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Home My WebLink About1945 MAIN ST./RTE 6A(W.BARN.) - Health 1945 Main Street `West Barnstanie A=216-041 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1945 Main St (Rte 6A) i Property Address Jack Martin ' Owner Owner's Name information is / required for every W. Barnstable ✓ MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any �a way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further E aluation by the Local Approving Authority 8-27-15 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. /QYPYt5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sage 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. i Check the box for"yes", "no"or"not determined" (Y, N, ND),for the following statements. If"not determined," please explain. The septic tank is metal and over 20-years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑-Y• ❑ N E] ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) , 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ' - ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. -❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® 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 r Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than %day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e p p (s) Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage pec g Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page_ City/Town State Zip Code Date of Inspection C. Checklist ' "yes"Check if the followinghave been done. You must indicate es or"no"as to each of the following: Y 9 Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a'plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8-2015 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 8-2015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1945 Main St (Rte 6A) Property Address Jack Martin , Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No . Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: , ® cast iron ® 40 PVC, ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: .1500 gal Sludge depth: 0 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 0 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 How were dimensions determined? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was empty at inspection from a pumping earlier in the month with no occupancy. Tank was in good condition with baffles installed. 6 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '�e 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 i page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , q r a Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑T Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts t _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VA 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: 3-Maximizer infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number;dimensions: ❑ overflow cesspool number: I ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leach field in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for ever y W. Barnstable MA 02668 8-27-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately • 4 -Do v` t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - M 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments NA 1945 Main St (Rte 6A) Property Address Jack Martin Owner Owner's Name information is required for every W. Barnstable MA 02668 8-27-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist p P ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF-WNSTA.B1L>. lLC)Cp'A'ION /� �il ✓� SCW�taE VILLAGE I� ti✓ S" S1rSSdJTt'S 1V1A1'&LOT INW'TAL�Ws bImw 8c PtIoNE Nt7: SF'IC 7('ANIt�CAP f�C1TY LEACI3TNG FA'c 6 T-- OYPO . ►'" (site) .�..,. NO CIF'Br-®R�OOiv�W�.� A RTxDA"X'k? ,a�� ,,,. —�.,; ol►lQatiS+t t1A►T�' .,.._ ,_.._�. ::._.... --_..�. Seps�ataoY�1r9�nt��Brtv�eera tRae l Maxlmuml+�ju CeclQrojadwai�v Table todio'Bnuomol?UaGhtn Ricility. .. .. ; . P�dv Qe�dVat�► Supply Wool>asicR' PaciutY (UPY V e19s cx(si Fcr�B ca.edtc�ac wlthdn FOR feet of'tsachiq��frtGility) - �cius iyt '�/et�aud alit l,,eaa�ttn��ciblQy(RE a9ty;wcti�nels exist witlaici 306 fec be-flobi 18 Pucd 1 r o � 1y +jt 4 -F-35-' 5S' Jr� o O BARNSTABLE LOCATION I LE A" SEWAGE # 7 VILLAGE ' ASSESSOR'S MAP &)LOT ke . O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l U LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER C PERMTTDK!=—: `�� 'a6. _ 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private di'at,.�r Supp°-Well and Leaching Facility (If any wells exist on site or withir 2UD feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands e.<i-t within 300 feet of!--aching facility) _ Feet Furnished by_. r J'jUpO C t eP A3 G :sC 0 No. Fee 3 puter: THE COMMONWEALTH OF MASSACHUSETTS Pf�,,J,rnteredincorn yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mie;pooar *pgtem Construction Vermcit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Localiqre�s oyj.bpt No.,.,,_ m s,� Owner's Nae4ddres�d Tel.N Assessor's Map/Parcel Installer's Name,Address and Tel.No. Designer's Name,Address and Tel.No. 7P/�a -.7/•v SaP11 c s "YA-A le Type of Building: Dwelling No.of Bedrooms Z Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3,30 gallons per day. Calculated daily flow 2-10 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Natur of R airs or Alterations(Answer when applicable 00 -,,C— 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 Tt 5 of the Environmental Code and not to place the system in operation until a Cert cate of Compliance has been issued y thi B d o e It Signe `' - �` Date Application Approved by Date Application Disapproved forte following reaso s Permit No. Date Issued .:.�: ------------------------------fir::— ---- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for ]Dizpozal *pgtem Con.5truction 30ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components I Locarjg� rey9t No//9_ ,y Ow is Name, ddresrd Tel.N Assessor's Map/Parcel Installer's_vame,Address,.and Tel.No. Designer's Name,Address and Tel.No. 7F 117,/1l.v Sap7%C S Type of Building: Dwelling No.of Bedrooms 2 ` Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �� y gallons per day. Calculated daily flow --Z_2-0 gallons. Plan Date Number of sheets _Revision Date Title -Size of Septic Tank Type of S.A.S. Description of Soil NatjV of R airs or Alterations(Answer when applicable �' ucr '`. .S Jr Date last inspected: l Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o Tit of the Environmental Code and not to place the system in operation until a Certifu cate of Compliance has been issued this B and o e t Signe Date Application Approved by e Date Application Disapproved for the following reaso s Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER at_tile On-site Sewage Disposal System Constructed( )Repaired(k')Upgraded( ) Abandoned )by � _�7� at / rr 6,4 constructed in accordance with the provisi fis f Tit G�a`nd the for Disposal System Construction Permit No. ated Installer �'`"'`- Designer The issuance` f this permit shall not be construed as a guarantee that the system will function as designed. Date 7 Inspector �. ——— /— —————— No. �——————— W� �� ` Fee—1�1,LL�—��_ THE COMMONWEALTH OF ASSACHUSE S PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpogar *pztem Congtruction 3permit Permission is hereby granted to Construgt( �Repair(X)Upgrade(Abandon( ) System located at /f� /� / 6 � &,/ �ar1 and as described in the above Application for Disposal System Construction Permit. The applicant recog izes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons ction ust be completed within three years of the date of thi Date: Approved by f NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL., WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI;< I, hereby certify that the application for disposal'works construction permit signed by me dated Af. /9 41 concerning the property located at /7�5/ off G� c'��' meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: ' 2� LICENSED SFYInC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. � !;--7rz owf . e } TOWN OF BARNSTABLE Q SEWAGE # LOCATION MAP & LOTc�/ls . O yh VILLAGE ASSESSOR S PHONE INSTALLER'S NAME 8c NO 44O. �� SEPTIC'TANK CAPACITY yc ize) LEACHING FACILITY: (type) ` d � NO.OF.BEDROOMS BUILDER OR OWNER PERMIT DA �'J a6 COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Wat-r SupF:v Well and Leaching Facility (If any wells exist Feet feet of leaching facility) on site or within 2W wetlands czist Edge.of.Wetland and Leaching Facility(If any Fect Within 300 feet of leaching facility) Furnished by 4 ,L A -C s�rz fm Q � YQ-) , 1 OQC*11