HomeMy WebLinkAbout1951 MAIN ST./RTE 6A(W.BARN.) - Health �1951 Main Street/Route 6A, West Barnsta5le
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COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Address of Owner: 676 MAIN ST. HYANNIS MA.02601
Date of Inspection: 9122/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
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 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
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: �`� Date: 1013100
The System Inspector shall s mit a 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 inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,.
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE.
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revised 9/2/98 Paqe 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9/22/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X 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.
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 o
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.
n/a 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/a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
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 9/2/98 "" Paoe 2 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9122100
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 I:
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 aseptic tank.and soil absorption system and the SAS is within 50 feet of a private water supply well,
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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 n1a (approximation not valid).
3) OTHER
n/a
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revised 9/2/98 Paqe 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9122100
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
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 n1A.
- 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
compounds,ammonia nitrogen and nitrate nitrogen.
tC?i
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large sy'stems 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:
l
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.
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revised 9/2/98 Page 4 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1951 MAIN ST#tST BARNSTABLE, MA 02668 M216 PO4
Name of Owner: JANE WALSH
Date of Inspection: 9/22/00
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)J
X _ The facility owner(and occupants,if'different from owner)were provided with information on the proper maintenance of Subsurface Disposal
Systems.
N
revised 9/2/98 Paoe 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSiH
Date of Inspection: 9122/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):1
Total DESIGN flow: 330 gpd
Number of current residents:1
Garbage grinder(yes or no):NO
Laundry(separate 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 two year's usage): nla gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: n/a �J
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present: (yes or no): NO
Non-sanitary waste discharged to the Tittle 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy: n/a ,
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
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)
_ I/A Technology etc.Attach copy of up to elate operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date.installed(if known)and source of information:
1997 PERMIT 97-620
Sewage odors detected when arriving at the site: (yes or no): NO
revised 9/2/98 Pape 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9122/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction: _ cast iron X 40 Pvc other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,•evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 6"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Ce"rtificate of Compliance(Yes/No): NO
Age: nla
Dimensions: 1600G L 10'6"H 5'7"W 5'8
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
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: n/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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
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:
(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 9/2/98 Paoe 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9122100
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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: NO
Alarm level:NIA Alarm in working order: NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX:X
(locate on site plan) r
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION 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
revised 9/2198 Paoe 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH .
Date of Inspection: 9/22100
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/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (nla)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (2)33
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH TRENCHES APPEAR TO BE FUNCTIONING PROPERLY. THE SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS:
(locate on site plan) y
i
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: nla inflow(cesspool must be pumped as part of inspection)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: nla 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
revised 9/2/98 Paae 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9/22/00
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)
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revised 9/2/98 Paoe 10 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1951 MAIN ST WEST BARNSTABLE, MA 02668 M216 PO4
Name of Owner JANE WALSH
Date of Inspection: 9/22/00
NRCS Report name: nla
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow— Moderate— Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained 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
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
'd
revised 9/2/98 Paoe 11 of 11
TOWN O,K BARNSTABL
LOCATION &, �� �� SEWAGE #
VILLAGE L� (`�7 ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. _8A6;
SEPTIC TANK CAPACITY /; O.C2
LEACHING FACILrrY: (type) rt�s� (size)
NO.OF BEDROOMS J�
BUILDER OR OWNER
PERMPTDATE: /1162� COMPLIANCE DATE: &
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S 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
R f3
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y. Rio D /50"
Fee
THE COMMONWEALN OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zfppltration for Migoar *p6tem Conotru>rtion Vermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
Locat'o Ad ress o t No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ;+-/'7
Installer's Nam, �4ddre�Tel.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 70 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
Nature o Repairs or Alterations(Answer when applicable) 6-06>
�-— �. x a2
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 Titl a Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this of I ith`
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
�• dy
.n D
3�Io. Fee
THE COMMONWEAL OF MASSACHUSETTS Entered in computer:
. - Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS -
ZIppYication for &gogal bpgtem Congtruction Ve mit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Locat oq Address oy�.,pt No. q0 Owner's
Name,Address and Tel.No.
Assessor's Map/Parcel ^..o PA Y� G V 6uA D
�J6Installer's Nam*
am ddress,.and Tel.No. Designer's Name,Address and Tel.No.
Lac-
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Type of Building:
Dwelling No.of Bedrooms 3 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 •.Number of sheets Revision Date f'
Title r
,S ,e of Septic Tank Type of S.A.S.
Description of Soil
Nature o Repairs or Alterations(Answer when applicable) S0
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore de9ccribed on-site sewage disposal system
to accordance with the provisions of Title-5- he Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been.issued b this B of th
c,
Signed = Date ' D' f
Application Approved by Date
Application Disapproved for the following reasons
Permit No,. - Date Issued
------ -- ----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIF�Oat the On-site Sewage Disposal System Constructed( )Repaired(,Y)Upgraded( )
Abandoned( )b G"�--K--
at J5Y/ 6 has bean constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer Designer
The issuance of this permit s 111 not b�construed as a guarantee that th sy's•em will function-as designed�l
Date Inspectorer 4u, , � !9 �� Vvik
—— —— ———————————————————————
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS
33t5po5al *pgtem Congtruction Vermit
Permission is hereby granted to Construct Repair( Upgrade( )Abandon( )
System located at
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:Constructio st be co 1 ted ithin three years of the date of ' pe 't. °
Date: Approved by
I
10/9/97
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
ENGINEERED,PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 577 , concerning the
property located at S7-/ meets alt of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)�®
SIGNED: DATE: -/O — —�
LICENSED SEP *SYSTEM ER 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].
q:health folder:cert
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TOWN OF BARNSTABLE
LOCATION, I SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT
i INSTALLER'S NAME&PHONE NO.
SEPTIC.TANIC.CAPACTTY / 5 o 6
LEACHING FACILITY:.(type) �ga1� (siW)
No.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: (I lv COMPLIANCE DATE: O 212 d 17.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S 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
13
,0000,
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ASSESSORS MAP Np`2/f�
P dam/
..._.. ARCEL N0
o :
5
N .... .---•------- F�a 3. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Divjipwial lUladw ( utuitrurtion 11amit
Application is hereby made for a Permit to Construct ( ) or Repair (ban Individual Sewage Disposal
System at: � � ��,���iL r�
..�i -------- --•--•----- ...-----------•---••----------j-.- ............................................
—12Location-Addre or Lot No.
�` -�Q-� uz�� �..._1'"�% .,....
_..___l__..
W G Owner ,77 .. o�. g Address
Installer Address
UType of Building Size Lot............................Sq. feet
�, Dwelling—I�lo. of Bedrooms.---_----/K----------------------------Expansion Attic ( ) Garbage Grinder CM
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/7® _.gallons Length---------------- Width---------------- Diameter--------------.. Depth................
x Disposal Trench— No- -------------------- Width___----.__----...__- Total Length.................... Total leaching area...._...............sq. ft.
3 Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (v&-) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------..............................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------.__--_-_--...
f% Test Pit No. 2................minutes per inch Depth of Test Pit._.__--.--______-_-- Depth to ground water-.._-_--.---_-_---_----.
04 ---•--------------•-•--•-------------------------------------•---•-----------------------•--•-----......--------------------------•----•-------.........---_. .
0 Description of Soil........................................................................................................................................................................
W .................-..........................................----------------------------------------- -------------------------------- _
V Nature of Repairs or Alterations—Ans�v r when applicable._.�l.E�_ -________________........._ _{.T-�i .-_- ............................
....c ............................................. .4E i9./��Y s---...... . 'f� / ®7C ....... .............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued b the b and o health. /
ry�
Signed�9® - _.. - -------------- �................
Application.Approved By ------- ------ ... ...... .._................ ------- --- ---- -
—.U.......... - ---...------- -- --- Dace [ V
Application Disapproved for the following reasons- ------------------------------------------------------------------------------------- -----------------------------------------
-------------------------
.. ....._....
i
-
Permit No. Issued ---------------
Date
-----.__--_--_._______________-_,__._..--_-_.__-_.:—._-- ._._.___._.-- —.—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
xTerttftrate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
2Gj�l - �' --- ---------------------
IInstaller
at ........_�...`SsS. /- ... .� .. .. ..T_----- ---9-T.l A...----- ---LC>...i.3-y j'-'.tom-------------------- ------------------------------
has been installed in accordance with the provisions of TITLE f T e Sta n .ronmental Code as described in
the application for Disposal Works Construction Permit No. .._....,_.__�....._-......... dated ._-...._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT ONS S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... .. ................... ......._.........---........_----------------------- Inspector ----------------------------------------.._._------------------------------------
No.- ................... s. FE$..............................
THE COMMONWEALTH OF MASSACHUSETTS
I BOARD OF HEALTH
- TOWN OF BARNSTABLE
r Appliration for Diopnottl Vorko Toostrnr#inn rantit
Application is hereby made for a Permit to Construct ( ) or Repair (�,4aan Individual Sewage Disposal
System at: J
or Lot No.
Location� ... .... ^
/g�............ ..... ••.. Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms---------!"................................Expansion Attic ( ) Garbage _Grinder M
Pk
' Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------- ----------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity/Sad..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 (vl-) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. I................minutes per inch Depth of Test Pit._------ _.---.-- _ Depth to ground water....................,...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.......---.---.--_ Depth to ground water........................
R: ......----••.....................................•--•-••-•-•--•--•------•---•-•-----.....-------•----........----------•--•----.............................
0 Description of Soil........................................................................................................................................................................
x
U ••••-•-----------•-------
W ---------------' -----------------------------------------------------------.---------------------------------------- .............. ------------ 4--••----------
,/
U Nature of Repairs or Alterations—Answer when applicable---//. -. t. ...-...... L.T_� _____Y______
............................................... ..............//e. .-----•.........._SI.aN -------------------o.f.3a x-..-------------•---------•--••••......•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the oard o health.
Signed ...... r...... //S/5'1'
--------------
r
Date
Application,Approved By ----- f------ ---!'- - ----- ---<------
t3 �7
Application Disapproved for the following reasons: .... fe �"J
-
_........ .. .....,....._..._... _..__................. �.r . Date
Permit No. ----- - -- _.......... Issued ---... .- --- -------.
1
Date
,__ -- -__.r- --.sc.—®®.—a-----e.—®—...�<..�_.:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Tantlatia ice
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
2Gh(..... o.. - .5 ".-------------
by --------------------- ----_.._...-------._.------------------.-1 ..._.. - ...........................................
hsta��er
j �
at ........-�.-`� -5�. ------- r�f� _...f` -5 --------- --R T ,/ - --------------------.... -------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 f Ttie Stare �AS
ronmental Code as described in
the application for Disposal Works Construction Permit No. ..... ... _.. _... .... dated --------...._..._.................
.....
_..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTR A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------ --------------------------------------------_----------------------- Inspector -------------------- ------------------------------------...._----------------
/„"'D �"�� -----THE COMMONWEALTH OF MASSACHUSETTS ---m. ^-------- -----
I �� Q�/lll����llll
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.....r_---.......... FEE.--=-
�io nottl orko Tnnotrurtion Wrntit
/-9 dL L/ eon-,7"
Permission is hereby granted............................................................................................................ .................................
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No. f `- !h.............................. `S Gt/ -�-st w�TA. /�E'
Street
as shown on the application f.r Disposal Works Construction -•e_rmit No..�._��_. Drat d&..---V.-..---------_----. - �_..
- Board of Health
DATE------------ ! f-----------------------------------------
FORMrr �
� V
38E08 HOBBS 6 WARREN.I C..PUBLISHERS l_7