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1515 MAIN ST./RTE 6A(W.BARN.) - Health
1515 MAIN ST. RTE 6A, W. BARNSTABLE e 6 c a aF.HA y„ CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) \�+ssrtcHrs'��� Report Prepared For: Report Dated: 5/5/2016 Ann Quinlin Laer Realty Order No.: G1692725 3821 Falmouth Rd. Marstons Mills, MA 02648 Laboratory ID M. 1692725-01 Description: Water-Drinking Water Sample#: Sample Location:--�-2-11'6-Main (Rte.6A)W. Barnstable, MA Collected- 04/28/2016 Collected by: d/ p" A Received: 04/29/2016 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 2.3 mg/L 0.10 10 EPA 300.0 LAP 4/29/2016 Copper ND mg/L 0.10 1.3 SM 3111B LAP 5/3/2016 Iron ND mg/L 0.10 0.3 SM 3111E LAP 5/3/2016 pH 6.0 PH AT 25C NA 6.5-8.5 SM 4500-1-1-13 DCB 4/29/2016 Sodium 120 mg/L 2.5 20 SM 3111B LAP 5/3/2016 Total Coliform 0 /100ml 0 0 SM 9222E RG 4/29/2016 Conductance 740 umohs/cm 2.0 EPA 120.1 DCB 4/29/2016 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician. Attached please find the laboratory certified parameter list. Approved By: (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195,Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory (M-MA009) Recipient: Ann Quinlin Matrix: Water-Drinking Water. Laer Realty Sampled: 04/28/2016 17:20 3821 Falmouth Rd. Received: 04/29/2016 11:50 Marstons Mills, MA 02648 Collection Address: 2115 Main(Rte.6A)W.Barnstable,MA Order#: G1692725 Sample Location: Description: rtn Lab ID: 1692725-01 Date Analyzed: 4/29/2016 @ 15:40 Sample#: Analyst: - yn Method: EPA 524.2 Dilution Factor: 1 Comment:- Sodium level is above the maxium contaminant level.Those on a low sodium diet may wish to consult a physician. EPA 524.2 - Volatile Organics by GC/MS Result MCL MDL Result MCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform ND 80 0.50 Chloromethane ND 0.50 cis-1,2-Dichloroethene ND '70 0.50 Vinyl chloride ND 2.0 0.50 cis-1,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,1,1-Tdchloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Tdchloroethane. ND 5.0 0.50 Isopropylbenzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichloropropene ND 0.50 Naphthalene ND 0.50 1,2,3-Tdchlorobenzene ND 0.50 n-Butylbenzene ND 0.50 1.,2,3-Tdchloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Tdchlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Trimethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene_ ND 1000 0.50 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Tri methyl benzene ND 0.50 trans-1,2-Dichloroethene ND 100 0.50 1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 1,3-Dichloropropane ND 0.50 Trichloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 Trichlorofluoromethane ND 0.50 2,2-Dichloropropane ND 0.50 Surrogates %Recovered QC 2-Chlorotoluene ND 0.50 p-Bromofluorobenzene 99% 70 4-Chlorotoluene ND 0.50 1,2-Dichlorobenzene-d4 90% 704 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND 0.50 Attached please find the laboratory certified parameter list. Approved By- (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. qrr Il DATE: la 1 Fill in please: APPLICANT'S YOUR NAME/S: Nn l'-5t R e kVic ti "irvl T a x. BUSINESS YOUR HOME ADDRESS: 15 IS* Aba.;va Sk T1 tl Y.1csl dc.,rnat, 4 1 /u A oa�68 TELEPHONE # Home Telephone Number s e>k a(.a-(�q 7 ci NAME OF CORPORATION: NAME OF NEW BUSINESS M GDDWGII C TYPE OF BUSINESS e_XcwJ AJ'�0V) IS THIS A HOME OCCUPATION?�_YES NO ADDRESS OF BUSINESS 151'S M ly\ Sk UJ.t Ad n 9 k D a66 a MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner'of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: ` 2. BOARD OF HEALTH This individual has b�or d of a er it requirements that pertain to this type of business. '—K-thoazed Signature -* COMMENTS: -✓ /-r/f 1-1 0ous v/Z_ H /» L�� ii S 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: r as /�r, TOWN OF BARNSTABLE Date: /� / 1 TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: M0 6tll C11 &qr75-e0 BUSINESS LOCATION: 15-I _ .t aij Sf W-600) At 0a66f INVENTORY MAILING ADDRESS: 50-vh-k TOTAL AMOUNT: TELEPHONE NUMBER: -7?q - 9gl1 — 6(-/S- CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: C507 ) ,�6a-6t17 % MSDS ON SITE? TYPE OF BUSINESS: eX eav&h6- INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive )6 NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) �llm�-lydraulic fluid (including brake fluid) Refrigerants 3 4111-yotor Oils Pesticides ® NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) Any other products with "poison" labels ❑ NEW ❑ USED (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes h4l IV clr f,,1 "15M&Z, 6n,16141 Laundry soil &stain removers (including bleach) CL�u.(9rsG�yn z' /py f��U, .J J Spot removers &cleaning fluids (dry cleaners) sj�l�� "o aLe°�- Other cleaning solvents Bug and tar removers Windshield wash Gym_ WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION ' d 191 (SAP g PARCEL O O Si ._ L07 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION [OAP Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 PARCEI Owner's Name: PETERSTON&DOWLING Owner's Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 Date of Inspection: 3/22/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 t Y Telephone Number: 508-564-6813 FAX 508-564-7270 , CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inform n reporta elowis true,accurate and complete as of the time of the inspection.The inspection was performed based on my- ining any&,`- , experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP apl ved system A inspector pursuant to Section 15.340 of Titl (310 CMR 15.000). The system: x . w m X Passes w _ Conditionall P ses N_ _ Needs Furt er aluation by the Local Approving Authority Fails Inspector's Signature: Date: 3/22/04 The system inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sh 1 submit the report to the appropriate regional office of the DEP.The original showld be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.RECOMMEND CLEARING ZABEL FILTER NOW AND THEN EVERY YEAR. ****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. Titla.S 1ncnartinn Fnrm 6/1 5/?000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.RECOMMEND CLEARING ZABEL FILTER NOW AND THEN EVERY YEAR. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a I I Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a i r Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 r - Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1955,NEW 1997 PER OWNER Were sewage odors detected when arriving at the site(yes or no): NO I Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 BUILDING SEWER(locate on site plan) Depth below grade: 10" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): WELL WATER- 100+FT.AWAY SEPTIC TANK: X(locate on site plan) Depth below grade: 4" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a i R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a INFULTRATORS leaching chambers, number: 8 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): PROBED DRY,INFULATRATORS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a A Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. in Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1515 ROUTE 6A WEST BARNSTABLE,MA 02668 M197 P009 Owner: PETERSTON&DOWLING Date of Inspection: 3/22/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 0 feet Please indicate(check)all methods used to determine the high ground water elevation: YES Obtained from system design plans on record-If checked,date of design plan reviewed:3/25/04 NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER ELEVATION IS 95.7-BOTTOM OF INFULTRATORS IS AT ELEVATION 100-MAXIMUM ADJUSTED GROUNDWATER TABLE AND BOTTOM OF OF LEACHING FACILITY IS 4' 4" FROM ASBUILT 11 COMMONWEALTH OF MASSACHUSES TT EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION C[ DECO Property Address: 1515 MAIN ST. RT. 6A W. BARNSTABLE MAP 197 PAR. 9Name of Owner OWENS �Address of Owner: 763 SANTIUT NEWTOWN RD.FORESTDALE MA.026" DDate of Inspection: 11/24/99 - Name of Inspector:(Please Print)JOHN GRACI 6 1999 `�'am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)Company Name: n/aMailing Address: n/a Telephone Number: n/a 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: X Passes The Inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs FurtjEvluaon By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:11/27/99 The System Inspector sha copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVEY TWO YEARS.RECOMMEND CLEANING FILTER OUTLET SIDE OF SEPTIC TANK. revised 9/2/98 Page 1 of 11 f , ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1515 MAIN ST.RT.5A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n/a 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wit 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 complying septic tank as approved by the Board of Health. n& 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). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n!a 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 revised 9/2198 Page 2 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1515 MAIN ST.RT.SA W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 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 nla_(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1515 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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 X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1616 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11124/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1515 MAIN ST.RT.5A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24199 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):I Total DESIGN flow: = Number of current residents:4 Garbage grinder(yes or no):11LQ Laundry(separate system)(yes or no): NO If yes,separate Inspection required Laundry system inspected(yes or no):..NQ Seasonal use(yes or no):JM Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): NQ Last date of occupancy: Wit COM MERCIAUINDL STRIAL Type of establishment: nta Design flow: Wa gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):JIQ Industrial Waste HoldingTank resent: es or no P (Y ) NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nLa Last date of occupancy: nLa OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: nla System pumped as part of inspection:(yes or no):NQ If yes,volume pumped W& gallons Reason for pumping: n& TYPE OF SYSTEM XSeptic 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.Attach copy of up to date operation and maintenance contract Tight Tank Copy of D E P Approval Other: Wit APPROXIMATE AGE of all components,date installed(if known)and source of information: 1997 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1615 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 4" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): to Wa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: L Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:-Q Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: A How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet Invert,structural Integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: Wa Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:jVA Distance from bottom of scum to bottom of outlet tee or baffle nLfl Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nla revised 912198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1616 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Wa Dimensions: Wa Capacity: nta gallons Design flow: n& gaffons/day Alarm present: NQ Alarm level:_nta- Alarm in working order:Yes_No_ NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nta DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) I]La PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1616 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n& Type: leaching pits,number: WA leaching chambers,number: 9-INFULTRATORS WITH 2'OF STONE leaching galleries,number: j3& leaching trenches,number,length: nLa leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: j3& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE SAS IS FUNCTIONING PROPERLY- CESSPOOLS: (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n/A Depth of solids layer: n& Depth of scum layer. nLa Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& PRIVY: _ (locate on site plan) Materials of construction:nta Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa i� revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1515 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11124199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a fa �, 0 0 revised,9/2198 Page 10 of 11 d � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1516 MAIN ST.RT.6A W.BARNSTABLE MAP 197 PAR.9 Owner: OWENS Date of Inspection:11/24/99 NRCS Report name: nta Soil Type: nta Typical depth to groundwater: n& USGS Date website visited: nca Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 0 Feet Please Indicate all the methods used to determine High Groundwater Elevation: XObtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers _ Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER IS DETERMINED AT 78"FROM ENGINEERED PLANS revised 9098 Page 11 of 11 � TOWN OF BARNSTABLE LOCA'o'N -- t MQ(l1n S SEWAGE # fESESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by __ __ . _ y. �` i .� (! , �� 11 a � /�If}IN -VO' TOWN OF BARNSTABLE L .:A,TIO?1 k fly.. SEWAGE # o VILUAGES 2X3C � cam,.- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SW t I F�zn�`LC `�7 �� S "1 GI SEPTIC TANK CAPACITY l 7<X 2 QC t,G I)OWS LEACHING FACILITY: (type) $ ': c�a—rd-T NQ1 (size) L)F4 NO.OF BEDROOMS-2 BUILDER OR OWNER QpSCCr PERMTTDATE:?If f C7 COMPLIANCE DATE. Separation Distance Between the: [` Maximum Adjusted Groundwater Table and Bottom of Leaching Facility (, 7 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ©U Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Cy Feet Furnished by I e c a A 4, A-�o D 240 Si pol No. 7^' 3 0 _ 4 Fee �V� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISfON'-TOWN OF BARNSTABLE., MASSACHUSETTS Yes Zipplication for Migozar *pztem Congtruction Permit Application for a Permit to Construct( )Repair(14)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. t w t S f r 2+'LA ner's Name,Address and Tel.No. Assessor's Map/Parcel /g 7 Q J- 16 A W(_Srk G? 5 IInCns�ttalll�er's Name,AAdress,and Te,J.No. Designer's Name Address and Tel.No. �J Type of Building: Dwelling No.of Bedrooms �, Lot Size sq. ft. Garbage Grinder;44 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Scax Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board pflTatdt. Signed Date l` 7 Application Approved by Date 7-11 Application Disapproved for the following reasons Permit No. �� 6 Date Issued No. 7— 3_57 0 l Fee Sy T EtQMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes *PUBLIC HEALTH DIMON- TOWN OF BARNSTABLE., MASSACHUSETTS s ZippYication for Miopool *pgtem Con5tr ction 3permit 'L Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 15 IS' 2�" !z� ner s Name,Address and Tel.No. CS "g Assessor's Map/Parcel 19 7— R k- BOA w,eSA Installer's Name,A4lress,and Te.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms �� Lot Size sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date 1 Number of sheets Revision Date Title Size of Septic Tank Wo- e)-isk Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��df S �t��!'� 7S����� �Vt'-f 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board ea f 1 q Signed �,c� Date`�/(` 1 1 Application Approved by Date Application Disapproved for the following reasons t t Permit No. Date Issued THE COMMONWEALTH MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance / THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( )Repaired (V )Upgraded( ) Abandoned( )by `l�Z S,;� t` at �S I S" 96J V<- G� [A has been constructed in accordance with the pr Yisions of Title 5 and the for D_is,"sal System Construction Permit No. 9 7 3.�� dated 7—��J 4. Installer , Cokt n C—S-V,_ 1"tG.SS CGV_)% Designer V-2 S cc,T� C' The issuance of Irmit shall not be construed as a guarantee that the sy tam ill function as esigned Date >3 �� Inspector 1 s i No. / Fee THE �y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS L Di5poOf *pgtem Construction Vermit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) t System located at ��^(� ouV < fc A C.?F S 0_<_r n S+,6 L-e and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completedwithin three years of the date of this pe i Date: 7— �� -' / Approved by G �' TOWN OF BARNSTABLE LOCATION ���5 RLN&�tk, 6A SEWAGE # - VI LLAGE1,2-C6 �� y lR_. ASSESSOR'S MAP&LOT 00 INSTALLER'S NAME&PHONE NO. CC- LC `2 2 LI SEPTIC TANK CAPACITY Mix Cc,G 000< LEACHING FACILITY: (type) t\Q b (size) (�,�a F�.e�±fv�•.� NO.OF BEDROOMS BUILDER OR OWNER " PERMITDATE:?/( l`7 _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7' �; Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) U Feet Edge of Wetland and Leaching Facility(If any wetlands exist /' within 300 feet of leaching facility) V3. Feet Furnished byQ � I �w 6A 3 © d v .. 3� ErawL A 4v A-k 0 Qwc . a+°st /a � l m SENDER: I also wish to receive the .o ■Complete items 1 and/or 2 for additional services. ■Complete items 3,4a,and 4b. following services(for an H ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ai j ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address v d permit. . d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery r ■The Return Receipt will show to whom the article was delivered and the date .. delivered. ir. .� Consult postmaster for fee. 0 3.Article Addressed to: 4a.Article Number d 7 c E 4b.Service Type v P•a• 6 V,.� ❑ Registered fV Certified W to ❑ Express Mail ❑ Insured cR c. LU 4r . '.S�w,4/5 T/a'�S �t i1, y c ' ❑ Return Receipt for Merchandise ❑ COD M a GZ 7.Date of Deliver 0 z g 0 p5.Received By: (Print Name) 8.Addressee's A ress(Only if requested c W and fee is pai ) r g 6.Signat (Ad ressee y Domestic Return Receipt PS Form 3811, ember 1994 c.v O �41q o a- -First=Cla��il UNITED STATES POSTAL�SE V,E u N M c� -oWge&Fees Paid w l7SPS I o —'�ermli No G 1HIM • Print Xo r n''RB6,address, and-ZIP Code.-i;-this--box I � I EAGLE SURVEYING & ENGINEERING, INC. 923 Route 6A Yarmouth Port,MA 02675 I lilt:„Fl1i1il„ir Iflihill,ll SENDER: ■Complete items 1 and/or 2 for additional services. I also wish to receive the w ■Complete items 3,4a,and 4b. following services(for an H ■Print your name and address on the reverse of this form so that we can return this extra.fee): card to you. ai j ■Attach this form to the front of the mailpiece,or on the back if space does not Permit. 1. El Addressee's Address � � y ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery r ■The Return Receipt will show to whom the artice was delivered and the date .. o delivered. r y' Consult postmaster for fee. E 0 v 3.Article Addressed to: 4a.Article Number a° d. P 384 ? 73 C o - 't•T Cr �pGG ��' 4b.Service �� /� ❑ Re ' e AnN�� Certified o� v '` ❑ E p Mail /�•�'�y ❑ Insured y I GIST [` 'JS[-e :Nsl. ❑ R to Re r" le'tch se ❑ COD ) 7.Da�o ° Z GZG�B u',o ry �� 'o p 5.Received By:(Print Name) 8.Addre e's Only if requested i 4 and fee is w LI F- !I 0 6.Si (Addressee o �{K fj�Q yq,�� N PS Form 3811, December 1494 0 w Domestic Return Receipt O Tlrsll CQass-Ma f UNITED STATES POSTAL SEAV,,E� O� `Postage BrFsA-g Paid • Print you,r-nat`ni0 address, and ZIP Code in this box 4 L`� EAGLE SURVEYING & ENGINEERING, INC. 923 Route 6A Yarmouth Port,MA 02675 {H„ „ijl�II.'I'"Id'I'l1',d m SENDER: . R v !complete items 1 and/or 2 for additional services. a ■Complete items 3,4a,and 4b. or. ,�, y;Jor an 0 �' n to your hams and address on the reverse of this form:,:.`,a,'Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address ` permit. $ ■Wnte'Retum Receipt Requested'on the mailpisoe below the article number. 2. ❑ Restricted Delivery N ■The Return Receipt will show to whom the article was delivered and the date M c delivered. Consult postmaster for fee. v 3.Article Addressed to: t ) 4a.Article Number d P 3e 5 -36 c/ ?7 2- 1 /VA"'J—jf L/ ��� 4b.Service Type d 0 ❑ Registered (W Certified ¢ 8 g G ❑ Express Mail ❑ Insured e LU 0 j— L� ❑ Return Receipt for Merch dise ❑ COD o U CGS 7.Date of Deliveryi+ w 5.Received By:(Print Name) 8.Addressee's Add ss(Only if requested r and fee is paid) / t 6.S' to :(Addressee or A nt) (@ ~ Qb Q orm 3811, December 1994 Gl,�,�w 102595-97-B-0179 Domestic Return Receipt UNITED STATES POSTAL SERVICE M� Fir - ass AAaiL �O Postage•8�eas ad. USPS, .__.. t.r m ; PeJWIt-�do.G-10 (, ! y G Print your name, addressV�nd ZIP Code in this box O EAGLE SURVEYING & ENGINEERING, INC. 923 Route 6A Yarmouth Port,MA 02675 K ! ai SENDER: 'o ■Complete items 1 and/or 2 for additional services. I also wish to receive the w ■Complete items 3,4a,and 4b. following services(for an ■Print d too r"name and address on the reverse of this form so that we can return this extra fee): ■pefrrrf this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address ■Write'Retum Receipt Re uested'on the mail piece below the article number. d a, v 4 a 2. ❑ Restricted Delivery � t ■The Return Receipt will show to whom the article was delivered and the date a delivered. Consult postmaster for fee. m •a 3.Article Addressed to: 4a.Article Number m a J'v b 177-+ 38 9 36`� 7'1/ E 4b.Service Type Zs � _�' ?� ❑ Registered Nt Certified lclESi � ,t>�Tlq-►';a&C "A ❑ Express Mail ❑ Insured LU w o G Z.&610 ❑ Return Receipt for Merchan ise ❑ COD a 7.Date of Delivery �� 0 z X0, m 5.Received By: (Print Name) 8.Addressee's Addr ss(Only if requested LU and fee, g 6.Signat :(A d see A t�) f �, Xv� N � PS Form 3811, December 1994 !�w�� Domestic Return Receipt UNITED STATES POSTAL SERVICFWate ail r v0 c� Pestage- ees id I fG� ,n Permit NO...0-10� ,. • Print your ream .�idr s, and ZIP Code in this box • EAGLE SURVEYING & ENGINEERING, INC. 923 Route 6A Yarmouth Port,MA 02675 w I CA All O�PyoftMEr°�♦� The Town of Barnstable Department of Health Safety and Environmental Services Public Health Division ��O,e�i639• 367 Main Street,Hyannis,MA 02601 Office 508-790-6265 Thomas A.McKean FAX 508-77 -33 4 Director of Public Health Peter Owens 1515 Route 6A West Barnstable, MA 02668 RE: 1515 Route 6A, West Barnstable Dear Mr. Owens: You are granted multiple variances to construct a replacement onsite sewage disposal system at 1515 Main Street, West Barnstable. The variances granted are as follows: • 310 CMR 15.211, Minimum Setback Distances: To reduce the separation distances between the leaching facility and the property lines to four feet and six feet in lieu of the required ten feet separation distance. • Board of Health Private Well Protection Regulation:ation: To reduce the separation distance between the leaching facility and the onsite private well to 100 feet, in lieu of the required 150 feet separation distance. • Board of Health Private Well Protection Regulation:ation: To reduce the separation distance between the leaching facility and the neighbors well to 120 feet in lieu of the required 150 feet separation distance. • Section 1 13 of the Board of Health Onsite Sewage Disposal Construction Re lgu ation: To reduce the separation distance between the leaching facility and the water course to 63' in lieu of the required 100' separation distance. • Section 2.11 of the Board of Health Onsite Sewage Disposal Construction Regulation: To utilize two feet of sidewall area as part of the calculation of the effluent loading rate for the new soil absorption system. The variances are granted with the following conditions: (1) The designing engineer shall supervise the construction of the septic system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the submitted plans. (2) The existing leaching pit shall be removed or abandoned in compliance with the State Environmental Code, Title 5. owns f C� The variances are granted because the existing leaching pit is malfunctioning and is, in all probability, sitting n the groundwater table during high groundwater seasons. The proposed septic system will alleviate a source of pollution to the groundwater in the area. Sincerely yours, =R.S. Chairman Board of Health Town of Barnstable SGR/bcs owens N0. TOWN OF BARNSTABLE DATE tN °� OFFICE OF FEE `~ �s BOARD OF HEALTH RECEIVED BY .65 0 387 MAIN STREET ►`1� HYANNIS,MASS.02601 8 8 d vnRlAxcE Rg�6T FORK �� ��cF� o ro 41 1, F® TO UST BE SUBMITTED FIFTEEN 1 DA `enitj ALL VARIANCES M THE SCHEDULED BOARD OF HEALTH MEETING. TEL. NAME OF APPLICANT Z � ova G� w�i'��S ADDRESS OF APPLICANT /S/S G��8 NAME OF OWNER OF PROPERTY �� SUBDIVISION NAME DATE APPROVED= ASSESSORS MAP AND PARCEL NUMBER LO CATION OF REQUEST /s/5 '�'e'U 6A ' wL s7 B �9��G SIZE OF LOT �, S�8 SQ.F'T WETLANDS WITHIN 200 FT.YNo VARIANCE FROM REGULATION(List Regulation) P/Lvi� y Li..c,C /S /Z f,.c�CS7�J. �/►r�x� P v5 /S4' /LG-C,�u/dam SGT�S / cw��i G 3' do>>osc iLapu 5� REASON FOR VARIANCE(MaY attach if more space is needed)______ ' -4 L t-717::•.'/ Zv 2 el , . pL11N - FOUR COPIES OF PLAN MUST BE SUBMITTBD CLEARLY ,�� OUTLINING VARIANCE REQUEST. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL BRIAN R. GRADY# R.B. t CHAIRMAN SUSAN Q.• RA .S. JOSEPH C. SNOW, M.D. BOARD OF REALTR TO'HN OF BARNSTABLE 07/03/1997 16:28 5083628506 EAGLE SURV ENG INC PAGE 01 EAGLE SURVEYING & "" .. ENGINEERING, INC. 923 Route 6A Yarmouthport, Massachusetts 02675 Telephone (508) 362-8132/(508) 432-5333 FACSIMILE TRANSMITTAL. TO : Date Re Comments : �f� � 1) j 2� This Fax consists of page(s), including this cover sheet. If there are any problems, please call (508) 362-8132. Thank you. 01/03/1997 16:28 5083628506 EAGLE SURV ENG INC PAGE 02 BACKFILLED WITH CLEAN SAND PRIOR TO PLACEMENT OF LEACHIN9 SrftVCTURE$- 9• ALL UNSUITABLE AMTER/AL IA,& 9 HORIZONS) ENCOUNTERED BELOW THE INVERT OF THE LEACHINO FACILITY TO BE REMOVED FOR A DISTANCE OF S' AROUND AND REPLACED WITH SAND IN ACCORDANCE WITH TITLE S. 10. INVERT AT THE BUILDING TO BE RELOCATED TO HEIGHT AND LOCATION AS SHOWN. VA R l A NCES REQUIRED : MAXlMaw FEASIBLE COMPLIANCE TITLE S. SECTION 13.211, At1NIMUM SETBACK DISTANCES 10• I S REQUIRED BETIIEEN THE PROPERTY L I NE AND THE SOIL ABSORPTION SYSTEM. 4' IS PROPOSED. A 6- VARIANCE I$ REQUESTED. Tv�,•,.J oA* $14Q.AJ-V-Ai3(- oYeA c77ie 2CG tic�/�T/v.c.aS �g•E - SEC77c.%) A i 3 lao 7 E w.���C�cA.25� �-.,-)2� 77l E S4S, 4 3' 1 S 5��o° Zj P/26 Pas&a, A 37 ' v�-�. cC �s �cWu sT�l. �. S�cnau /. 141 A vir A7x 6- /Z&qu(--5M-0 rd AJA57- 03 �-s SP�c. �, c a �� �►-�s ���c now . �� SAs AtJZ 771C Wd-c.`i Idol if /4P_G oie?03C-e�. VIh/•r�1-�►��� C?iC ,% i I• 1!MlNEa 4' / / HELL IPQI Gom / Lo / / 3 � MMrnN aut a No.� Pon 1 Or'!/S MAP III ` ABUTTERS LIST 1515 Route 6A, West Barnstable 197/9 197/8 Judith A. Desrochers 1525 Route 6A ' West Barnstable, MA 02668 197/14 Natalie Lowell P.O.Box 86 West Barnstable, MA 02668 197/15 Robert L. Pogorelc P.O.Box 186 West Barnstable, MA 02668 197/40 Pasquale J. Russo P.O.Box 207 West Barnstable, MA 02668 TOWN OF BAR.NSTABLE LOCATIONIS-I •� SEWAGE #� VILLAGE W,� /��} /y�?`�i� �� ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. Az e c a 5 r SEPTIC TANK CAPACITY f U C D CA9- / i LEACHING FACILITY:(type)AZE G AS T- epl r (size) d'o06� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER G ,"Gbl/ R OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L� i .� �rE % � �,� �/ J � y ,a �'/ � J / � �l P,�� D,' �I r' 1�%�' �� . No... ......... . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................... .---------.....OF......----------------------.........------------------------------............_.....--- ApplirFation for Bi-spaa al Workii (foustrurfuaaa rmnit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .....------.J.5L 3............ ...........:�1...---••--•---- �J_-A3Ts: 1- =------------------------------- ---- ------------ r /� - cat n- dddress `, �9 or Lot No. .. ....-�'-�/ ..... .. f-----•.... 11v5............ ................................................... a � f ! Owner Address Installer Address UType of Building Size Lot.___._-.-_------------•----Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic Wo Garbage Grinder (ATE Other—T e of Building No. of persons....................... Showers — Cafeteria Otherfixtures ------------------------------------------------•----------•--•-•-•-••••--•-•••••--••-•-••--••••---••--------•----•-----......••-•--•.......--------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No...................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date....................--------•-•------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------._-___. �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •---•------•---•-•---•••-----•----•-•----••----------•••---.....•••---------•---•-------•-----------......................................................... 0 Description of Soil........................................................................................................................................................................ W x ---------------------------------•----------- ••-••-••------•••------------------•......-•--............................................... ----------- --------------------------------.------ U Nature of Repairs or Alterations—Answer when applicable.__Zf...GQ60 A_.._. �`_ ?.� ...................................... Agreement: .The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of t•1T t1a.�l: t� 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 b_oard of health - . tom. ? C_.� ------------------------------Signed- l Date Application Approved By �- ---------- --------------- Dat-='e Application Disapproved for the following reasons:.............................................------•-•-------•-------------•--•----------------•---......------ ------------------------•----•---------•----•-•.....---••-•--....-----•--•••----------.......-------••-•--•-----------------------•--•-•---••--•----•---------•-----------••••-----------•-•--•--•----•- Date PermitNo........ .' - ........................ Issued....................................................... No.... Fm&.......................... THE COMMONWEALTH OF MASSACHUSETTS ,' BOARD OF HEALTH .................... .................OF..............................................._'_...................................... Applirati6n for Ili-spaaal Workii T oustrurtion "rrmit Apphication,is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at .............. -----------**-------�'o'c'at i o*'n....A_'d'd"res_'s-----------------*----------------- -------------------------------------------or...L--o,t---No------------------------------------------- ................................................................................................ ............................................................................................... Owner Address ........... ...�j........ Ala Installer Address PQ U Size Lot------------------_--------Sq. feet Type of Building) Dwelling—No of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons....__..........._.......... Showers Cafeteria ( ) Otherfixtures ..................................................................................................................................................... Design Flow..... ... -------------------------------gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank——'squid capacity............gallons Length................ Width._.___.____._... Diameter__-_____-_______ Depth..........._.... Disposal Trenc t .................... Total leaching area....................sq. ft. No. .................... Width._._................ Total Length Seepage Pit No..................... Diameter............___..... Depth below inlet.__...._.__..._..._. Total leaching area..................sq. ft. Z Other Distributiombox Dosing tank Percolation Tes�Results Performed by.......................................................................... Date........................................ Test Pit'No. I................minutes per inch Depth of Test Pit___._..__.._..._..._ Depth to ground water.___....._.._......._-_. rTq Test Pit No. 2................minutes per inch Depth of Test Pit........_...._.__... Depth to ground water_--.._...__._._....____. ............................................................................................................................................................. k 0 Description of Soil........................................................................................................................................................................ U ............................ ..................................I......................................................................................................................................... ................................................................................................................................ ---------------�;--------�0----------------------------------------- U Nature of Repairs or Alterations—Answer when applicable__j�??__j��f!�� ....... .......................... ------ ------- .... ..... 7- '.9 ............. . .................................................................................................................................................................................... _Agreementr : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with he provisions of'T'IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in t 'L operation until a Certificate of Compliance has been issued by the and of h Signe ...... Date -/- sq, ........................................... ........... Application Approved By............ Date- .............. Application Disapproved for the following reasons:..............................................................................................................- ......................................................................................................................................................................................................... N". Permit No. ........................ Issued...........................................Date------- ......... .......... ----- D-t- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... . _OF............il.......... .......................................................... ToWrtifiratr of Tautplitturr THIS IS ��OCER�TIF th-Ind'uvidual Sewa D* al S Y�, �,�J. System constructed or Repaired by-------------------------------- ................0.............................................. ............................................................................... 12. Installer at •j ............. . . . .T....................................... .......................................................................... has been installed in accordance with the provisions of TIT of The i&A - . �ate Sanitary Code as described in the application for Disposal Works Construction Permit No---------------------------------------- dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---- -...................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL .............OF........ ...................................................................... No.... FEE........................ 'isposal AA k v Tian tudionWrufit Permissioherebgranted .. .y ... ............................................................................................. to Construct- oyRe air an Irldivoi*1 Sewage Disposal System atNo........... ------- --------------*---------------------"-----------------------------------------------------------------------------------*---------- Street 6 as shown on thelapplication for Disposal Works Construction Permit No..... .......... Dated.......................................... ... ......... ........ . DATE.._.._.... . (. Board of Health ........................................................ 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H N 9 ,,MINIMUM.MUM. 101 . 71 INVERT A7 BUILDINGDES FLOW: . • D N L S GRADE 6 OF FINISH A uM Co v R ,� MAXIMUM E CONSTRUCTION MX G AND. E DESIGN S OR THE SPAN ! F'l. THIS LV C ,. 101 . 5 3 BEDROOMS AT_LLQ_G.P.D. PER , INVERT .. IN SEPTIC . TANK ONLY.- BEDROOM' , E SEWAGE DI SPOSAL SYSTEM OF TH EQUALS . G. . D. OUT SEPTIC TANK: 101: 25 _ P MIN 2 OF PEAS TONE INVERT EP C A D 1 METHODS AND MATERIALS AN INVERT,-I N D/ST. BOX• 2. ALL'CONSTRUCTION METH `. .....Z_ PVC _ q 3/4 1 1/2 D l NO MA f NTENANCE OF THE SEPTIC 'srsrEM sHALL GARBAGE GR l NDER . I00 6 ., SCHEDULE 40 _ W S 0 INVERT OUT DIST BOX. 00 `O A SHED T NE 5 AND LOCAL �_ ;` CONFORM TO MASS. D.E.P. TITLE o � l00 58 5 0 7 O/ Gas100, 58 - ; I __._._ V I AC - a o IN ERT N LE H 0 LT REGULATIONS. .v .BOARD F HEALTH _ STANDARD !NF I L TRATORS _ e FFLF / 8 STANDA 'SEPTIC TANK REQUIRED. D.a AN E E _ • 00 0 5 CHAMBER:W STONE AROUND, -7 x 5 BOTTOM OF LEACH CHAM E ' OUTLET /2 �. 660 J. ALL`SEPTI C SYSTEM COMPONENTS LOC ATED UNDER 33O G.P. D. X 200x GAL . D B X IN 6!o M JUST GROUND WATER. 9 . ADJUSTED N 1000 - 1500 AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER GAL SEPTIC C .TANK PROVIDED: GAL • • w H- 95. 7 ; H BE CAPABLE OF !T SEPTIC TANK S 0 S V D GROUND WATER. THAN 3 -lN'DEPTH S ALL SEP / 6 CRUSHED STONE RASE 8 ER E G 0 WHEEL LOADS, (EXISTING)` STANDING H 2 ( , BOTTOM OF TEST HOLE. 94. 2 SOIL ABSORPTION SYSTEM REQUI RfO. 5 DES/G PEP RA E MI /1NC p {- INDEX :WELL SDW 252. ZONE A N T N H 4. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR I- ROr "I L E NOT TO SCALE SO TEXTURAL, ASS APPROVED EQUAL. - SOIL TEX AL. CLASS 5/97 46.2. 0. 3 ADJUSTMENT 0 EFFLUENT LOADING RATE �� GPD/SF , -SAF 5. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. GP G /SF -. _446 S.F. 330 D /.�0. 74 PD ! 800 322 4844 AND THE LOCAL WATER DEPT. UTILITIES. FOR LOCATION OF UNDERGROUND TlL! STAR D INFILTRATORS W/2 ' PROVIDED:.._$ DAR � ` 6. VERTICAL DATUM /S. ASSUMED S 0 RDU D A 447 S 7 55 x Q .. TNEA N .F. x 7 7. FOR BENCH MARKS SET. SEE' SITE PLAN. 0VED AND ' 8. _ EXISTING LEACH PIT TO 8E PUMPED DRY: REM � � SOIL TEST PIT DATA . ` RACKF I L L ED W/TH CLEAN SAND PRIOR TO PLACEMENT INDICATES I NDI CA TES OF LEACHING STRUCTURES. --�- '� `PERCOLATION = OBSERVED TEST GROUNDWATER - y - OR ONS 9. ALL UNSUITABLE MATERIAL: (A 6 ,8 H 17 ) O THE LEACHING TPt T ENCOUNTERED BELOW THE INVERT F 0 .. ! 2,2 DISTANCE OF 5 _ GRND EL. FACILITY TO'BE.REMOVED FORA AND REPLACED WITH SAND IN ACCORDANCE G.W.EL. 9-5- AROUND • WITH TITLE 5. / , ti . U COLOR HORIZON TEXTURE' OTHER ..'� 0 102.2 Y 10.- INVERT AT THE BUILDING TO BE RELOCATED To LAM IOYR HEIGHT AND LOCATION AS SHOWN. / V� a SAND 2/2 R .. 0 ' . ..... 101.9 5 "` LOAMY• IOYR P / p UP J5/703 - p SAND `: 5/6 r/ Y pR Cp / , t FINE MED -YOyR �o , S6 / VA R l A LACES REQUIRED : � ��, g C .. SAND - 6/6 MAXIMUM FEASIBLE COMPLIANCE - r o Q 36 TITLE 5. SECTION 15.2I1 MINIMUM SETBACK DISTANCES 6+�HE coR STEP 10 IS REQUIRED BETWEEN THE PROPERTY LINE AND THE I — E. 102.!7 RELOCAT •AND RAISE . , ) ,.•, � fxISTN� 1000 84L SOIL ABSORPTION SYSTEM. 4 IS PROPOSED. A 6 VARIANCE l SEPT19 TANK ! w / O IS REQUESTED. ' 1 ,r ti ., DATE. MAY 27. 1997 _.r . STEPHEN HAGS .. / I • / _\a� _ TEST BY / / / i c� � ✓ WITNESSED BY: JERRY-DUNNING ;oe /9 / / > 5 PERC RATE: 'l 4 MlN/INCH / / 5 D-eox / d STANDARD INFILTRATORS / // W/2' STONE AROUND PA R CEL ? ,0. o'00 MAP / 9 7 i o , o ..� 6 •\ w OREA7 N 5 ivaesNEs ,� WELL (PER OWNER 1/V E/V S I R/VS TA'SL E MA 02668 '/ S / S R O lJ TE 6A". WEST BA C i �( M LO r SC�i L E . ! 20 a ,� _ G S"UR I�'.E Y•I�T G 1sL :E1V'G' I NL�'.�'R h : _ 19 2 R O dS' S yr _ y�,, �� � �, .,�_. ,• . Ycz.r�to tr t h O z � M.r4 � 6 POND � F ?E4` 51 v 32 •-- .5.333 . 9 0 1 2 0 40 _ 0 , S W ,CHECK:. CF DRN A /E K CALL AH/TA HE A JOB N0. ,,97 247 . FIELD T W E LaC US M P _ t „ s rv, ,