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0020 HIGH STREET - Health
20 High Street,West Barnstable A= `-33 f 4 i n ffyy� SI V TOWN OF BARNSTABLE oa?y- 003 'LOCATION 3 SEWAGE # �D VILLAGES��"e���1��l/� ASSESSOR'S MAP & LOT f®r INSTALLER'S NAME & PHONE NO. . 94.�- �w,6 SEPTIC TANK CAPACITYAl LEACHING FACILITYAtype (s i z e= NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER I�,�P BUILDER OR OWNER DATE PERMIT ISSUED: 5 J DATE •COUPLIANCE ISSUED: f© " . VARIANCE GRANTED: Yes No I O � 6 z r wSESSORS IWAP NO: f PARCEL NO.. _ a 18 A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TQ. ` ........OF..... ................................... ApplirFation for Uhip ii al Works Cnomitrurtion Prrmit Application is hereby made for a Permit to Construct (Lj or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. a Owner Address`mod............................ D --------..................... ��7� ....................... -------------------•----.....••-•-•--•••- Installer Address �- Type of Building Size Lot- 3....Sq. feet Dwelling—No. of Bedrooms.................�--_____-_-__._---.-_Expansion Attic ( ) Garbage Grinder U ( ) '4 Other—Type of Building No. of persons............................ Showers — Cafeteria PaOther fixtures ...............................................------...--------------------------------------------------•-----------------------------•---•••------- 33 0---------------------gallons. W Design Flow...................��................gallons per person per day. Total daily flow........... gal 9 Septic Tank—Liquid'capacity_/geAgallons Length Width..I:Z//.. Diameter................ Depth_.-S $.�. Disposal Trench—No._---.-_--/-_.._-. Width......-/� ..... Total Length-_-...- ®._._.__ Total leaching area..._-�8o.....sq. ft. Seepage Pit No..................... Diameter.................... Depth p below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank,( ) `" Percolation Test Results Performed b �_ i`'R'�.............................�._ _•...... Date..� 7.... �l�'E'er Y ... •------•----. aTest Pit No. 1... .-minutes per inch Depth of Test Pit------ ��_ Depth to ground water----------------------- Test Pit No. 2....�--- .-minutes per inch Depth of Test Pit...../?�e. .... Depth to ground water........................ ..................................... ---•--•-----------....-......................................................... O Description of Soil.......d'r=-=30�� = 'Sv 3Sor C, �O-�, /a 8"----.�--"....... :............. U ! ......................................'` � �� Gr W DESIGNING ENGINEER IViUS'I SEiSc =�=I x ----------------------------- ----- INSTALLA CIO wl�Rt� (,�R i"I iivi vve�1 I� ---•------ U Nature of Repairs or Alterations—Answer when applicable----..._-..... . . THE �VSTEIiIi�tVHS iiv �T-it:LE -Ili--VFRi10T--•------- pC.C.DFil7HIV(:t"i r�"ri +i Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of iiT E p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healt . Signed------ ---• .................... . . ..�!j�... t� Application Approved By..... QXVv- , 1 Date _ Application Disapproved for the f ollowi reasons______________________________________ ................•-............ ---------••_ -------•-•----------------------•------------......-----.......----------•------•--..._..-•-----------..._....------------------------------------•------------•---------------------------------_••-•- Date Permit No..... �.-•----------• Issued.............. �.• ------ ........•---...._..----------•----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF........ S G ......................... C�rr�ifirtt#r laf f�um�li�aatrr THis is TO CFRTIFY, t e :vidual Sewage Disposal System constructed or Repaired T� � g P �' lt�� P ( ) Installer has been installed in accordance with the provisions of iT"'% ; 5 of The State Sanitary Code as describ n the application for Disposal Works Construction Permit ............. dated------- ......�.._. ---------------- .THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... •--•- ........................................ Inspector--•-- - eC' u, ----------------------------- CUMMAQUID SURVEY, INC. Box 51 Cummaquid, MA. 02637 Edward E. Kelley, President October 19, 1989 Town of Barnstable Board of Health Hyannis, Massa Ref: (86--"10�1 Lot # 3 High Street West Barnstable The sewage system was installed in the approximate area and elevation of the approved plans and the system meets all the requirements of Title V and the Town of Barnstable health regulations . p` `atiti OF s ` E AL6 1111 RU °! KELLEY o. ;. R Sa�`�`tari�. Re�g;.,�Pr�of�es�sio�nal 9F c . Q sye y Zari�d o;r; `POITAMO i e 03 Fizz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........7ou✓^....----....OF....f� e6 Appliration for Bispoii al Works TomAr ion "truth Application is hereby made for a Permit to Construct Jo) or Repair ( ) an Individual Sewage Disposal 'System at.: T. �Zp c'72-r : /A t�YEST �v b .3 Location-Address or Lot No. f7Z G .,/Es -`�vc.��'J'/ -9osTa n./ 11A S S- ......................-........................... .....'------.............----•'......------ ... -•••--••-- -----------...---.---- Owner Address ........................................ lnstalier Address Type of Building Size Lot : �_ --.--Sq. feet Dwelling—' No. of Bedrooms....•._.___...__�........._.•....___....Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures ........................................................ W Design Flow.................4 ................gallons per person per day. Total daily flow........... .....................gallons. G4 Septic Tank—Liquid capacity./�qe gallons Length_!OX Width.:I �G_'_. Diameter................ Depth_.5...8 . Disposal Trench—'To. ......../........ Width_..__��.�._._. Total Length-----:F�....... Total leaching area-___-38j.....sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. it. z Other Distribution box ( ) Dosing tank ) Percolation Test Results Performed by '' � •..._.... Date_.5�2`4 _2! ^ 14 Test Pit No. 1--- :.. -__-minutes per inch Depth of Test Pit..... ` ". Depth to ground water........................ ti. Test Pit No. 2... ...Z'_._minutes per inch Depth of Test Pit.....d 7�_��___. Depth to ground water------ "........_ W O O "-30" !dam - '�,.Soi C. . . a ' /Q '� CZ,->1'`i e Descri tion of Soil------'-- . ---------------•------• ...-- ... '------ -- -- ................................................. W ------------------------------------------................................................................--------------'-------................-------'-----------------'-------'--------------•------- VNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T: LEt of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healtA. - / Signed... . ... ......... ... ------ .......---------•- 1 u b- D • -- � � - Application Approved By.._.. .(�.!!' �1✓1----------- ------ --------•-... -----......... -- ----'--- Applieation Disapproved for the f ollown reasons______________________________________ ..........................................•--------•--.Date............_ .---'--•--•---------------------------------------•-----------'•----•---•--.................------------•._........------------------------------•--------------------------------------------------'---- i Date Permit No.--- .......................................... .---- - Issued............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH VIA...oF..........�°�'.*'�'?' � �. ,�',(..�'�.......................... Tatifirate of loutpliatta THIS IS 0CERTI Y That t e- aividual Sewage Disposal System constructed ((/)"-or Repaired ( } b ► v —Lot 'i, x Installer 3t -•'. .......... , ,_,r _j. .V- ........dL'a�' .._.. - --------------------- .... has been installed in accordance with the provisions.of T I;TI a: j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. =O....._�.. ... .............. dated-_-._-_�_��.� .s 'f................ THE THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT mE. SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector....................................................... j r _ C) THE COMMONWEALTH OF MASSACHUSETTS YE S t ff BOAR.D OF HEALTH U vw'.'.�/........OF............................................................. � ........................ _V 0............. FEE.t.:::...!............ Disposal orkii CDonotr ion r amit Permission is hereby grante - ---------------- ==---•--..�_1: 1'I � - '" .......-•--•-------•--•----...............--------.....---....-----•--- to Construct (6.-Ifor Repair ( ) an Individual Sewage Disposal Sy tem Street ' .. �'. %' I as shown on the application for Disposal Works Construction Permit,No..................... Dated.__.�__�............................. { ..........-•---_.._.rell �.:_ " ? <.. r .l (=-'---------------------------- t Board ofT FIealth ~ DATE_ �` r ......................... 1 .............. . .. ; FARM 1255 HOBBS & WARREN, INC.. PUBLISHERS I j M4 L l t_ rl Department of;fnvirorimentdf,,Management/Dwision of Water 113psources.. r. —WATER 'WE'LL:COMPLETION AEPOART I WELL LOCATION Address City/Town. G.S.Quadrangle Mapes --� -- •- i'h'�' Grid Location ' . � L?, Owner fiY7L.IM.a WELvL USE CONSOLIDATED WELL Domesticf0� Public ❑ Fndustral❑ Type of Water-bearing Rock Other Water-bearing Zones j Method Drilfed Az t I From To + y� 2) From To j DateDiilled e1j 3)'From To 4) From To 1,CASING r, , Depth to Bedrock Length 14-1 Diameter °`Type.' UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface .6 ' Sand'. fine❑ medium❑ coarse❑" Date measured iZ ems-YipTA Gravel: fine❑ medium❑ coarse❑, Screen: GRAVEL_ PACK WELL t P� Slot#lcr- length from .i toy 1 Yes ❑ No 0� -- Split Screen(or.2nd screen) WATER QUALITY TESTS MADE Slot# length from to_ ' Chemical. ❑ Biological ❑ Depth.To Bedrock PUMP TEST ` Drawdown. feet after pumping days I i hours at f GPM. How,measured Recovery feet after hours. _ LOG of-FORMATIONS COMMENTS: (On well or water_) Materials From To 4'IZ Lily. _ Zt/ DRILL--ER•, - Firm&6 4�-Iyl 41-_. ' T- ':_. Address— City.tii�ararci�l 1�-�r�►-� 0 y a Registration No. f � -- - Operator's'Signature ease pmot firmly s MAW,OF THE 'TH COPY zeM ea izsa , s� 7Z-7 PG/- -^j L -sArcars LOCATION .WL�j,.J-S !STHf3« hl SCALE . �� � . . . DATE .!`.A, . .. PLAN REFERENCE 406 0 e oy"Y . •ji \ ll.' � P/Zo�o SE�b WGsZt O 2V�N N ' ao• Lo T- '�3 Rio s -,ap w 7g ' b" / S e, \ D�FFvso2s : #�• "� I I ! IDESIGNIV,G ENGINEER M S.P SUPERVISE IINSTALL.�.TIO N AND CERT = IN WRITIN ITHE SY:.,TEM 'W?,a NSTAL W IN STRIC ACCORDANCE TO PLAN. P ( t � .S/!e&?" .Z 0/c Z- So4l&Z I L. TOP OF FOUNDATION T CONCRETE COVER T CONCRETE COVERS 4.i3' "e 4"CAST IRON . 2"MAX. r OR SCHEDULE 4d 12"MAX. �* P.V.C. PIPE 4"SCHEDULE 40 PV.C.(ONLY) PITCH 1/4"PER.FT PIPE- MIN. PITCH 1/4 PER.FTa'✓ct/ PRECAST o' �INVE�tT e /oKgp ;•.. FLoW- EL INVE T INVERT e . 77had� e SEPTIC TAN K ��,q bl ST. /B �3 ;� ,� EL..... ..`1. . EL... .... ,�e INVERT BOX E.L. �.' �oai�so,es ��` /OOD GAL. INVERT INVERT 3/4"TO IIli' d; ..`I....... - EL./8.I0 •..' WASHED , jet. STONE — 1 PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM N°'g" "u NO SCALE .WZ-4 D W,r,V CZ&A" SALAD. S01 L LOG WITNESSED -BY . DATE .,?Cr/��985 TIME. BOARD OF HEALTH TEST HOLE I TEST HOLE 2 .�: �•�j2G�,ra,✓6c�s /°C. ENGINEER ELEV. .?9:79. . . . ELEV. . DESIGN DATA : NUMBER OF BEDROOMS �►b�, Sao TOTAL ESTIMATED FLOW . . 3 j0, , GALLONS/DAY BOTTOM LEACHING AREA 3c7O . SQ.FT. /PIT/G.P.D_ (0S rT-&t LrZ, /,Sp SIDE LEACHING AREA . . . .BQ. . . . . SO.FT./ PIT/ZooC,PD, CLE�aw CZ6=A GARBAGE DISPOSAL: . NgNC1 .(50% AREA INCREASE) Mr"D til�"D. SsruD SiriiD TOTAL LEACHING AREA . 380 Sq FT PERCOLATION RATE 044'-S . � � 77N0 MIN/INCH Y.�..WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .-50P.. SQ.FT�C,P.D . NUMBER OF LEACHING PITS �7� - APPROVED . . . . . . . . . . . BOARD OF HEALTH DATE . . .. . . . . . . AGENT OR INSPECTOR nl' r Qr �P�gH Of Ass No. h 77 PETITIONER Coi d .by HIGH GROUND-WATER LEVEL COMPUTATION Site location: Lot No. 3 Owner: Address: Contractor: Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. in/ ii/8S 9 a date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: - A Appropriate ro riate index well . . .�. .. S) Water-level range zone STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to ¢7 water level for index well . . . . . . i0/9S" mo yr STEP' Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level zone (STEP 26) determine �, G water-level adjustment . . . . .. . . ... . . . . . . . . . . . . . . . . . . . . . . . . . STEP S Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 7 � � level at site (STEP 1) . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . ... . . . . . . . Figure 3 -7- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL�A�F DEPARTMENT OF ENVIRONMENTAL ION .� ONE WINTER STREET, BOSTON, MA 02108 617- -:�0 e� 2 w1LL1AM F.WELD 4 19 � � TRUDY CORE Governor Hof PjrAeff 9 ,4/ Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.. Commissioner PART A 4 CERTIFICATION Property Address: 20 High St, W Barnstable Address of Owner: Mark & Linda Begley Date of Inspection: (If different) Name of Inspector: Wm E Robinson Sr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1089 Cent-Prvi 1 1 P , MA 02632 Telephone Numbers 5 0 8 j 7 7 S-8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _✓ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails p Inspector's Signature: ev, t 1 Date: 7 d7_-11-j -7 The System Inspector.shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: Bj STEM 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. lndi to yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:llwww.magnet.state.ma.ustdep `J Printed on Recycled Paper r v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: 9 B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FU THEIR 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: cj_;L I/-q 17 D SYSTEM FAILS: You ust indicate ei;!-,er "Yes" or "No" as to each of the following: 07 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LA GE SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The own r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirem nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. !:revised 04/25/97) Page 3 of 10 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. yr� _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. y! _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] V (revised 04/25/97) Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 High st, W Barnstable Owner: Begley Date of Inspection: -7 FLOW CONDITIONS RESIDENTIAL: Design flow:i-/1/6 ¢.p.d./bedroom for S.A.S. Number of bedrooms: `) Number of current residents: Garbage grinder (yes or no): ti a Laundry connected to system (yes or no):_Ec�3 Seasonal use (yes or no): n-d Water meter readings, if available (last two (2) year usage (gpd): n/a well water Sump Pump (yes or no): t/o Last date of occupancy:ff-72-A-1�7 CB MERCIAUINDUSTRIAL: Type f establishment: De sig f1, :_gallons/day se Grea trap present: (yes or no)_ Industr al Waste Holding Tank present: (yes or no)_ Non-sa iitary waste discharged to the Title 5 system: (yes or no)_ Water neter readings, if available: Last d to of occupancy: OTHE : (Describe) Last to of occupancy: GENERAL INFORMATION PUMPING RECORDS an source of information: System purKped as part of inspection: (yes or no) >L O If yes, volume pumped: eallons Reason for pumping: TYPE OYSTEM �/ 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) I/A Technology etc. Copy of up to date contract? Other � APPROXIMATE AGE of all components, date installed (if known) and source of information: , 3 /61 yes Sewage odors detected when arriving at the site: (yes or no)/� (revimad 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: 9-J.4-!-^4 B LDING SEWER: (Loc a on site plan) Depth below grade: Materi I of construction: _cast iron _40 PVC other (explain) Dista a from private water supply well or suction line Diam er Com nts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_v (locate on site plan) i Depth below grader Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:_-� G `'ti O �•i Sludge depth: -5 Distance from top of sludge to bottom of outlet tee or baffle:3 2, Scum thickness: /- "S dti Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: 9 How dimensions were determined: 4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level J' relation to outlet invert, structural integrity, evidence of leakage, etc.) 13 e r1<� /%r..- 2/64. � G d ® ¢•� e G,• GREA E TRAP: (locate n site plan) Depth low grade: Material f construction: _concrete - metal _Fiberglass _Polyethylene —other(explain) Dimension Scum thick ess: Distance fir m top of scum to top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee or baffle: Date of las pumping: Comme s: (recom dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a idence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: TId T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (local on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime Is ons: Capaci gallons Design f ow: gallons/day Alarm le el: Alarm in working order _Yes-, _ No Date of revious pumping: Comme ts: (condit' n of inlet tee, condition of alarm and float switches, etc.) t DISTRIBUTION BOX:_v Jocate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUM CHAMBER:_ (locat on site plan) Pum in working order: (Yes or No) A.lar s in working order (Yes or No) Co ents: (note ondition of pump chamber, condition of pumps and appurtenances, etc.) 4x' (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: 3 leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: �4note condition.�of soil, ns of hydjWulic failure, level of ponding, ccndiuon of vegeta on, et .) ° 3— sig -/d -A s S c' �� U„4116Z v 36 o KJ. CESSP OLS: _ (locate site plan) Number a d configuration: Depth-top f liquid to inlet invert: Depth of s lids layer: Depth of s um layer: Dimensio s of cesspool: Materials f construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Comme ts: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI (loca on site plan) Mat ials of construction: Dimensions: Dept of solids: Com nts: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) f G� b �)I C i 0 �0z 57-0 Ir—�Ah � 1 �. C I ) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 High St, W Barnstable Owner: Begley Date of Inspection: 9^;?-c/-.9y7 Depth to Groundwater $ Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions I/Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in y'o�uj own words how you established the High Groundwater Elevation. (Must be completed) I (revised 04/25/97) Page 10 of 10 No..�... .......... Firm... J THE COMMONWEALTH OF MASSACHUSETTS 0,3 BOARD HEALTH I �J �" 1 ✓ 1-------....OF.....:. .. . ,� lint ila `fir Disposal 19orho Tonst.rnrtinn Prrntit Application is hereby made for Permit to Construct (�or Re air ( ) an Individual Sewage Disposal System at 1'JV . . ..... ................................................... oca ddres or Lot No. - .................•-----•---- ---------------••---•-•--•----•-..._...------ - ------•-•-----•................................ wn_er ........ ----.............. -.................. Address a nstaller Address Type of Bui dinV Size Lot............................Sq. feet Dwelling No. of Bedrooms.______.__ ______________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type e� yp of Building _______________________ _____ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .. w Design Flow_. ______________ _ __ _ allons per pers d on per ay. T otal daily flow---------------- =f�_._.<!_._.___gallons. W Septic "Tank Liquid capacityallons Length................ Width---------------- Diameter---------------- Depth---------------- x Disposal Trench—N _____________________ Width.............. �+Tgpl Length_________________-.- Total leaching area---- ___ -Sq. ft. Seepage Pit No_______ ____________ Diameter/�l�_ 9 Dept below inlet...______________._ Total leaching area__ ______sq. ft. Other Distribution box D idg Z ( ) os g tank ( ) aPercolation Test Results Performed by........................................................................:. Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..--_-_-___-__-____.-_-. t14 Test Pit No. 2................minutes per inch epth of Test Pit.................... Depth to ground water______---___-_______-- Ix --------------------------------- -••----•-- ODescription of Soil ---------- ------- - ---- -------------------------------------------------------------- x w VNature of Repairs or Alterations—Answer when applicable---------______________________________________________________________________________________. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. eed-- - --- -•----f.•-•••••---•••••----•-•••---•----•-•-••---------•-•••••- ---------------- _ ,+ ate Application.Approved By••••---- •• • --------• •••• � � --------- { z 7 Date Application Disapproved for the following reasons--------------------------------•----•••••-•-••••---•--•---- ................................................. ............................................................................--....................-.............................-....................................................................... Date PermitNo....... .............-•--.......................... Issued..................................... ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Qf. HEALTH , Appliratilan for Uiiipuuttl Works Tomi#rurfin t rum it Application is hereby made fora Permit to Construct (�or'R�pair .( ) an Individual Sewage 'Disposal System of `r J. - ` . � ------ ---� � - -•..---------------------------- ---- oca on-Addres✓d- or Lot No. ...J/ ---- ----- - -------- = -------------------------------- --............................ [( -- in - Address a ,J,.. Installer Address UType of Buik it g' Size Lot............................Sq.-feet Dwelling—No. of Bedrooms_______:__ _______________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons......................_----- Showers ( ) — Cafeteria ( ) dOther fixtfu ----- W Design Flow________________= _._: _IY gallons per person per day. Total daily flow.......___.__." _ _--___gallons. WSeptic 'Tank—Liquid capacityf27...._..gallons Length................ Width______-___.-____ Diameter----------------- Depth_______-____---- Disposal Trench—No. .........::......... Width............. r:T`al Length.._.__._:._.._.____. Total leachin are t..__. sq. ft. Seepage Pit No____________________ Diameter/2' q <V Depth below inlet................. Total leaching area__`-':______ sq. fi. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date-----------------.:-----............... ,� Test Pit.No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-____________________--- t=� Test Pit No. 2................minutes per inch `Depth o 'Test Pit---- ____.__.__ Depth to ground water___________________-__- - Aw---------- ODescription of Soil--------------------- -- '` ` ` ------------ '--- --------------- -------- ---- ------------------------ x W UNature of Repairs or Alterations—Answer when applicable.__-- ____ _________________________________________________________. --------------------------------------------------------------------------------------------------•-=-------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board.of health. Application Approved B ' moo to PP PP By--------- - - --••=----. _C -- Date Application Disapproved for the following reasons:--•------•••-•--•----------------•- --------------•-•---•--•---------------------••-••---------•---••- --- Date PermitNo............................... ...••---•-•• Issued.---••-•-- ............................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA ffiratr of fluutpliatta ,- T,-IS AZ TO 1 Individual Sewage Disposal System constructed ( or epair ( ) by== = - ----- -- f� _ d=p --------••--- .Installer /"°' � --�-- A-• - ��a�,�7�,w•. Ilas h installed in accordance with the rovisions of°Article of;The State Sanitary Code as escr' ed in the P �� � Y .� application for Disposal Works Construction Permit No....... '�"f-_-. -----------•---- dated_. __ -- - the THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UE® G RANTEE THAT THE SYSTEM WI •L . FU... T ATISFACTORY: .................................... �! � DATE � - THE COMMONWEALTH OF MASSACHUSETTS BOARDF HEALTH, o._ I-..... ..O F.. -- N •-•- ..... -- FEE ----•---•---•-•--- Permissio `ereby' granted= `f f" t._�r _....:. '' to' Cots uct ) oiry'Re `r ( Indi_ a1,S wage Isposal Syste _,.----- _ -- ----- "...z f Street ' as shown on the application for Disposal Works Construction P No __ ' __ . Dated_ "`""�,, -- t -.. -e-------........... ---------- -- - ........ Board of Health 110 DATE......- , FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '` -.