HomeMy WebLinkAbout0040 KNOWLTON LANE - Health 40 KNOWLTON LANE,IVIARSTONS MILLS
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Commonwealth .& Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
GSM 40 Knowlton .
Property Address ..
Kathleen Hitchcock
Owner
Owner's Name
information is required for every. Marston Mills Ma. 02648 11/15/13
page. City/Town -State Zip Code.: Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist gat the end of the form.
Important:When .. ...
A. General Information
filling out forms
on the computer, -use only the tab
_:_1. Inspector:
key to move your �I 2
cursor-do not
Ricky L.Wright.
use the return
key. Name of Inspector
B&B Excavation
�y Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. :. 02644..:::.
City/Town State Zip Code
(508)477-0653 S14595 -
Telephone Number License.Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the:inspection. The inspection
was performed based on my training and experience,in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15000). The system:
® Passes ❑ Conditionally Passes ❑ .Fails
Needs Further Evaluation by the Local Approving Authority
11/15/13
Inspector's Signature- .. Date -
The system inspector shall submit.a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design.flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if.applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time..This inspection does.not address how.the system.will perform in the future under
the same or different conditions of use. -
� �� 113
t5ins•3/13 Tide 5 Official I fl. , orm:Subsurface Sewage Disposal System-:Page 1 of 17
L
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GSM 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owners Name
information is required for every Marslon Mills Ma. 02648 11/15/13
page. Citylfown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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.
Check the box for"yes", "no"or"not determined"(Y, IN, ND)for the following statements. If"not
cetermined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
Lnsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 40 Knowlton
Propert, Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/ day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No -
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts ..
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form 7 Not for Voluntary Assessments
,M 40 Knowlton
Property Address.. ..
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
..
page. City/Town State Zip Code - Date of Inspection
C. Checklist
Check if:the following.have been done. You must indicate'':yes" or"no"as to each of the following:
Yes: No
Pumping information was provided by the owner, occupant, or Board of Health
El M Were any of the:system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
El ® this inspection?
Were:as built plans of thesystem.obtained and:examined?(If they were not
® El
available note as N/A)
® 0 Was the.facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?. .
.... .... _ _..
® 0 Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
.... .._
Was the facility owner(and occupants if different from owner)'provided with
❑ ❑ information on the proper maintenance.of subsurface sewage disposal systems?.
The size and,location of_the Soil.Absorption System.(SAS) on.the site has
been determined based on:
® El Existing information. For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue
® El
approximation of distance is:unacceptable) [310 CMR 15.302(5)]
D. System.Information
Residential.Flow Conditions:
Number of bedrooms(design):_ 3 _ Number.of bedrooms (actual.); 3
DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms).- .
330
t5ins•3/13: :: Title 5 Official Inspection Form:Subsurface Sewage;Disposal System Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage n/a
9 ( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is
required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Septis tank is original to dwelling,leaching upgraded in 1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
i
Septic Tank(locate on site plan):
Depth below grade: 3
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal.
Sludge depth:
6"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 40 Krowlton
Proper Address
Kathleen Hitchcock
Owner Owners Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. Cityrrcwn State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
31"
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet invert.Septic tank has a zabel filter.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 40 Knowlton
Prope-ty Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owners Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. CityfFown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box appears to in working order no sign of deteration, or carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
co Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 infiltrators
11x25
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to in working order no sign of hydraulic failure.Leaching was
dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 40 Knowlton
Prope-ty Address
Kathleen Hitchcock
Owner Owners Name
information is required for every. Marston Mills Ma. 02648 11/15/13
page. City/T:)wn State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view-of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate.all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
4 3_ ` ill
0
3 h5 J 45'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >30
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 4/28/99
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
perctest on file
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 40 Knowlton
Property Address
Kathleen Hitchcock
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 11/15/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
A
r
LOCATION Co/ q /cNobuL77)ti/ z^1 SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /6o 6 c .
LEACHING FACILITY:(type) (size) 6
NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER
O BUILDER OR OWNER /Y/CY.ULAs Ho�•,r� s
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�rA/
/ 6`
ASSESSORS MAP NO:
ARCEL NO.:
No. i Fes$ ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
App iration for Biipnsa1 Worko Tnnstrnrtiun ramit
Application is hereby made for a Permit to Construct { \) or Repair ( ) an Individual Sewage Disposal
System at: _ ;�Z
... .. .............................................................-............
Location-Addres � „o Lot No.
Owner d r
� / —I --• e_._... ;.!. h4.... c �v'�!....... ...•
,-
a� Installer Address
Q; Type of Building Size Lot.... -� . Sq. feet
--_....-
�' Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage
a
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ...........................................
.el ----------=•------------------- =---••-•--•-•_-••••--------------- ...-•----•..........-------•----•
W Design Flow............................................gallons per person per day. Total daily flow____.__......_._..:�-� .............gallons.
W' Septic Tank—Liquid capacity. .gallons Length................ Width................ Diameter................ Depth................
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 ( )
a Percolation Test Results Performed by............................... ......................................... Date.......... _.
Test Pit No. 1-__-_.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____-_---_--•----__-____
•-------•--------------------------•----....-----•-•---••----------.......--•--•----••-•-------•--•..........................................................
Description of Soil.............................................................. .
x
c, -------------------------------•••-•--••---
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI:LZ 5 of the State Sanitary Code— The undersigned further agre iot to place the system in
operation,until a Certificate of Compliance has been issu.d by the b iea t P.
• Signed............. ---- ----•---..:.. ........-- ----='�-------•-----•-- -•-•--��-••� �'S�"
Date
Application Approved By..........--J. L -----ZJ___._ IR-`
Date
Application Disapproved for the following easons:------•--------••--•----•-------•-•-•--•------------•----------•-•-••-••------------------ •-•.............-
.........................................................................................................................................................................................................
Date
PermitNo.......................................................- Issued-.......................................................
Date
FEs. .....0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c- ....oF........ ..a��..ztv......= ................
Appliration for Disposal Works Tonstrurtiun Frrutit
Application is hereby made for a Permit to Construct ,F ) or Repair ( } an Individual Sewage Disposal
System at: ,.� ✓_. _
... ,...,...r--....- ..-- ......?......3: ._' !` �.... �...:..:: �...._. ....':: -- --- -- ..... ....----
f Locat
ion
-Address j /{ or Lot No.
..... ... . ....-= '-e•=�/:/�lrw..f!� ----- �. 6�if. /_---!,fit--- ---� ? ------�. /
' Otw,ner cfr'" Addre§s
- fs --'�)F? - _ .tJ
Installer :. Addres
/�/L
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........... ......
..................... Expansion Attic ( ) Ga�r�bage 0_.linden.-�---�}
'4 Other—T e of Building No. of persons............................ Showers_ — Cafeteria
Pa Other fixtures .-------•--••---•--••---------•. .
W Design Flow............................................gallons per person per day. Total daily flow................ ..............gallons.
P� Septic Tank—Liquid capacity,t_�..gallons Length................ Width................ Diameter---------------- Depth................
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 b ............... . Date y
,.� Test Pit No. 1---- ...A-----minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
(i Test Pit No. 2...L_?!�._niinutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ••-••-••-•-•----------------•---•-•-•-••-•••••-•-••--•••-----•-..........-••••-------•-•----__...-----•----•------'•--------•-•-•--••••---•--•--•------•••---
0 Description of Soil............................................................. 1....'.---
------- ".....---------------------------------------------
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------------------------------------------------•----------------•--•-...........--•-'----•-------------------------------------------------------------------------•--------••--•••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I-,TiE ; of the State Sanitary Code— The undersigned 'further agrersnot to place the system in
operation until a Certificate of Compliance has been issued by the board`Zf-`ea`Tt' . ` f/Da�:;�
Signed ,! "r ........ .......... .. .fi-Application Approved By.._.. � ._ .......... •-
Date
Application Disapproved for the following reasons:-------•--•------------------------•--------•----------•-----------•-•---•-----------••••-••-•-••........._..._
•--•-•---....-•--•-.......•---••-----••-•-••-•-••----••-•--•••-•-•-•-••••--•--••-•---........••-----•----'-•--•••••-••••................•-••--•••-•---...................................................
D a t,--
PermitNo......................................................... Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
Yam . BOARD OF HEALT
✓,,,7 i ............................` O F........./.x)41 ..:...:......................
Trrtif iratr of TumpliFanrr
THIS IS,T0 CERTIFY, That the Individual Sewa e )disposal System constructed ) or Repaired ( }
by � . . �?y :.......4 ..rx-._.._ t '-..-'------'-'--•------------'----•---'-'-•-..........-•...............•---------•----...
// _ Insta ler
= 1 }= ) Z�
has been installed in accordance with the provisions of TiTIE 5 of The State Sanitary Code as descri.ed in the
application for Disposal Works Construction Permit No. ,-_.�a. .�______............. da.ted------- %_z-_S_---------------------
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
A ,_ /O 3/ l THE COMMONWEALTH OF MASSACHUSETTS
(�T a!� 0 4 D.
VV BOARD OF HEALTH
4' . l ct c � 'z�'�.... o F. f.: ?.: �z 3. r '1....: �.................
..No. •... FEE... 5 ..............
Disposal luorkii Tonstr wit rumilt
Permission is hereby granted.........
..............................
to Construct ) or Repair ( ) an Individual ewrage Disposal System
at
Street C�
as shown on the application for Disposal Works Construction Permit No.rf--._��( �
_ ----- Date ---•---------"--•-----•................
Board of Health
DATE-------•-•--.... `- ----- ..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
I
41-
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L 'I' C4 1 C•rj _ 14 J/s /O
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— 57- Qj0 1000 CA L \.. .
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17el I�' �
— . 90.s�
p
OF
�o DAVID P. y —--,_ 2i
PAARIANO 'f;, "
CIVIL �cd
�/ £°� PA U L A.
G/311�15DQ LEVY ^,
.�
Oki SY <Y� /J:o]e Pr i J 0�`�c L a n 'L u No. 1 63'!`�. La I
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LEGEND
EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN
EXISTING CONTOUR --- 0 - -
FINISHED SPOT ELEVATION
FINISHED CONTOUR 0
Lea e.
NOTE: The location of any existing underground sewerage, . . -----^—�
wells, .or other utilities, shown on this plan is approx-
imate only as determined from records and/or verbal J�
d A J1 A -S-140 1 2,.W AS-+
information. The contractor is responsible for the •i
verification of the existing locations in the field. SCALE, 111= e-/0 / DATE , is
LEVY & ELDREDGE ASSOCIATES, INC. CLIENT. i CERTIFY THAT THE PROPOSED
ENGINEERS-LANDSCAPE ARCHITECTS JOB NO. /433 BUILDING SHOWN ON THIS PLAN
PLANNERS-LAND SURVEYORS DR.BY �2TIU CONFORMS TO THE ZONIN LAWS
OF 'tras�cc�/t. MAS '
712 MAIN STREET CH. By '2�3P/,r�
HYANNIS, MASS. SHEET'! OF z AT G. LAND SURVEY R
20 FT. M//V. N07E /F E/TNER THE SEPTIC TAN.�C OR
%E/iC.A41.vG P/T ARE MORE TN�9,�/ /2"BELOW
lG �. MIAI. rRAOEM f� P4 'O/AM.ETER CONCH'-=T.E CONE.?
�— SVALL &AF BROUGHT To GRAAD.E.
4 PYC 0/PF
£`_ �/�• GONCRE'7'E M/N. P/TCN l`/EAVy Ci'1 ST /RO/Y CO{iER Sh/AL L 43E USED '
COVERS �B�PFR FT. !F/N OR/VEJ1/A y
2 f�J• MiN. CO/VG,e 1-7
o_ GItAOE CU ✓ER
CLEAN SAN.0
Ll<NJ/D LEVEL _ j
LAYER I
IRON ®L°' Q�o O P o" QF l�g 318
•'tr MIN.PrMN /000 GAL. o• I • . . • . • r r o o4e W,45HED SrOAc
Peer Pr. SEPTIC TANK • • • • • • 1 I • • •
f) • • • 1 A' •
%� ♦ P � r IEFFECT/V�• r e • y 3 4 - � I2
.`. • • r 1 • OLPTN • • • r • v o WA5//ED STONE
00
..� IS/Xz,5 - 3�), S /ice✓F.ct s . • r1 . • • • • Ir
D p PRECAS T SE.EPAG E
-- a 1,• r r • • • • • rr eao EZ9V
P/TDR EQU/V. i
lNe CAT 4LEVAT/osN l'rrcf,rn��r,r : y�✓�7 5 G/1G/i�/!p' e 73,7
/NYERT AT BUILDING FT. 6 /AM
INLET SEPTIC -r4/1/K �FT, �_ _lam FT. O/A!+'1. C SEE TABULATION,
OU?LET SEPT/C TANK FT.
/NL,Fr D/5TR/4aurloH F7 SECT/ON OF GROUND ltrfiTER TALE
0(/TLE'TD15rA?1BLUT/01v BOX 'l29 FT
/NLET• LEACH/Na O/T FT. SE14/.�GE l�I�'PCJS�.� 53�.STE/19 7- J4/1-ATID/V
L EACHt/VG P/T'
SCALE %4~ _ /= 0� Dll►9EN-'/ON A
DE$/GN CA/TERIA 01NkAl5/0N ' FT. 1
Nvl&faER OF&EDR00/y,S _3 _ D/MENS/ON G y FT.
GARCA6,FP/5POSAl- UNIT V91•e- SO/L LOG 716.5 '
TOTAL E,ST/MATED FLOW 33o G,4L,1,oAY SO/L TEST A/ SO/L TEST#2
/!UMBER OF ZOAC///NG PITS_ / fFLEK �/;S ' 1-• DATE OC- 5 0/L- TEST T. S�Z7�ssG
S10,E l e.6ACNING PER P1T 151 SQ, frT. �Fr. RESULTS YVIT/1/ESSED BY wl,
EA
BOT•roM LCH/NG oER P/T i�l S4. 2 / c, gip; Pt,��^QL/�T/ON DATE / Z M/NCl/NCK
TOTAL LEACHING AREA ZGy SQ. FT. 3 C./� PE.�COLA7/ON RA71E
,aESFRvE LEACHING AREA lG`/ SO. F7
t,(tt 0FM
O` DAVID P. �3G
o MARIANO GOB /1 l�Ot�I yOln Ln I!C. _ i
p CIVIL .,
,Q No.31115�0 LEVY & ELDREDGE ASSOCIATES, INC.
Op lz =
. �L69•S T /r
7/2 MA S . , 1Yfl�//v�s MASS,
N l ND GI�OUNc7 Y�iQTEF@' ENCOUNT€R.�G' L'L/ENT;,{�� ��„_ DATE & 6 e&
' GMOUNo yvATER AT ELE�! JOB ND: �033 SHEET ZOF 2__
gq�ST
t '�i1t6® W M9 O LE
LOCATION SEWAGE #
Y VILLAGE � � � ' ASSESSOR'S MAP & LOT ZO 01-F
INSTALLER'S NAME&PHONE NO. AiP CAi2e__ T e-424 L
SEPTIC TANK CAPACITY __loy_d
LEACHING FACILITY: (type) 1 ern_[t1W Td2 S (size) t X 2 S
NO. OF BEDROOMS 3
"BUILDER OR OWNER d� I
PERMTTDATE: 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 gf leac 'ng cility) Feet
Furnished by
pp_ A
rl
'I
' f
3
� 2 . � 37
No. Fee
q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Migw6al 6pgtem Cow6tructiou 3dermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcello�
Installer's
Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
V &,, 1J—L Of-a-S-e 42-ti L
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 33 U gallons per day. Calculated daily flow C gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 10M Type of S.A.S. JA 0 FA `_CC.PCf y- jj,�f lr
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �t.<-b l�( l �—c� ��` c �C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has b
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
Fee v
THE COMMONWEALTH OF-MASSACHUSETTS Entered in computer: Yes
F PUBLIC HEALTH DIVISION -`TOWN OF BARNSTABLE., MASSACHUSETTS
Zippricatlion for �i.5pogar *pgtem Construction Permit
{
Application for a Permit to Construct(' )Repair( )Upgrade( )Abandon( ) El Complete System individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.`;
Ms
Assessor's Map/Parcelt6a
t
Installer's Name,Address,and TO.No. Designer's Name,Address and Tel.No,.
4k ()—c
Type of Building:
Dwelling No.of Bedrooms T Lot Size sq. ft. Garbage Grinder( )
Other Type of Building J,l No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '37?U a gallons per day. Calculated daily flow �S gallons.
Plan Date ` Number of sheets Revision Date
Title `+
Size of Septic Tank SKr S,'l IC Type of S.A.S. tA•• C oce c, L
Description of Soil
{
Nature of Repairs or Alterations(Answer when applicable) —'t.� l�( � cam, \``• C c c"�
.a L -6L c. UT(f ti-',a T 1 S't-c g=e- O wCi i -e-C -14 y`
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 bisstt d xh
Signed Date
Application Approved b ' C Date
PP PP Y
Application Disapproved for the following reasons
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( )Upgraded(�
Abandoned( )by
at tc a.C'Cc it..S as be constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issua e.GUhis ermit l t be construed as a guarantee that the s ill function as rgne .
Date L7 > � Inspect
No. v( Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mgpool OpMem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(t/f Abandon
System located at aU �4y`.ca`-N C, , �tih
,s
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:Constructi°n Lust b co leted within three years of the date of thi pe 't.
Date: "I Approved by
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 ON TR TI C S UC ON PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated it cke( , concerning the
property located at �� ou cJks _ kt&Q') meets all of the
following criteria:
— The failed system is connected to a residential dwelling only. There are no commercial or business
611-1!es associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
ere 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.
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
ethod when applicable]
• 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) —LI— , L_—
B) G.W.Elevation +the MAX.High G.W. Adjustment. = l t
DIFFERENCE BETWEEN A and B
SIGNED : DATE: '�I
[Sketch proposed ransystem on back].
q:health folder:cert
LT
V. -4
- � 1
5
TO g Ip�NS ABLE
a,�
LOCATION JQ A vp SEWAGE #
VILLAGE
ASSESSORS MAP & LOT/e3--
INSTALLER'S NAME&PHONE NO. ^a c 12e 4eip�� -7
SEPTIC TANK CAPACITY _led o
LEACHING FACILITY: (type)._ 1.✓,n!rgA r6 S (size) X 2 S
NO. OF BEDROOMS 3
BUILDER OR OWNER s� I' I
PERMITDATE: CJ - 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 9f.leac IM,facility) Feet
Furnished by
�h
�7 -g( V l
V