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HomeMy WebLinkAbout0065 ABEGALE SNOW ROAD - Health 65 ` u V, Snow Rd -~ r `West .Bar s' bie ll7f.A 02668_ , , A = 088 - 001 F i TOWN F BARNST LOCATION w ffSEWAGE # 1A VILLAGE a ASSESSOR'S & LOT r INSTALLER'S NAME&PHONE NOR 17 SEPTIC 4' AP�4CITY D LEACHING FACILITY: (type) (siz 0 d1b? NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �f�cK 4 F 14 a u 56 �f r.• 2 , - 2 d3S,g �, a, 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information t filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. kCompany Name 14 Teaberry Lane 1111,10 Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-477-0653 S 14595 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 o" site sewage disposal systems. I am a DEP approved system inspector pursuant to Section:15.340;of Title 5(310 CMR 15.000). The system: e ® Passes ❑ Conditionally Passes ❑ Fails 4 ❑ Needs Further Evaluation by the Local Approving Authority Uj 6/16/10 Inspector's na 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. lY t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo System• agell�17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 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 Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r— Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is West Barnstable MA 02668 6/16/10 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is West Barnstable MA 02668 6/16/10 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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"to each of the following, in addition to the questions in Section D. Yes No i ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. City/Town 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: has not been occupied 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 the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of ail components, date installed (if known)and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"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.): At time of inspection building sewer appears to be in good condition. No signs of leakage Septic Tank(locate on site plan): 19" Depth below 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: 10'6"X 68"X 68" Sludge depth: no sludge t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Abigale Snow Road M Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in good condition tee's present and no sign of backup Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address ` Bank of New York I Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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.): At time of inspection d-box appears to be in good shape-no signs of solids carryover or leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching was in good working order no sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road �M Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is every West Barnstable required for eve MA 02668 6/16/10 page. Citylrown State Zip Code Date of inspection- D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately . 1 Al = 4X' 5 y A?.- 35' g A : y31 Ay- Spy g A5 : 5W 7 `82= 18 ` 133 = 5 Vi �B v 59' 3 " "B5 - I V I „ t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts 52 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. CitylTown 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: >12feet 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: 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: You must describe how you established the high ground water elevation: Hand auger hole Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Abigale Snow Road Property Address Bank of New York Owner Owner's Name information is required for every West Barnstable MA 02668 6/16/10 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable Regulatory Services ► Thomas F. Geiler,Director BAMffABM $ Public Health Division + f� Thomas McKean,Director cry f 200 Main Street,Hyannis,MA 02601 . Office: 508-862-4644 i+ax: 508=790-6304 rn rn Installer&Designer Certification Form Date: —4 '2 8 ' 0 Designer: �rinj(VerffnInstaller: M V/ L Address: Address: P D�/� Ma COoTT On L.; 6 was issued a permit to install a'= (ins e .-(date)--------. ..=.-- -- - - - - septic stem at Ui based on a design drawn by p (address) d d y[ (d signer) ` I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 1 certify that the septic system ra ren Ced above -w s installed major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. ���,'CH OF�AAs� • ARNE H (Installer's Signature) OJALA ` CIVIL No. 3o792 STER� Affix Desi '"`-Snp Here) PLEASE RETURN TO BARNSTABLE-PUBLIC-]HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form AUG-03-2005 10 :25 AM DOWN CAPE ENGINEERING 508 362 9880 P. 01 Town of Barnstable Regulatory Services Thomas F.Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790.6304 jnstaAer&Designer Certificatio_u Form Date: 2 L-0 5" - 1 1. J' Designer: Installer: P - R�V, Address: Address: P fJ yA z� 5F- DL M On L 7 was issued a permit to install a -�'( ins a �_ septic system at based on a design drawn by ess d d _ signer I e�rtify that the septic system referenced above was installed substantially according to the desiYi, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank• es i.e. I" tilq�t thee system referenced above was installed with meter.. 8 tan h 10, lateral relocation of the SAS or any vertical relocadon of any component of the septic s )but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. ESN Ol MAs� ARNE N cOJALA er ssignature) CIVIL CIVIL •, ,$ N o. 30792 y (A x OR p ere TON. CERTNICA TO BARNg E OWL TK YmT Q:Hea1th/5eptic/Desipar Cattification Form No. — t Fee /ev t THE-MMMONWEALTH OF MASSACHUSETTS_ Entered in computer: c. r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 4 ZIPPricati a for Dizpqol 6 otem Construction Permit Qrs�rc� ���nra,�.l � W, isa,. Application for a'Pbtmt to Cons )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components LocatioD Addres Lot No. "L., Owner's Name,Address and Irl.N 077 nr ` Assessor's Map/Parcel IH�P�/ /� ' Z ®�-' 'Ong/ 1V f to AU 4 /Z//p f/ 1n Ll r V3 Installer's Name Ad ess,and Tel. o. y Df s- ner's N Address IN5 l.No. 35;-WiliAll Type of Building: Dwelling No.of Bedrooms Lot Size ,7DC sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow Hk1D gallons per day. Calculated daily flow �y(] gallons. Plan Date -o7-C3/ Numb r o s ets Revision Date TI Title i c i M �• �v TI» C " Size of Septic Tank Type of S.A.S. 1i, 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 T' le 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. ,9 Date Issued No. Fee �v� t I ©�nw—'/9 p T+1'���,9 MONWEALTTH"OF MASSACHUSETTS Entered in computer: PUBLIC tHEV'H.DIVISI6N TOWN OF BARNSTABLE.,,MASSACHUSETTS -: �,tY ZIPPrication foriogaY *pztern Cottgtructiotternttt Application for a4A Io Const uet )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Locatio AddreMot No. j,P ty, hj_ dT1 N ( 7 ' wersame,Addressn 16 Assessor's Map/Pazcel VS Cal VS�z, Installer's Name, da�ss,and Tel.No. �� �/� Designer's Name%Address d Tel.No. e � V'U.uSc�cG)) ��C2n�.� I"�/7. Od6w 1t1(11n �1. f'�/l 0,�)62 Type of Building: / Dwelling No.-of Bedrooms `! Lot Size kf1, 20G sq.ft. Garbage Grinder(104? Other Type of Building No.of Persons Showers( ) Cafeteria( ) _ Other Fixtures - Design Flow /0 gallons per day. Calculated daily flow L� gallons. Plan Date �/ U� Number o ets / evision Date /v Title/ �` ; � r, Lv /0 /�{�,�1' hC.� Wd U. � Gn)VR Kv 7U, /1110Bk< <G1- Size of Septic Tank /SZL� Type of S.A.S. _(,�c 1ilr - Description of Soil �4 Nature of Repairs or Alterations(Answer when applicable) f, F 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 Ti e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons ,L� Date Issued Permit No. w THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, th t the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )byda•- at LU'f has been constructed in accordance with the provisions-of Title 5 and the for Disposal System Construction Permit No. _L/— 7 G 7ated Installer by 11, k C Designer The issuance of this permit sh/aif nnooj be const ued as a guarantee that the s stem 1 ft� ctio as designed. Date /� ��✓� , Inspector s R' s , - i No. WV �'��y � ----------------.------Fee ler)(�! _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Ziopo5at 6 item Construction Permit Permission is hereby ranted to Con�t Repair( Upgrade( )Abandon( ) System located at // ' i aj- 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 m dust be completed within three years of the date of this e it. f Date: / 4`!/ " Approved by l( / w f �\ — _ _ 7- : y t 10 u�;u Ftsan-twu,unnt( -.__._._. _T _ - . I_j4 U4E CT�ss- Vy NJ P : �.� .. l 1 " _ - 508428.6191 I - ,. : o eVi in -- H ter. aesions 9 coPYright 02004 -4 _ �V'ACY SN[Ftc� q. I - • o " 7 ,. Preliminary plans and layouts by DC.D.are for the use of their Customers Only.Any Other use is StriCtly PrOhibite Y ,d ' ------- -ems---- _. H y : r. 1 ' , f J - / [. .:� � � cuuT'a"t;^:n it sty'ti: --_r•: ROst wcL45AILL2�'rn.J�..__ _..- I Isla : r It 10 r } I J r r io - SCALE DATE J h-'_t4•s-^-' 4� .. k b o 1 G4 II _.... — - 1 -- - -- f— — 508 428.6191� .a T T } LLI custom o o esigns - r ... -� copy hht . i'a :�. e 2000 I r ' i ed t o• r / C I ?1 n ... q•w q.o" ro : - s4 0. .�_............�. 111 j ' Preliminary plans and"layouts by D.C.D.are for the use of their customers only.Any other use is strictly Prohibite �' to.11 L4 4 _... 01 ED 6 Jam._, �__ L� �' � � � • i ,,' r,•, 4cticr✓�:i� ; '' i __... ,. ..:�. 4 STL Yc$S S08.4]8.6191 Vol a evl i n -- t (Bustorn STJp.K: l s' �cYcrt Y�il,rtYq—. �.es.�gns 'copy right 6.2OO4 I g' — ` • �,. .. Ali Rights , A I r Reserved i Pow i —I — — — I � • -..- 1 I a �c• 1. + � i ! a ....... ... : .f..._ _., ...... -.. .._ .6.. ✓a O 3:G "S o 3 0 I' 12 0„_ I ,. l ! .. I 5 O C W - Preliminary plans and layouts by DC.D.are for the use of their customer.s only'.Any ocher use.ii strictly Prohi Dite } tR I : Y jf • - r 3 ar'.. i r .�„ �. fob ?.:•; s ._....4 G � - t f i : �F 4. 1. ..,...• ' •', ,. .. .'.-: •: 4l f,'. :®,...,�,., �,-. � ., :r.. - ..: .:,: `.:. Y evlir* .SCALE } • I } � `'S08 448'�6191 ry i � C63usfom 13rn.<rx� le, a es`ignsLIT All Rig tdip ! Reserved r c i I . : ny:Othef use i1 Strictly PrOhi Dl[e Prellrninary plans and layouts by DC.D.are for the use of their customers Only.A 77. I ' i ri dd t � tt it Vic IF 1� u �. t .�: i i li ; � �•� .�:.. � I 'I�- � t �lk —1xl`'.R� 4E {I 1 t I ; 1 1 t 7 I - , I 1 77 1 it Al 7777�s 77 _ 6 1 .. ' 1 �• .�• —�— -/i.::541 F/1TNl�5C�'::i]F,!2ti10 YIC2>, ..:�• � .. i2v�LA1»- '— , 77 r r tl , l 7 ' TT .......... , , • -7 i Q 2 7'- t 17/4" 5'-5" 'l'-O° 2 2'- I 'l/4" W Q- 0 7'-0" 1 2'-9" 3 O c' ¢ ¢ ¢ m 1� 0 V tr p a Z 1L1 C N .... 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