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HomeMy WebLinkAbout2040 MAIN ST./RTE 6A(W.BARN.) - Health 2040 A 4 A I N ST./RTE 6A 'NEST BiARNSTABLE A = 2.17 019 , I � 5 r; AA aIh Lot f TOWN OF BARNSTABLE L OCATION' 20(/Q I Iy(p t h S1 SEWAGE 4'ILLAGE UJ, 4, _ASSESSOR'S MAP&PARCEL✓ (2j-qSo INSTALLERS NAME&PHONE NO. V SEPTIC TANK CAPACITY CE©Q LEACHING FACILITY:(type) � � (size):3 7,)OS x f,0 NO.OF BEDROOMS 3 OWNER e2A,.e" PERMIT DATE: 6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching7Facility 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 e ching fac' ' Feet FURNISHED BY s r r� Au 3 h A� A t."Ire _ arm' TOWN OF BARNSTABLE f c p LOCATION SEWAGE # ,p_ ` VILLAGE � l'05 -Ale ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE'NO. �01 3gD(.� ��a1'v��i 771-0'101� SEPTIC TANK CAPACITY 000 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWNE PERMITDATE: !r&,31490 COMPLIANCE DATE: o Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 ' a 3 -3 0P-3 -Y 3% (. -� a�6 . r 30 - 3 33 r TOWN OF BARNSTABLE LOCATION cu_ Y /��. J �w[�o� '///C .4Z9 EWAGE # VILLAGE ��,� � ASSESSO MAP & LOT— NAME&PHONE NO. SEPTIC TANK CAPACITY ��,,,, � LEACHING FACILITY: (type) / (size) /00& NO.OF BEDROOMS 4 BUILDER OR R PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 it ' '' � � `� �� �,@ ^l✓I LOCATION SE GE PERMIT NO. L Y•tLLARE js 7- /fti,7"/)6) cE I N S T A LLER'S NAME i ADDRESS BUILDER OR OWNER F_�` 04 oN DATE PERMIT ISSUED ,_ �r_ DATE COOPLIA-LACE IS-SUED Sir i4 e 1� t� ►/�s Lp OF J L)OCATION ,.,---"SEWA PER IT NO. 57 , VILLAGE FSr JAeI-sr,01-9 i INSTALLER'S NAME i ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � � �/ r Pe P li \G 5 r� t'IG TANK LVCAT10 SE NO. VILLAGE C) I NSTA LER'S NAME i ADDRESS a . .., //?1 R UILDER ;Olt OWNER I DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��� , �� ;,/ . -. I 4 � f ® ��, No. Fee G / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applitation for ]Disposal 6pstPm ConstrULtion j3Prmit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ;to qo 14.41AJ 5• W/8a Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ;a f 1019 b® As ® &AW _5_r kv,- sfi f6 Installer's Name,Address,and Tel.No. 21811 Designer's Name,Address,and Tel.No. d0VC-W11)6; eV760421ses Y/ �u e� .37- HAS�� 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) u—rC&T Te-g-s- .5.0 G oTi4 1#S7X,,(_L_ R L<E P 01Q &] ct. - `MIJ'lam, 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 Certificate of Compliance has been issued by this Board f He Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued `..1.., - � ,i�zya'*�,r:'r„._.`'.... �'�.., 4'.r, i�ft.4.l�'"& C".tiT. 4...rr.--....rr'�`^r .r.+�`'.....,,,..•�. .. ,r.•..o.t-. ,,,`..,., vvee ''Loa �jLt, No. n r- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ' 2pphtation for Vognal 6p$trm Construction i9Prmit Application for a Permit to Construct( ) Repair;* Upgrade( ) Abandon( ) ❑Complete System AV Individual Components 4 Location Address or Lot No. 204 0 Mkt'J -vr w/st Owner's Name,Address,and Tel.No. ' Assessor's Map/Parcel ,2 L7 Q L A0 0 f f*+1A,J'_VV W4FS p- Installer's Name Address,and Tel.No. $'OQ-477-$811 Designer's Name,Address,and Tel.No..�• t�� 04&CGIAC S'7 HAS606:;- 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Q u-rt e -r,5z_ ohJ IScxr -E 5 ? 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 Certificate of i Compliance has been issued by this Board of He Ith, ` Signed ' Date I — ;L Application Approved by r !A..&t C(t ,r�...,,f_,t_ Date + -('R -- a V - 7 Application Disapproved by /) Date - for the following reasons i Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned t(V)by'`CAIPe?c b E EA-)�IJS� o0-at jKA1,\) ST WE=S"r RAA)U. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Q4EW 1 D 6 G(J-ZE 2PPAIS6S Designer N A #bedrooms Approved design flo~w�-� gpd The issuance of this permit shall/not be construed as a guarantee that the system will fimction�asdesigned. Date �(� �I 6 (J� Inspector _ No. _o` ! '' 7S Fee --7 -.,.,..-. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( )) System located at ;j T Q &A!10 .S 7" t,Ce�S" 8AP.IJSTj�6� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction /truction'must be completed within three years of the date of this permit. Date In n� ,J 4_ r� f j�_ Approved by P(�1� BORTOLOTTI CONSTRUCTION, INC. �� 7 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 1 508-771-9399 508-428-8926 FAX: 508-428-9399 ti�if`. <000 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. 'i� PARTA � CERTIFICATION Property Address: Date Of Inspection r7,0 L?f Ins eetor's Name: 3 O� rer's Name and Address: t- ��, CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.Th system: Passes Conditionallyyas s Needs Further alua on the Local Approving Authority . Failure f 1 Inspector's Signature Date: a The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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. INSPECTIONSUMMARY: A) SYSTE ASSES: PI have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or•Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes, nor,or not determined (Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or extil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) - Broken pipe(s) replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year clue to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): Broken pipe(s) are replaced Obstruction is removed. C)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' lire System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy is within 50 Feet of a Surface Water Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a Septic Tank and Soil Absorption System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption Systei.n and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 106 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: 1 have determined that the System violates one or more of the following Failure Criteria as defined in 3:10 CMR i5.303. 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. Backup of sewage into facility or system component due to an overload 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwaler elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. 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. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone.II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of.315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been clone: "Pumping information was requested of the owner,occupant,and Board of Health. _jZNone of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during period.that eriod Large volumes of water have not been g introduced into the system recently or as part of this inspection. --L/—,As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. rThe system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected 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 existing information or approximated by non-intrusive methods. _ 3 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design Flow:330, gallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: '-- Laundry Connected To System: Seasonal Used Water Meter Readings,if available: Last Date of Occupancy: 64?J,4 �iLPL f/IiL COMMERCIAL/INDUSTRIAL: ""' Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present:— Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: System Pumped as part of inspection: ,; ff yes,volume pum ed: gallons Reason for Pumping: TYPE�F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): AP ROXIMATE AGE of all components,date installed (if known) and source of information: 13 Sew.ge odors detected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: 7 �r � '" ���Depth below grad Material of Construction: k-/concrete metal FRP Other (explain) Dimensions: �',Y S` Sludge Depth: /}tom' Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of liquid level in relation to o et invert,structural integrity,evidence of Vk 1eakag etc.) %QpU j'm, ` ��✓ �Pify) `I GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR.HOLDING TANK: Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.). DISTRIBUTION BOX:�� 2 � Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: /a/ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - � j SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site play,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type:. r Leaching pits,number: / . Leaching chambers,number: Leaching galleries,number Leacahing trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool,number: Com cents: (note conidtion of soil,signs of hydraulic failure level of ponding,condition of vegetation,etc:)_ v .o CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY:- . Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.). - 6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. 9 i O DEPTH TO GROUNDWATER: Depth to groundwater: l- 7 Feet `J Method of Determination or Mpxirnation: Ulv� Lt -ss ✓C- - 7 - f � OCl -��l �- ����. zl? - d19 f✓®� No. woo - Fee j THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZppYication for 0igoal bpetem Construction permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System e1ndividual Components Location Address or Lot No. />� �� Owner's Name,Address and Tel. o. Z4147 /i CT JO)af G .Oe-419113 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. go rt""101-, Co&sue 77/ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( Xyle Other Type of Building�_/ ,e Puree No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�3lJ gallons per day. Calculated daily flow J� � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank lai9O /rP Type of S.A.S. Description of Soil l�iC �OXZ 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 y this ard of Health. Signe Date Application Approved by ® Date Application Disapproved or the following reasons Permit No. Date Issued No. ._. vvd� ;�, Fee THE COMMONWEALTH OF MASSACHUSETTS V Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYtcatton for �Dtopogar *pgtem Construction 3permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System E<Individual Components Location Address or Lot No. Owner's Name,Address 4no Tel. o. Assessor's Map/Parcel 1 ,) ✓1,��� D��Lc, Installer's Name,Address,and Tel.Now. !�(6 Designer's Name,Address and Tel.No. CDlIS�- 7 7'/ Type of Building: f Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( �0 Other Type of Building /?!°S// ��Ce No.of Persons Showers( ) Cafeteria( ) Other Fixtures ., Design Flow 7je gallons per day. Calculated daily flow ✓a.3D gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /ODta /0 Ae�r/.9)`/rJ9 Type of S.A.S. " /,/)9�1 �4i��C�/Y Description of Soil ��X 3�'Y7 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 beEgg ' of Health. Signe Date Application Approved by Date 0 Application Disapprovedns Permit No. 00 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed( )Repaired (✓)Upgraded( ) Abandoned( )by r at Z� 7ti /9w, Q!h j`O has constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. daJted Installer I Designer /1 IX A—I The issuance of this t al. be construed as a guarantee that the s slte �il n t' s de�sYgned / n Date � � Inspector �� f V v V 1 —— No. 1/ �( — - ------------------------Fee 1� C 0 no THE COMMONWEALTH OF MASSACHUSETTS - . PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �Dtgooai *paten Conttructian-i3errntt Permission is hereby granted to Construct( )Repair Upgrade( )Abandon System located at ?i�p Ila 1`- �'/GI/rJ J�` 4t-­, ' ���✓����Z" - 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 followinglocal provisions or special conditions. Provided:Constru 'on must a com leted within three years of the date of t Date: D Approved by ! 1 r NOTICE: This Form Is.To:Be Used For the Repair Of Failed Se tic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, 1okRT " hereby certify that the application for disposal works construction permit signed by me dated lzzl D concerning the property located at 7a fj� W, f3�1'j'�ty�a°�� meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business /uses associated with the dwelling. Y The soil is c' f assuZed as CLASS I and she pe:coianon:ate is Less than or equal to 3 minutes per:nch- r The:e are no wetlands within 100 feet of the proposed septic system There are no private wells within 1f0 feet of the proposed septic -,,,stem +� There is no incase in flow and/or change in use proposed Y There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the ma�dmum adjusted groundwater table elevation. (Adjust the groundwater table using the rrimptor method when applicable] tar If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation 1dL+the MAX&gh G.W.Adjustment. DU ERRENCE BETWEEN A and B 7 SIGNED : DATE: (Sketch Proposed plan of system on bade]. q:hum Ma-am d � i �a� No..... �� '.�1.3� FE$/V.. ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ........................OF.................I..............................----:.. ............................... ,� lirttti�an for Mipoiial Workii Tnntrnrtinn Vrrmit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal PP Y ( g P System at: Lo ti n-Address or Lot No. ......................6 T-... r...,..--------•.............•-----------•--- --........------------....-------•--....-- --------•----------........---..............-- wn r Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 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............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 ( ) `-, Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------------------------------------------------------------••..:_.._••_.._......................................................... 0 Description of Soil-•-----------'-.......-•--------------------- ---•----•--•-----------------------------------------••-•• ..........:_... ---•--------------------------/? � 1�--------,? .....-. 1� - ✓. 0 v-T-----..�A".. r W12----------- x •--••- ---•----------------------•---••--•-•-••--•------•---....---•-•------•--•----•-••--••----•-•----•--•-••-•-----------•--•••----••-•--•---••---------•---------•-------------------------•••------ U Nature of Repairs or Alterations—Answer when applicable....._ 4-oG�-_.__..__.. !?11f ._GL_..._ � `rG.. t ^ K fi` I9 f.x 6 X. eff............................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITA IE 5 of the State Sanitary Co e The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ss dtbl ealth.Signed. . _---•- ---•--•---•--•----•--•--••-•----.._..---•............. ................................ Date ApplicationApproved BY.............................. ................................................................. Date Application Disapproved for the following reasons:-------•----•-----------•--••-------------------------------••---------------------------- ••--•--•••--•-••- ......................................................ry.................................................................................................................................................. Date PermitNo......................................................... Issued....................................................... Date VNO.....`Zl�3y Fmc/v.................. THE COMMONWEALTH OF MASSACHUSETTS y BOARD OF HEALTH .........................................OF ........I........................... Appliration for Uiopooal Works Tonotrnrtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location•Address or Lot No. ..............v�............... ✓'Uf T%.>-...................................... ........................................................ wn r Address a ....._VI r��-�r�v.... �_��..........�`�.................... ..........••--•--.._....._._._...................... -•- � Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) pa.I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) tsI Other fixtures ................................. . . 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test. Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ---------------------------•--•---..............•-----..............•----------•.....••••--•-•----•-......................................................... ODescription of Soil-- . ...................... ----------•...................... -- ......................... U w U Nature of Repairs or Alterations—Answer when applicable.......7 C...........f61uv._6_:�?.� ...._S !�T'G -------�.'.�- ............ J----••-..1-_.`_A7- A...----�-x•`Tf-�!_---•-••----••••----•••-••...••-------••-••-••-------••-•-•-•-- ....--••-•------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Co The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ss ed bb`'h r � Signed. = -f(!. ...... ............ .........................•••••...•----_..--•--• ................................ Date ApplicationApproved BY............................... ............................................................... .................. ............... Date Application Disapproved for the following reasons_______________________________•.___.__.._..______._.__........___.___._.___________.._.........._............._ .........-•---•---------------------•--•-•••••••....---•------------•-•-•.....------------.........---...._._............................................................................................ Date PermitNo......................................................... Issued........................._............•................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................I........OF......................................I........0..................................... Trrtif iratr of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....................••••--•••-•••--•---•-•-............----------•--••••----._...----•--•--•------ --•---••••----•---...._...--------••------........••••••••...••--•••........_•-•--......__..... Installer at.....................•--_._.._.--_..____...._-------------------•-------_-__.._---•...-•-------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANC OFT IS CERTIFICATE SHALL NOT BE CONS AS A GUARANTEE THAT THE SYSTEM WILL F NCTI S TISFACTORY. DATE._,f' �. .-•------. .... Inspects ..- ----------------------------------------------- •............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF— .... .............Nad._.3... _. FEE........................ -/: ko �unotrnrtion rrnttt Permission is hereby granted_ to Construct qr,. Repair ) an Iri ' Sevc age i sal System _- /� atNo.............� ...........................� --..._._._._.......-• ......-•••--.t?_.- _.._..-------••----•••• -----------------------------------------------•-------____ Street as shown on the appli tion f9r Disposal Works Construction Permit .................. Dated..____.__._._............................. ----••-•-----•-- -----` •-------------------------- ---- Board of Health DATE...... _ /......._.. ....................................... ---------------••-•-------..._•-••••-•• - FORM 125:5 A. M- suLKIN. INC., BOSTON i Fizz......M............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............. ...... ...............OF...............I——........................................I........................... Appfiratiun for Uhipagal Works Tunitrurtiun lirrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........... © -d.........fr!41A----U ....... .. ...............................................•..----............................................ Location-Address or Lot No. ............... ........N---0 0_1V...................... •-•-•--•-•-••-------.....----... ................_...._.............................. O Address w er ...............••..__....----... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. .Expansion Attic ( .) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 d Design Flow.Other fixtures ..............._-gallons per person per day. Total daily flow........_._.............__...__........._gallons. W g g P P P Y Y 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 ( ) Percolation Test Results Performed by........................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-______-_----_-____. a ------------------------------------------------------------------------------------•-•-••-•---.............................................................. 0 Description of Soil........................................................................................................................................................................ x V ..............................-....................................................................................................................................................................... W -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•-•---- VNature of Repairs or Alterations—Answer when applicable.______- ALl#G,-_---_-_-14).Osrr ........0 � UL -------- 7-'`-------------- ----a-A'------ .-tr......%....----.064Ci�.........0.-'Z -------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'iU 5 of the State Sanitary Code—T undersigned further agrees not to place the system in operation until a Certificate of Compliance been ' e y the board of health. gned--- -------- ---------------------------------------------------------------------- ------- ------ --------------- ApplicationApproved BY----- ----- _ .....-L- ------ ----------------••----•---------•------------------•-- // Date Application Disapproved f e following reasons:.............................................................................................................. -•-------•-------------------------------------------------------------------------------•-----------------------------------------------------------------------------------------------------...------ Date PermitNo.............................. ......................... Issued........................................................ Date 'NoJ!.-1;Z0_ FEB....... . ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .................OF......................... Xppfiratibn for' Eliupuuaf Workii Tonstrurtiun ramit I Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal f System at: y, ..........••._-P.&.0........MOM,..6.11"..... . --------------------------------------------------------------------•-------------._.....-•----... Location-Address or Lot No. •--------- MAEAL......... ±-------------------- ..........--...................................................................................... Ow er ................................Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (, ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---------------------------- p ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------------------••-••••-----•-----•-••-•-•--- W Design Flow.................................::.........gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity..........._gallons Length................ Width................ Diameter................ Depth................ x Disposal Trend—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 ( ) Percolation Test Results Performed by............................................................................ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •---•--------•---------••••-••-••-....---•--••-----------------•-----.....------•--..........--------......••--•--------...--•-•••---•---•........-•---_•---- 0 Description of Soil..................... W V ....-•-•--•-----------••--•----•.....-•-------•....••------...-•-------------•••-•---------....-•-•--------------••---•••-••---•-----•---------•----•-•-•••---------------•--.......-------------_------ W ---------------------------------------------------•----------------------------........-----------------------------------------------------------------------------------------••-•-------•-•_••••-- U Nature of Repairs or Alterations—Answer when applicable.........#ft..t d` X 11r ....... = ....................� `7 ......C&A�......7" -.....%.......... ....... ` - ---------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITiZ- 5 of the State Sanitary Code— Th undersigned further agrees not to place the system in operation until a Certificate of Compliance been y the board of health. Application Approved By.............. .....--..-..........••-•- --� � �' ''�------. ••---------------•--------•------------....._.._. Date 1 Application.Disapproved f o t following reasons---------------------------------------------------------------------------------------------------------------_ .......................................---------.--------•---,---•-........----:..:...--•-----------•----------------•------••--••-----•---•-------••----•-----••---••---------••••----•--•-----•--•••- Date PermitNo........................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................;.................................................. (9rrtifirate of (Ilampfittnrr THIS r *'ER IFY, That the Individual Sewage Disposal System constr ted ( ) or Repaired by... . ---inst r` `. ........... at •.--------- •• -----.... has been installed in accordance with the provisions of T 5 of The State Sanitary s erd in the application for Disposal Works Construction Permit No. .�.-.. :-3.1............. da.ted_... _.:...:_________._.....____--•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILVFUJtCTION SATISFACTORY. DATE....4.__ll. .................................................... Inspector--••-- •--.------•-•••••--- V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................OF.................._............................_...._.................:............. v FEE.... ............. Disposal � �r ��n�trnrttirrntirrutit ' Permission is herebyran l � granted .. --------- .. ---------•---- -- `to Construct ( )moo} Repair Indivi � excage D s S --. .._.. Street as shown on the application for Disposal Works Construction Permit No..............:_.__ e�d _... _ .._._.___...____._._........ .............................................. ------ --------••-•••-••------•----•----f-• - _ ' t DATE................................................................................ B rd of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS