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HomeMy WebLinkAbout0159 PARKER ROAD - Health WEST BARNSTABLE A = 176 016 003 �l�U 0 • r�j 1 r IDA TOWN OF BA:RNSTABLE E LOCATION 3� 61/0 eta /�`✓1/ Wa tZ SEWAGE # Zed—?6l VILLAGE /rt�! i^�157o�lG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Z!'9, >" -7, SEPTIC TANK CAPACITY 1000 4A'l LEACHING FACILITY: (type fatica1 C1�., (size)l7.$fu-Y33.�L- 2'-�1u epty, x 11 ,t- I- . NO.OF BEDROOMS BUILDER OR OWNE 0 x p f l 'I PERMIT DATE:f 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 Finished by f,. h r -� h ti f _ COO 3r�" .w , No. W o�� �3 00 Fee BOARD OF HEALTH TOWN OF BARNSTABLE r 2ppYication if or Yell Cou5tructiou Permit Application is hereby made-fo'r a permit to Construct(Alter( ), or Repair( ) an individual well at: Location-Address ` c t -Assessors Map and Parcel l U0 C �Vl�1�,`i Y\ \�� �0.Y�c F_V -�-, �. Omaler Address C-c � �6\ la6s 4 Installer-Driller Address Type of Building Dwelling_ z Other-Type of Building No. of Persons Type of Well ���,�\ \I C� Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed c Date Application Approved By Yam. 1NL L V&/ 4 - U Date Application Disapproved for the following reasons: Date Permit No. bi �D �- (O Issued Date ------------------------ -------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of om Yiauce THIS IS TO CERTIFY,that the individual well Constructed! Altered( ), or Repaired( ) by nt- ICJ J x �, \`�` —� — Installer at GJcj "Pc,,,zkx, -V2A. has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SArTISFACTORILY. ' �Q Date LO a� 3 C �Q Inspector � �,wc yy�zle , �� i 2 // r No. W a u ( J 1 �I n , Fee ., BOARD OF HEALTH .k TOWN OF BARNSTABLE 2ppUtation jfor Yell Cou5truction Permit Application is hereby made for a-permit to Construct Alter( ), or Repair O an individual well at: 15�i �a�r 1 Location-Address �< ( Assessors Map paand `Parcel 111wL t� l p C ��VIC�\1 Y1 1Sc 1 0wher Address Y1LL C-c,�� W 0\ j S6,C0j h � ry Insta ler-Driller �` Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well ���}c,�\ ��/C ' Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Application Approved By V1� VVl kD Ie Application Disapproved for the following reasons: ` tt Date Permit No. �L! D I�� ( � Issued I Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of �Con� Yiauce t THIS IS TO CERTIFY,that the individual well Constructed Altered( ), or Repaired( ) by mil_( . �' \t,36\ C� Installer at 1 �G.V P V " I�CA. has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated Ilk THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. (� Date �.J V lGl' Inspector F Y ( �'( �C�C..v\ Z ( I`"_ I' BOARD OF HEALTH TOWN OF BARNSTABLE Vern Cou5truction Permit No. -,J a. o ) 3— 6 W, Fee Permission is hereby granted to L Q-C. �Cxa W Q Installer to Construct'(✓Y,�Alter( ), or Repair O an individual well at: No. --Pa, ,C . Street c as shown on the application for a Well Construction Permit No. (D Dated 0 v� Date Approved By �<,lih ?ic�� f-5 .,vas `a' ao r � Y h 0 � 4 k ' s a'va g9 j I' TOWN OF BARNSTABLE LOCATION 3� 240 �� �y✓� wg�' �� SEWAGE # ZGbO-76� i VF.LAGE W, /��"r1570��� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Ael2Ga Za ) j SEPTIC TANK CAPACITY !sop y.yl LEACHING FACILITY: (type) (3)_neQjl C_ha-M y_ (size) rN� NO. OF BEDROOMS n t rrT r4cU no . I u v u.ai+-,ate va♦ v/ _ I PERMITDATE:/ COMPLIANCE DATE: I 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 _., 1 . ,Ty ^ i I � rr` MtiV` 1 l � f No. 7t000—J U, Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migpogar *pgtem Couttruction permit Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No.3 OldC'Daf1 Y"r Owner's Name,Address and Tel.No. �wfi Assessor's Map/Parcel ��� Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 77� -9 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 f�� gallons per day. Calculated daily flow L L O gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �DfJ 15'7` • Type of S.A.S. !11 Description of Soil Z ✓� �` ��-�'�� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 17 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is Boar of Uealth. f Signed Date Application Approved by Date a Application Disapproved for the following reasons Permit No. '70Cw —7 La I Date Issued al 7 1(-n —— — — ———— — ———— ,a 70 _ MOO—. �.tC� ^ � � _ Fee �1� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLVIC HEALTH DIVISION - TOWN`OF BARNSTABLE., MASSACHUSETTS 2ppricatiou for Mgoml *pgtem Construction 3permit Application for a Permit to Construct( )Repair( 4pgrade( )Abandon( ) El Complete System EP41vidual Components Location Address or Lot No. 36 Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1A), Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 271 �9 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building ao.of Persons Showers( ) Cafeteria( ) ' Other Fixtures aDesign Flow /9 gallons per day. Calculated daily flow gallons. ✓ " Plan Date Number of sheets Revision Date Title Size of Septic Tank / OQ4� /'�'%S7`/4!9 Type of S.A.S. ` Zee) Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: l 7 6—and• �0 3 Agreement: The undersigned agrees to ensure the construction and maintenance,.of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is B'�oa�f jo�f alth. Signed L? `t,� .z�rs l. Date Application,Approvedby th �{� U {-r Date /a b' Application Disapproved for the following reasons °3 Permit No. 7_0(7U 7 LP I Date Issued f Z�72 AY) --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( I-�`Upgraded( ) Abandoned( )by O`7-11,40111 _ at ,36 ©lO 6�14/& 1 Y zt w, Aald has been constructed in accordance with the provisions of Title 5 and the for Disposal Systemellonstruction Permit No. ;a 0-7 &/, dated CAD Installer Designer J ,C The issuance of this permit shall not be construed as a guarantee that the system will function:s desig led,. Date I /7t� r r Inspector11>> � t` --------------------------------------- No. 70M —7 Q,o I !/ ?; - o�6.oa 3 Fee 50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopooaf *pgtem ou.5tructiou permit Permission is hereby granted to Construct( Repair(✓)Upgrade( )Abandon( ) System located at 3f> I Z�l /��`✓t l{fG� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: �� I C;)S i Approved by ILGIL", t sck cu n 1/6/99 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 PLANS) �D/ `rllereby certify that the application for disposal works construction permit signed by me dated ` Z l Z g1z520 , concerning the property located at 3,&l ®� �aGr �`r�� 'Y lt/ ���",� meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. w/ The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. r There are no wetlands within 100 feet of the proposed septic system y 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. r The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when /applicable] +► If the S.A.S.will be located with 250 feet of an vegetated wetlands the bottom of theproposed Y � � 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) , �� 7 B) G.W.Elevation 257+the MAX. High G.W.Adjustment.S i./= J D 3 DIFFERENCE BETWEEN A and B SIGNED : r DATE: l 2— [Please Sketch propose plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. 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I. _ .. : _ f _ ' - -e - tr - .. [asNr_.w,.^v .<,«., ...7 .Fen r' 1 a w ? rY� fti r. My� k , -__.._ _._.�J.�'--- 1 Zjsi 0 o ^ � w o i lot A—I n � ti .e 8 _ TROY WILLIAMS SEPTIC INSPECTIONS Pe i kA Certified by MA Department of Environmental Protection 199 08) 385-1300 19 Hummel Drive 4 1 South Dennis, MA 02660 �4_ Commonwealth of Massachusetts O U Executive Office of Environmental Affairs coo Department of Environmental Protection WilNam F.W*ld Trudy Cox* Argeo Paul Celluccl LL x David B.Stru sh Cormrrlorrr '} b O ��U,rv►S�o�bU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �f � PART A _ CERTIFICATION PropertyAddr" 1 S Cf /9G.r- ke.r Ra• W• 13'r ^ S /u 6 fG Address of Owner: )?obGr 4- r Date of Inspection: ,�j /�a �� 7 (If different) Name of Inspector—� /1-* C"An S Company Name,Address srt7d Telephone Number. Ste- f�So�C, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system; Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's signature: S/Lvt7 /^L�C� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or bas 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. Thee original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A B,C,or D: A] SYSTEM PASSES: �I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: /%//19 One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exAltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n CERTIFICATION (continued) Property Addre" I S y YAr ke-,, K d Owner. Date of Inspection: Cr B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distrj t on box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced 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 C1 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT 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 within a Zone I of a public water supply well. The system has a septic tank and soil absorption system 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 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. 3) OTHER (revised 11/03/95) 2 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: S C1 Pam.r �: ✓ �� Owner. Date of Ins � Inspection: S /a a / DI SYSTEM FAIL: AV/� I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to dete failure. rmine what will be necessary to correct the — Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. — Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAIL: N // The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11.103/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S �/ ��.►� 2✓ / J. Owner. n c Date of Inspeotlon: s/aa /y Check if the following have been done: - Pumping information was requested of the owner, occupant,and Board of Health. V 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. ZAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow ZThe site was inspected for sign$of breakout. �AII system components, excluding the Soil Absorption System, have been located on the site. YThe septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffies or ZThe tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address s A pay ✓ k�✓ Ro� Owner. / Date of Inspection: � s /ate /y � RESIDENTIAL- FLOW CONDITIONS Design flow:X 4 �sllons Number of bedrooms: Y Number of current residents: Garbage grinder(yes or no): /VO Laundry connected to system(yes or no):—Zr S Seasonal use(yes or no):_ZVO Water meter readings, if available: r i 0- Last date of occupancy: 0 c- v�,.�S. COMMERCIALANDUSTRIAL• Type of establishment: Design IIow:____gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /16 J c �✓ S System pumped as Part of inspection: (yes or no)_&O If yes, volume pumped: p1ons Reason for pumping. TYPE F SYSTEM Septic tankldistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known) and source of information: s , /!� `) —lie , l � 76 Sewage odors detected when arriving at the site: (yea or no) NO (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION (continued) Property Address: I S y Qo,r k e✓ RCA ' Owner. i C Date of Inspection: . s /,-�fq7 SEPTIC TANI{:--/ (locate on site plan) Depth below grade: 9 Material of construction:-Y-/10acrete_metal_FRP—other(explain) Dimensions: ���X cl /6 00 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping,condition of inlet and outlet tees or bafll es,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage etc.) 1 u )- o 3 f c c. cal r v.a u , ,_ or C✓ h S O c. 4 t OF GREASE TRAP: (locate on site plan/�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: Distance from bottom of scum to bottom 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: �S 5 /�a✓k<✓ !�� - Owner. Date of Inspection: ' ` ' L 5 /o22 /y7 TIGHT OR HOLDING TANK_/1Y (locate on site plan) Depth below grade: Material of construction:tion:_concrete_metal_FRP--other(explain) Dimensions: Capacity: eallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:, (locate on site plan) / Depth of liquid level above outlet invert: /�J Comments: (n if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) S ) �. i Ae W u. S L Hn c,y. A 2 o w t 4 oA—& u i _c._ p r o a, OJ G✓ w 7 �J i ( � /t.�- A . �.�W Cr h r� �I�c-V t+� �' /"0. 'f�. 1 J G�-�e- PUMP CHAMBER: N14 - (locate on site plan) — Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: `?, f�a-✓��c✓ �a. Owner. Date of Inspection: �\ lea/1 SOIL ABSORPTION SYSTEM(SAS).—k--*' (locate on site plan,if possible;excavation not required, but may b approximated ye PP ted by non-intrusive methods) . If not determined to be present,explain: Type: leaching pits, number:_ leaching chambers,number._ leaching galleries, number. leaching trenches, aumber,length: ` leaching fields, number,dimensions: �� �.e�.� 1, �,' I d 141"6e. overflow cesspool, number: pL✓ 5_ J Mn e-h 5 0 C h Comments: oomment: (note condition of soil, signs of hydraulic failure, level,off ponding, condition of vegetatio etc.) Sa c.l ,, C.�c<<2 �r-,.A Sa-I..cA ✓r r. /y J 5 i <1 i. CESSPOOIS: (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(cesspool must be pumped as part of inspection) Comment:(note condition of soil, signs of hydraulic failure, level of goading, condition of vegetation, etc.) PRIVY: y /� (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comment:(note condition of soil, signs of hydraulic failure, level of Poading, condition of vegetation, etc.) (revised 11/03/95) 8 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: IS � e-,-- gJ Owner. ,Q Date of(nspedion: " ` ' C, s /aa A � SKETCH OF SEWAGE DISPOSAL SYSTEM: Indude ties to at least two;permanent references landmarks or benchmarks locate all wells within 100' 33 R17 13S ' Imo- i a'� At /ol . o- .. d, A,N-t. DEPTH TO GROUNDWATER Depth to groundwater, feet adjusted high groundwater level method of determination or approximation:__ ,, 4- ✓ l o�..� /cam. 4 9 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE r"` 4 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. �— -�• ' ' r� SEPTIC TANK CAPACITY /G y LEACHING FACII.PfY: (type) 1A (size) Sy NO.OF BEDROOMS BUILDER OR OWNER> PERMITDATE: 4 /-2 51 7 6 COMPLIANCE DATE: 4a Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1� 5 III 14�1