HomeMy WebLinkAbout0010 SALT MEADOW LANE - Health 10 SALT MEADOW QfjJ L
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c
No. ® a'7� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpliLatlon for Disposal *pstem Construction permit
Application for a Permit to Construct( ) Repair( 0 Upgrade( ) Abandon( ) ❑Complete System In ' ual Components
Location Address or Lot No. Jo SR t--T M eA%bo uj LANE Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel J S(o l$ W-4 pad _rR o m A S S PA M o — S-A m G fa D D Rt S S
Installer's Name,Address,and Tel.No. SOB -4 1')-8 s 77 Designer's Name,Address,and Tel.No.
Q,GNJ,LT B 00(Z Co
3 3 t 1�•��c s t S . �1"e.nao JTH f3 Z 4Pik
Type of Building: 6 00J akg
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder{ )
T
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �o �� gpd Design flow provided gpd
Plan Date Number of sheets Revision ate
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) '
hcL.-, J93 010 QDX w. f Rta-cr 4c%to C2406'
� i iit.-, l
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenanc the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental C and lace th st m J/erationtil a Certificate of
Compliance has been issued by this Board of Health. ��!/��
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. .c. �-7 Date Issued -7 �lr:•--� /
No. Fee / J
THE;COMMONWEALTH OF MASSACHUSETTS Entered in computer:
P CY•es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Vi
application for Dispo,sal lopstem Construction AgErmit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑In dual Components
Location Address or Lot No. �0 SA%-1' i,s c,�k;w LAm E Owner's Name,Address,and Tel.No. '
Assessor'sMap/Parcel 6A kg,f �0y-k(•1 S PAN o — SAniis FIeDReS
�z
Installer's Name,Address,and Tel.No. 0 'i 1 i - ��' Designer's Name,Address,and Tel.No.
Type of Building: 4�5% 1111 + d1 I
Dwelling No.of Bedrooms t`!" /T Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) n A— 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
I
Nature of Repairs or Alterations(Answer when applicable)
sL(A, yo PQt, F,UTit_1- .{miD-Ait_1 jt^
Date last inspected!
Agreement:
-- The undersi ed a rees to ensure the construction and maintenance,of the afore described on-site sewage dis osal`system in
accordance with the provisions of Title 5 of the Environmental Code and of 9A ace thersyst in operation until Certificate of
Compliance has been issued by this Board of Health. `
Signed " Date
.a t. Application Approved by lJ f n„ r Date
Application Disapproved by V Date
'for the following reasons
Permit No. '2 c.77 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,¢that the On-site Sewage
iisposal system Constructed( ) Repaired( ) Upgraded( )
rt-._Abandoned( )by /af c " 1�u. _/i!.rf�f d f/'!s 1
at /Q J fL f✓c1. / has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.;-4w` dated
Installer r p�y% �JI,e. r Designer
#.bedrooms > A /4" Approved design flow ,� gpd
The issuance of thiisperni t shall not be construed as a guarantee that the system willQ1tion as designed.
Date ti ( � i Inspector
r
No. f—.2- Fee / )�
THE COMMONWEALTH OF MASSACHUSETTS
1 PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal 6pstetn Construction Permit
Permission is hereby granted to Construct
/ ) �j�Repair( ) Upgrade ) Abandon( )
System located at )U 5>0
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 rmust be completed within three years of the date of this permit.
Date � -/Z, •21 Approved by 4� w-, l
�i �
do r Massachusetts Department of Conservation and Recreation
MossacHusem Office of Water Resources
Well Completion Report 13-AUG-09 11:29:30
WELL LOCATION 263580
GPS North: 410 42.6151 GPS West: -700 22.5351
Address: l0;Salt'Meadow'lin Property Owner/Client: c/o Clifford Well Drilling
Subdivision Name: Mailing Address: P.O. Box 430
City/Town: Barnstable City/Town, State:South Yarmouth MA
Assessors Map: Assessors Lot #: Permit Number:W2009-016
Board of Health permit obtained: Y Date Issued: 08/04/2009
Work Performed Proposed use Drilling Method Overburden Drilling Method Bedrock
New Well Domestic Auger
CASING
From (ft) To (ft) Type Thickness Diameter
1.00 -57.00 PVC Schedule 40 4.00
SCREEN
From (ft) To (ft) Type Slot Size Diameter
-57.00 -60.00 Stainless Steel Well .015 4.00
Point
WELL SEAL / FILTER PACK / ABANDONMENT MATERIAL
From (ft) To (ft) Material Description Purpose
WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS)
Date Method Yield Time Pumped Pumping Level Time to Recover Recovery
(GPM) (hrs & min) (Ft. BGS) (Hrs+& Min) " (Ft"$GS)
OE/04/2009 Constant Rate Pump 15.0000 1:30 17.0000 �„xa0s:01
STATIC WATER LEVEL GALL WELLS) PERMANENT PUMP (IF AVAILABLE) NJ
Date Depth Below Ground
Pump Description:
Measured Surface (ft) r
Type: Intake Depth:>
08/04/2009 13
Nominal Pump Capacity: Horsepower—
WELL DRILLER'S STAWMEIW
ADDITIONAL WELL INFORMATION Driller: Thomas E Desmond III
Developed: Yes Fracture Enhancement:No Supervisor: Thomas Desmond III Rig #: 100
Disinfected:Yes Well Seal Type:None Firm: Desmond Well Drilling Inc.
Total Well Depth: 60.000 Depth to Bedrock: Registration #: 764 Date Complete:08/04/2009
Comments:
OVERBURDEN
From To Description Color Comment Water Loss/Add Drill Drill
(ft) (ft) Zone of Fluid Stem Drop Rate
.00 40.00 Cobbles Light Gray Yes N/A
40.00 60.00 Fine to Coarse Sand Brown Yes N/A
BEDROCK
From To Code Comment Water Drill Extra Drill Rust Loss/ # of
(ft) (ft) Zone Stem Large Rate Stain Add of Frac
Drov per ft
1/1
�------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion ffor Well Congtruction3permit
Ap lication ' hereby ade for a permit to Construct ( ), Alter ( ), or Repair ( an individual Well at:
l Location — Address Assessors Map and Parcel
Owner Address
Installer — Driller dress —
Type of Building
Dwelling -----_—_— __ —_—__---
Other - Type of
Building- No. of Persons-------______.
Type of Well Capacity— —_—
Purpose of Well---
Agreement:
The undersigned agrees to install the aforedescribed 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 u e 'fic liance has been issued by the Board of Health.
Cgne7ddateApplication Approv
date
Application Disapproved for the following reasons:
��/f/ — -------� - -^ — — date
Permit No. _ -- Issued----- -�- —1-�`--------- -------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS O Egl4FY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (--r-
1 � installer
at
-----------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well rot ction
Regulation as described in the application for Well Construction Permit No. j� -g—� ated
- ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE - __ Inspector ------- -------- --------
Fee----
No.----------_G � � �-----J
------
BOARD OF HEALTH
TOWN OF BARNSTABLE
pphration or eYr Conotruttion Permit
Application i hereby }ade for a permit to Construct ( ), Alter ( ), or Repair ( an individual Well at:
Location — Address Assessors Map and Parcel
Of
Owner Address
Installer.— Driller _ Address
Type of Building
Dwelling---..----------_----__..—_._._____---
Other - Type of Building- __— No. of Persons-- --------- - ---
Type of Well 170 11,4 --r�,r— 1� --_ Capacity 6y,- °°'?---- —__—
Purpose of Well-.- —
Agreement:
The undersigned agrees to install the aforedescribed 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 a jficate' Coo liance has been issued by the Board of Health.
CR
gneddatApplication Approvy — ----— -' M_
date
Application Disapproved for the following reasons:
/ date
Permit No. Issued----- - //-- ------- --------
date
----------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS VISJO �I That the Individual Well Constructed ( ), Altered ( ), or Repaired (�,1
Installer
------------------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of HealthPrivate Well JProtection
Regulation as described in the application for Well Construction Permit No. —O-/6'/Dated --E-'-L- ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -- - — -- - - Inspector—_-- --- -- ---- ----_----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ivell Con0ruct ion Permit
No. � Fee-
q_S7
Permission is hereby granted
to Construct ( ), Alter ( ), or Repair (6-)an Individual Well at:
No. - -----------------------------------------------------
-
Street
as shown on th application for a W ll Construction Permit f
No. >cv` �l -- — Dated----- ` ------------- -
---------------....------
c� / � — -- Board of Health
DATE--�_
.h•
\ COMMONWEALTH OF MASSACHUSETTS REcE�ivEO �®
EXECUTIVE OFFICE OF ENVIRONMENTAL AF RS �
DEPARTMENT OF ENVIRONMENTAL PRO t
49 3 1 1998 .
-� TOWN OF BARNSTABLE
ONE WINTER STREET. BOSTON. NIA 0?108 617-292.5500 � HEALTHDEPT. war
WILLIAM F.WELD �., .�TRUD Secr tan•
Govcrno: '
DAVID B.STRUHS
ARGEO PAUL CELLUCCI Commissioner
Lt.Governor /�G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
0/t,
CERTIFICATION .�
Property Address: /0 �i�t Qa d pK/ 4" {1V/✓arhr 41i Address of Owner: ,27 OC Pati-r
(If different) '
Date of Inspection: /Z- 30- 98 /tGiNhi
Name of Inspector: 'jolln n, �Q v
I am a DEP a pro+Hved system inspector ursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: V� all dA ico
Mailing Address: SV Q. s 14 ,
Telephone Number: Lf7�= S 9C
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:
L/ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: 0Date:
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 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.
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.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
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, 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 conforming septic tank
as approved by the Board of Health.
(revised 01/25/97) Page I of 10 ,
DEP on the World Wide Web: http:1Mww.mapnet.state.ma.us/dep
8 Printed on Recycled Paper
at tiy�� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
al CERTIFICATION (continued)
Property Address: 10" �t PadOw rti `rz �u
Owner:
Date of Inspection:
/,� 30-98
B) SYSTEM CONDITIONALLY PASSES (continued)
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). Describe observations:
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
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
i
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 15 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 to 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.
stem has a septic tank and soil absorption system y
The stem and the SAS is within 50 feet of a private water supply well.
s
-
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 (approximation.not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /Ot%vri'hStKii
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
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 determine what will be necessary to correct
the failure.
Yes No
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 chwed 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.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
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 11 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 04/25/97) Page 3 01 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /O a�C,Kj
Owner: ���Aw, !; /q�et � GrCBr +�• '
Date of Inspection:
Check i(the following have been done: You must indicate either "Yes" or"No"as to each of the following:
Yes No
y _ Pumping information was provided by the owner, occupant, or Board of Health.
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.
�✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
L/ The facility or dwelling was inspected for signs of sewage back-up.
✓/ _ The 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 beerrlocated on the site.
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:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
✓ Existing iniormation. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(zevic*4 04/2S/97) Pays 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM_INFORMATION
Property Address:
/O Smolt ti-•rq�atc. ��� l� �Grht�l/yla�
Owner: wr11uH. 4 ��{�cc 6r�p�•
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:_yyy g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents: O
Garbage grir•.der (yes or no): M,
Laundry corrected to system (yes or no):_w5
Seasonal use tyes or no):_ 7�
Water meter readings, if available (last two (2) year usage (gpd): 41,Phe
Sump Pump Ives or no): A119
Last date of occupancy:'
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow:_gallons/day
Grease trap present: tyes or no)_,
Industrial Waste Holding Tank present: Ives or not_
Non•sanitary waste discharged to the Title 3 system: ryes or no)_
0, Water meter readings. if available
:0�_ Last,:,date of occupancy:
r
OTHER: (Describe)
' Last:<date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of infor
'= mat on:
q—//— 93
System pumped as part of i spection: (yes or no)--N.
If yes, volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
y 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 7 taus $— / "S7'//,,/
7AGiK .AAaI fac� 04 �rv«.o Op ocvN
A/
Sewage odors detected when arriving at the site: (yes or no)Ld
(revised 04/25/27) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION-�(continued)
Property Address: /O .Sa f��+^-0-daK� Lci1,4 ,�•I�A7S"�,-
Owner: ���iok. 9 #J C t�rtlr
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_z
Material of construction: _cast iron 40 PVC_other (explain)
Distance from private water supply well or suction line /AO'
Diameter VIf
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth: at
Distance from top of sludge to bottom of outlet tee or baffle: 11
Scum thickness: O
Distance from top of scum to top of outlet tee or baffle: D,t
Distance from bottom of scum to bottom of outlet tee or baffle: o
How dimensions were determined: ,meafAf ice vwoi 9 At err
Comments:
(recommendation for pumping, condition of inlet and outlet tqes or baffles, d pth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) . -� ��
.G 7,7&, /
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness: v
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
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 04/25/97) Pays 6 of-10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0 5'q at �
Owner. ar il+..a
Lion: � 47ct J,
Date of Inspection:
/2-362- 9B
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —Other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/da%
Alarm level. Alarm in working order_ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet inven:_0
Comments:
(note ii level and distribution is equal, evidence of solids rryover, evidence 9f leakage into or out of box, etc.)
b�l�O?C in ofoO� SZ.a&= lie" Ij2�dw �l�ir P
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No).
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(ravimad 04/2S/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /D
Owner: W o/1110.4- 9� /I/Y ce ;% `,e II-
Date of Inspection:
99
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods).
If riot determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:__
leaching galleries, number:
leaching trenches, number,length: , G
leaching fields, number, dimensions:36
overflow cesspool, number: .
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS:
(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)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Dimensions:
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
I
paq• ! of 10 �
(revised 04/25/91)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /0 �f rnpa�ar1�j Je,",e I�a�r tOo•�h S h�o�/�q,
Owner: (�/i�/ias-• SiF )V ly-l- Ti 6re e r
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks I /
locate all wells within t 00' (Locate where public water supply comes into house) p,Z /°"'t o&r b
r
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(:wised 04/25/97) Page'9 of+20
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SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /O H.o
Owner: a/'
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
t/Obtained from Design Plans on record
_Observation of Site (Abutting property, observation hole, basement sump etc.)
i/Determine it from local conditions
_Check with local Board of health
Check FEMA Maps
Check pumping records
t/ Check local excavators, installers
'/"�Use USGS Data
J.
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Oof ,I wr► �s.,lo�M�
9r0ukd � 6, 7
� e / /o 0
�� �� � .9r•�vNN�wa/iv �6�7
4qo! -C�.
(revised 04/25/97) Page 10 of 10
TOWN OF BARNSTABLE f) IJS(p �) )lb
LOCATION �� sue/ �yle� ccy r,��. SEWAGE
VILLAGE IZ/i 1.5oyt ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. J04;1 )5�,
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �hdr'/ ' S�
-���� � (size) 36 x CA <0 NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER --
BUILDER OR OWNED��i��» �r�-r
DATE PERMIT ISSUED: U✓ J ��
DATE COMPLIANCE ISSUED: — g1
VARIANCE GRANTED: Yes No
I
!qj' i
i
ij'3
� ;
1 .
J,
No..?.•-- Fxs....a ..Q..-............
..
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnstable Conservation Commission BOAR® OF HEALTH
TOWN OF BARNSTABLE
Signed Applirat for Dispaa al Workii Tomitrnrtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
e Locati}Qn-Address or Lot No./
00.4
......................_.......................................................................... .......... ...............................i.........................................._.....
/ O er/ // ddress � 2
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a Other—Type g --------------------•-----•• P ( )--- Cafeteria ( )
A4Other 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 ( )
14 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......._.... ..._.. De th to and water. _._..._...__.___._...
Description of Soil..........._ _ ��
U ----------•----------------•--------......._...---...----------•
W ..........................
U Nature of Repairs or Alteration —Answer when applicable__ �,�1� N__..___.0 i.... ...... /'e........ �/...............
---•----------•---------------------------------•--•--------------•-------------•------.....•-•---•---------•--•--------------------------•---------•---•--------------------------------•••-••---••----
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 Compliant as b n issued by the board of health.
Signed /"
Date
Application Approved By .... 1; ►^.w .� ............................ . ....... g� ...
Dale
Application Disapproved for the following reasons- ------------------------------------------------------------------ -------------------------- -- -----------------------------
...... .............. ... .... - -
Date
Permit No. ' . Issued .............................
Date
- 1)0 K,;
No..71:: 3 Fiz$.... o...''..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_��'l f• ' ,�v TOWN OF BARNSTABLE
Appliration for Klispusal ?lurks Tomitrurfiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......... 1..o....s4/f tip{ � -...L�.. I..e.•........ ..................•--........-•---....-----.......
Locattii to-Address t or Lot E
..............................................................C3'1't�f ......... / .....................................................Ltyi'n e
� O r Address
...._... " / J
•.. .._ e
Installer
Address
Type of Building ' ` l� Size.Lot. ......................Sq. feet
Dwelling—.No. of Bedrooms......... ..................._..:..._Expansion,Attic Garbage Grinder ( )
a`k Other—Type of'Building ......_..._. No. of ersons.t.............. ___' Showers —
g ------•--•-------•-------•---•---•------••-P----- �-•----_- ( ) Cafeteria
Other fixtures'--------------------- ------------.........---•--............:---------------•....... )
WDesign 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 s Performed by......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' •--••-----••------------•---------•-----------•......................••--•-----•--........_..................................................===
Descriptionof Soil "=--------•--•--•--•--•------•-•------------------------------------=---------------=-------•-•----••----•-------................
x
UW -----•-•--••---------------- = =.............. :;-------------------------------•-------------------------------------=-----;--
Nature of Repairs or Alterations—Answer when applicable.. �'t S
//
..........................................-.............................................................................................................................................................
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 Complianc .h.as b en issued by the board of health.
_- - Signed .-.:.... - --. � `" _ _ � . X—
........ ..................................
Date
Application Approved B .............................. .... . ............
• � - Date
Application Disapproved for the following reasons- ---------------- ---------- ------.---- . ------------------------------.---------------...........
........................................... ...3.Y.......... ... _.---2----s-------------------...----------....----..........-...--..........---...---'-----------.........-_.......---'-- --......"--...Date..--...--------
PermitNo. .. . .......... ------------ Issued --------------- .......... ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(9Pr#tftca#e of Compliance
THIS ISO CERTIFY Tha i
�j the Individual Sewage Disposal System constructed ( ) or Repaired
by . .. (5 t.-�--------------------------------------------------------------------------------------------------------------------------------------------
------------------------
Installer
. .- - --
has been installed in accordance with the provisions of TITLE f The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .... zi...`: .t�. ............ -dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------ - -----'".. J ..... Inspector ..-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ 2 TOWN OF BARNSTABLE
RaVosul lurks duns a iun "anti#
Permission is hereby granted -- -- -----
to Construct ( ) or Repair (mac) an t�ividual Sewge Dispail Sy tem
at No.-----••-• , ? Q' �. �"l�_..---tom?------ ' '
a� Street
as shown on the application for Disposal Works Construction Permit No.__. __ Dated..........................................
9/ .................................- -- -- ---...........................................................
DATE............. f•- % �` .......................................... Board of Health
----
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS