.Q �r- p -_._ R-�... O Description N.._�.. c, ............................................ r' ------!-`------------•--------------------------------- x ------. ----•-...._:V?._-•-� -----•• s-^%�•••••. -•- --------- •• --•-•-•••---•----•------•------•--•--...._.....•. U Nature of Repairs or Alterations—Answer when applicable.............................._................................................................ Agreement: lie tin igned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e isi is f m he State Sanitary Code— The under ' ned further agrees not to place the system in o do f Compliance as b en is ed by the boa of heealltth. _Si ned..... .6�'Cra we► .._._. .......... _.. .-------•-- -------- --------------•-----.._....._._. = ---= Date p ion Approved BY ............................................................. `lC Date PPlieation Disapproved for the following reasons_______________•_-_-________......._.......-______--_._.._._...____-__-_-._...._..._._._.._:..----"';.._------.. --••.....................•------•---•-----•-•---......••----....................--••-•-•-----------•--------•-----........______...•---------•-....----•-•••--•-....._._......_........__-...._..__----- Date PermitNo......................................................... Issued...........----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............................................. Appliration for Uhipoott1 Works Tonotrnrtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst t ..... ...l ••••---- /f Loc Address � or Lot No:- .1c1c7 ® 0`i ' .......G(�.Qa !�..... ........ ............` , ner � �„� dress e. Installer Address d Type of Building Size Lot__ �� !.::. �q. feet U Dwelling—No. of Bedrooms-------4--..............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) al Other fixtures ................................. . W Design Flow...........!2 7D......................gallons per person p r dd Total daily flow_--_--.� .. -..... ............gallons. WSeptic Tank—Liquid capacity/offgallons Length_ _.- Width...� Diameter................ x Disposal Trench—No. .................... Width......-- .......... Total Length........ _......... Total leaching area... ft. Seepage Pit No--------------------- Diameter._4.�-�._�-�_- Depth below inlet.._�.��..... Total leaching area....Z: C.sq. ft. Z Other Distribution box ( ) Dosing t ( ) Percolation Test Results Performed by._.._ __il_`Date.. ....^.......................... aTest Pit No. 1...Z.........minutes per inch Depth of Test Pit.................... Depth to ground water......................... GX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---- -------------------- -................................................... =----: --•-•----------- O Description of Soil....... �. x ......._-- .........�v s - r." _. _.._ .�'._..V ---------------------------------------- .................................... ................. '------.-----..... .. ...... .............................................................. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------•---------------------------------------------------•---........-•----••--------....----------------•-------------••---------------._.....----..._.•-•-----........-----•--• Agreement: t° he un signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e ovisi iis •,o'f Tt he State Sanitary Code- The under fined further agrees not to place the system in o atio t e f Compliance has been is-ued by the bo rd\of Health. 4 Signed._ ` . •--•-•------....._.... _ ........_ !. :..=� Date Ap ion Approved BY------- --- � --•----------------------------- Date PPliation Disapproved for the following reasons:--------•------------••---...-•...............•-----._...-----•---------•-•. ................................. ---....----•--•------•-----•---------------••--------------.....................................---•----------------------------------------------•-------•-•. ..... Date PermitNo........................................................... Issued-........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH }. ................... ...............OF....... .............................. v Trrtifiratr of Tong haurr THIS 1 TO'CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) 1 - Installei PP been i provisions r �� The Mate Sanitary Co s described in the application li ation for'Disposal cWorkseConstru Construction Permit No TITLE, 5 of .. u dated-------� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1 DATE ------- .................. Inspector............... �......... .. �-�L� ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '* ..........OF.. �f. �...'.t.' ................... e? l FEE._ ...---•-...--....-- O. .................... ` Rio oo�t ,arks Tonstrnrtion ,rrutit = Permission is ereb ranted-------_-- --_�-----------��-•-------------••--------------•----------------------------•--...---------- ....... ....... Yg to Construct ( o Repair ) a Individual Sewage Disposal System at No.-----i.2?�-- �--...`^' _. -'•.4c...... g ---------------I as shown on the application for Disposal Works Construction Permit No.............Og+_ Dated........ .:.:.. ..2tt.�`........... _ t.... ' /O / Board of Health DATE------------------- --- -----•--------- ................................ FORM' 1255 A. M. SULKIN, INC., BOSTON l« gi POLL 1 i)fl A N T/C. ► LIZ 'tl d 1 r,r'f - ,.. pk' 2# �. Jm f ' f uF ►� D(2T Tto A n J M (� so LrJE�L,Ui✓IJEi2 SKL[d7 4,6 7. �( r '. SO r � fi 4 "ate N V, s t *e A(SERT t VE \ p t �f/(1111, 'UUO'�AG.. Cl) Opel✓�`� � ��w'0 '� \ N TANKG .60 n1 � '� �i J. 'O 2 .._' y�, jQBERT sod ` Ztv;(�C�U S,r. , k D TL'G?"/0 N P� vsfx K' B , , lua Lv�- P DT 'gy! 19367 -w y=- �"�' EG►STfR{ k E G E N D 3� o ;EXISTING aPOT ELEVATION 0.0 ';6XISTINo CONTOUR -- 0 --- i r CERTIFIED PLOT PLAN �c A✓i �le1NiSNED .SPOT ELEVATION (� Lo7- z 3 W/�.�/MA'.v7rc 4,INISNEO CONTOUR 0 / ,d, ,�a_s-rc��,;,; /HILL s- j1►QT6t rTh' location of any existing und�w;d sewerage IN We�l ,ror other-utilities. shown on ,this plan is approx imdtti®�Z°4nly ; s determined.from 'records and/or verbal ��, •�'� �, �� Fpfo�rmaton,` 'l;he contractor .is responsible for the r 6 SCALE / ="3 0 DATE �7 tfcation of'-the existing locations in the` field. " ' 2. �9S I gig �. EDGE ENGINEERING 2q2N9 CLIENT-f/°,.�! '* I CERTIFY THAT THE PROPOSED S 0 7 6 BUILDING SHOWN ON THIS PLAN 018TE.RE REGISTERED k.,. JOB NO. ........— "CIVIL`' i` LAND CONFORMS TO THE ZONING LAW8 Oft.fly A... OF 9ARNSTABLE � MASS a r 'kkt{ T12. 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