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HomeMy WebLinkAbout0027 GEMINI DRIVE - Health 27 GEMINI DR, - W. BARNSTABLE A= 131-035 1 No. 4210 1/3 BLU 00 M GO ESSELTE 1 fl% (D 0 o g o t� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M Property Address } �//2✓l ce m��, ✓1 Owner Owner's Name / / 1 f /� p information is '�. 0" 6q � �� �O required for every page. CitylTown State Zip Code Date of spec on 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 S( ! 3 g 3— filling out forms on the computer, use only the tab 1. Inspector: • key to move your l�/ cursor-do not (�✓�''1" Q /fe, use the return Name of Inspector key. Company Name /f Company Address City/Town'50-0-9 State ! _D Zip Code ; 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 C 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �0 l Inspector 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 . oe at Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M Cpe_Wl#11 �r Property Address Owner Owner's Name / L/ information is f /es 6� 9 /Q//g required for every w page. City/Town State Zip Code Date of In pecti(fn B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all.of Section D A) System Pa s: 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ell f, Property Address Owner Owners Name / /�! �� Ile �j� �� !6? /O information is (V_�/ J (� /•/ f� required for every page. City/Town State Zip Code Date of I pecti n B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): br okenpipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ P ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M Property Address 1 Owner Owners Name / �5� �A rf information is /w/ �/��p 10 /V required for every page. City/Town State Zip Code Date of I ectio 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 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 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 ❑ Ud' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tatic liquid level in the distribution box above outlet invert due to an overloaded ❑ R/z or clogged SAS or cesspool El than depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 00e Property Address Owner Owner's Name �Q f �� information is * 61L � 6(of required for every page. City/Town State Zip Code Date of Inspect n 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. [Phis system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence s m of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp , provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ e 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 ❑ ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 2 (;CON,41 ' �r Property Address �^ / r O r'T t Owner Owner's Name information is f4 oa 6 �j 5p Ws required for everypage. City/Town State Zip Code Date C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ 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 El thisinspection? 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? r� ❑ Was the facility owner(and occupants if different from owner) provided with L1 information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has een 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: 2 Number of bedrooms (design): --- Number of bedrooms(actual): 0 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage�Disposal System Form -Not for Voluntary Assessments Property Address Fo,,4,y7 Owner Owners Name/ /' information is / _ / g4 9wmf, A4 A 4G,1 required for every w gage. City/Town State Zip Code Date of nsp ction D. System Information Description: / eJf /_�A / " _�7/ � �-Dovie e Number of current residents: Does residence have a garbage grinder? ❑ Yes 2eeNo Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 2<No information in this report.) / Laundry system inspected? ❑ Yes No Seasonal use. ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Yes No 1A#6 Last date of occupancy: 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 the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I` Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is / _ / /L,���J `� If D�:ode /Q// required for everypage. City/Town State ZipC Date of I pect' n 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: - Ty;�Pteptic 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C;� 17 r�_t YMI y? Property Address Fa v41v7 Owner Owner's Name �f information is required for every - page. City/Town State Zip Code Date o nspe tion D. System Information (cont.) Approximate age of all com2017 , date installed (if known),and source ofinformation: /P s &" A -lu-- /64-.6 Were sewage odors detected when arriving at the site? ❑ Yes []�o Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;4/0 ❑cast iron PVC ❑ other(explain): -- - -- - - -- _ - / 1 / 0 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet/ 01— Materi f 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: "'/ /o Sludge depth: " t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SystemForm -Not for Voluntary Assessments co��ollol Property Address Owner Owner's Name information is s-�— 04 6 61 required for every page. City/Town State Zip Code Date o nsp ction D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 o k AA5 �yrc� How were dimensions determined? — — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I�0,/J1 l7^ �7�.�, 7 an 4, -god 4ees / e7 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.doc•rev.6/16 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 Property Address r o•' r7 Owner Owner's Name ��5� &rr �l 4 /��4 _ _ 'information is s �a G iv v �J � 8 required for every --- — — — -- page. City/Town State Zip Code Date of I pect on 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 n Desi Flow: -------- - ---_---- ---- ---- -- - __ --- g 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C2 e4l#11 0(:�_ Property Address Fod, ' Owner Owner's Name , ✓� �[ _ /� information is required for every — — — page. City/Town State Zip Code Date of In pectin D. System Information (cont.) 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 leakage into or out of box, etc.): 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.): ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 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 / �1MI✓7 1 Property Address F0 r4l I? Owner Owners Name /J /� 1 �f information is 04/l,G��! 6 61 �� v required for every w �y page. Cityrrown State Zip Code Date of nspe ion D. System Information (cont.) Type: & w/a 74--f S� ❑ 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, etc.): '54 044e 6ZP4j L�l 0 cle-4 61/1 C 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.doc-rev.5116 Title 5 Officiai inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts REW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M I 62e*411 "' , I� Property Address 1 Owner Owner's Name&"4s� ,p information is l �S � Ord6�required for every page. City/Town State Zip Code Date of nspe tion 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.doc-rev.6/16 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 Property Address ..//. Owner Owner's Name �� R�� LL, /O �� information is tv4?4 /`�✓�S.�6k (/ VOrequired for every page. City/Town State Zip Code Date of I spect n D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least tw "ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below E] drawing attached separately Q/9-6i✓ g . Uo0 0U�Non d -, l c✓�d�f S4,o,-e- Al If /t �- /o 7 i i 3 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rl a Property Address p�l✓1 Owner Owner's Name information is ` / pa 6 6$ /O /g required for every — page. City/Town State Zip Code Date of I spection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: Date El served site (abutting property/observation hole within 150 feet of SAS) Checked with local-Board Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You mus scribe how yPu established the high ground water elevation: 0(tadj,,jov [©C D -a-�- 1 c / uAe" � � �I ��7�eil ✓lC vte_ 6le /OW Cj-0 -7- -- _4 h., 14112o kf c�rin"#n t./ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 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/m FQormM-Not for Voluntary Assessments Property Address ' Owner Owner's Name ,(� information is ��S-� �4/! Qa(� /Insp kcto� required for every - - a e. City/Town State Zip Code Date o P9 E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Syst Information—Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L TOWN OF Sewer Permit No. Name ��� ����A) Location Installer's Name &Address / CRh�o 5'� /lei" /ltles� v,�,�r�cLt� ?? 900 'Fler' ec Date Permit Issued 71,rz x% 19 Date Compliance Issued _,T— </" ! r � � __ �� � 1' � P � 4 �. �,' �, o , •.,��` � 0� ( � ., \� r" _. .,. � .. 31 l�THE COMMONWEALTH OF MASSACHUSETTS ,8arA.)J/1961f- , MASSACHUSETTS cNyyltrativn for Pisposal Sgstem Tanstrurtion jhrmit Application is hereby made for a Permit to Construct( ) or Repair(tan On-site Sewage Disposal System at: Location Address or Lot No. 1 �" Owner's Name,Address and Tel.No. �+C , t-oiZ rrAl 36 . 9&,�'7 Installer's Name,AddreA,gleldANco .7,75 s�e00 Designer's Name,Address and Tel.No. 350 Main Street W. Yarmouth MA 02673 Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building 1 S e No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when appli able) lnstogIf f' IS-00 Xelo « `�-ArVK +p 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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 Certificate of Compliance has been issued by this$oard of Health. Signed (�° — Date 7 ;No-9 S Application Approved by �' Date �. •— Application Disapproved for the following reasons Permit No. Date Issued " No. ` 6 FEE 3 O nTHE COMMONWEALTH OF MASSACHUSETTS.. - �.. �0r6)J 119/J� MASSACHUSETTS 40ration for Visposal S C oUstrurtion jJerntit Application is hereby made for a Permit to Construct ( ) or'Repair(v)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.7 /+�� , ! Or .f o?7 Ger,1;ly ; �}�. I�al'NS4A�3�e of CT ,°'. L)iV_X AJ - (o 7 Installer's Name,Addre A 1.OkNee 'Designer's Name,Address and Telallo. 350 Main Street 7$-�1900 *` + W,Yarmouth, MA 02673 Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other' Type of Building ��5• No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow as gallons. 4 Plan Date Number of sheets Revision Date Title 1 Description of Soil ^ 11 I Natur of Rep irs or Alterations(Answer when appliFable) ln$ AEI !' /S",60 .�'eAf!G fA T5 A OX 0 Y 2.lUF;ItrA+orS W/ l�(y vader- •t- A' Afdl2»d1 A-4-�+, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed 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 Certificate of Compliance has been issued by this oard of Health. Signed O " - Date 7" a to Application Approved by Date-+ Application Disapproved for the following reasons Permit No. �-�� 1 6 Date Issued` �Z 4401—jr- �. { THE COMMONWEALTH OF MASSACHUSETTS &tAblg6/e MASSACHUSETTS �. • C�ertittrttte �# �om�li�tnre THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( )or epaire /replaced on by A t Q CAAJCo for Tyt4u✓ at Co &em 0 Saps*be4 �hhasbbee�const;;ucted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on DATE e 1� Inspect L_!:;_�"" THE COMMONWEALTH OF MASSACHUSETTS ,�� �► No " '� �c[//L�s , MASSACHUSETTS FEE ptspesal Sgstem QTknnstrnrtton f ormtt Permission is hereby granted to e*AAJ60 to construct( ) or repair(V-�an On-site Sewage System located at d7 66-nil : Dr cvI1tJS61 lc 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. All construction must be competed within three years of the date below. DATES % Approved by FORM 1255 Rev.3/95 A.M.SULKIN CO.-BOSTON,MA i". CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, JEFF eo 1M n a-,- , hereby certify that the application for disposal works ' construction permit signed by me dated `ca2�; � , concerning the G�, property located at t�fN-meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. `- r SIGNED: Vly, DATE: Cc " LICENSED SEPTIC S M STALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. O 0 03 Ll o� atoon� )L J