HomeMy WebLinkAbout0105 MAIN ST./RTE 6A(W.BARN.) - Health 105 MA N STRE-ET, . BA 1E
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
F DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner's Name: BONNIE SCHULMAN
Owner's Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Date of Inspection: 4/19/01 RECEIVED
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 MAY 9 2001
Telephone Number: 508-564-6813 FAX 508-564-7270 TQWN OF BARNSTABLE
P HEALTH DEP7.
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 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 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furthe aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 4/19/01
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspect' n. 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.
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM NOW AND EVERY TWO YEARS
TO PROLONG THE SYSTEM'S USEFULL LIFE.
****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.
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM NOW AND EVERY TWO
YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years bid* or the septic tank(whether metal or not) is structurally unsound,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.
ND explain: n/a
n/a 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT VOLUNTARY FOR V L ASSESSMENTS
O O U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
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
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 I 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP
certified laboratory,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, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.)
_ (Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
s
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 tiny 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.
n
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 105 MAIN ST.RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks`?
X _ Has the system received normal flows in the previous two week period'?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out"
X _ Were all system components,excluding the SAS, located on site?
X _ 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 ?
X _ 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:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
Page-6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUR
FACE SE
WAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 105 MAIN ST.RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 5
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1984
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/O1
BUILDING SEWER(locate on site plan)
Depth below grade: 66"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 60"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth:4"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING
NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
500 GALLON LEACHING leaching chambers, number: 2
CHAMBERS leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
n/a Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF
FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: nia
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 MAIN ST. RT.6A WEST BARNSTABLE,MA 02665
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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Page I I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 105 MAIN ST. RT. 6A WEST BARNSTABLE,MA 02668
Owner: BONNIE SCHULMAN
Date of Inspection: 4/19/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
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TOWN OF BARNSTABLE
LOCATION �OS ��6� ��ljl�ST SEWAGE #
VILLAGE ASSESSOR'S MAP&LOT&Z 00.�L
INSTALLER'S NAME.&PHONE NO. BDetrze)941 Ge,41- r 7./-Z�"
SEPTIC TANK CAPACITY %Oce, 64
LEACHING FACILITY: (type) 5270 64� C,-e,4 size)
NO.OF BEDROOMS 3
BUILDER O OWNE Sc 6�L�zen
PERMTTDATE: l � 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 �S.O f
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) /U '+� Feet
Furnished by
TOWN OF BP LE
ATION � SEWA�G�E #
LAGS S ASSESSOR'S MAP r& LO1 ��" C -t2-
STALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER J tC—� —
PERMTTDATE: COMPLIANCE DATE:
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 Q�
� r
a
.41
gD
44 ti
41
� S1
6A 31 L
CA 41 e
eg t��
_ TOWN OF BARNSTABLE
11!3TALLLLER'S4
y / [ SEWAGE# 9,93 7ZjAGS W IQl��jt? /� ASSESSOR'S MAP&LOT �4zZ `NAME&PHONE NO.
SEPTIC TANK CAPACITY woo 67t,L
LEACHING FACILITY: (type) 5'270 64( Le*r4 Cho,-, (size) &.5
NO.OF BEDROOMS 3
BUILDER O OWNE d�Ca
PERMTTDA r���3�Q� COMPLIANCE DATE:_
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 3--i/ 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 Feet
within 300 feet of leaching facility) 0-4
Furnished by
;rtJ%dr
xj ,
No. — &76 Fee. C
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for �Dfigp al *pgtem Con5truction Permit
Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System T dividual Components
Location Address or Lot No./,o �/ / Owner's Name,Address and Te.No
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. f Designer's Name,Address and Tel.No.
7 71-q,3jO"
Type of Building:
Dwelling No.of Bedrooms 17 Lot Size sq.ft. Garbage Grinder(�®
Other Type of Building e#Ge—No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /ia gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /O '®R,r7vim^ / P Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 7-i7`1e- 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 been issued this B d o Health.
Signed Date
Application Approved by Date to —
Application Disapproved for th follow g reasons
Permit No. 7b Date Issued
No. L- 7y Fee 1-eq
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: o%
r c►` Yes
PUBLIC HEALTH DIVISION -TOWN& BARNSTABLE., MASSACHUSETTS
Application for Migogar bpgtem (tongtruction permit
Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) El Complete System 19 ndividual Components
dwner's Name,Address and Te.No.
Location Address or Lot No./
Assessor's Map/Parcel 1v
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No.
7
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 gallons per day. Calculated daily flow �J '>�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /O D ��-7`i Type of.S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
I
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this—Bo d o Health.
�. Signed "���/ i Date
Application Approved by ��..� ,` _ 'r Date 10 — 13 4 —
Application Disapproved for th follow' g reasons -
Permit No. — 6, 76 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS//l/
BARNSTABLE, MASSACHUSETTS '
(Certificate of Itompriance �>
THIS IS TO CERTIFY,that the On-site Sfgwage Disposal System Constructed( )Repaired( tl<Upgraded
Abandoned( )by O/, „o C1//15177
at_�/,,� _� �y1�a5f' Lfi'� dre, 75 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. &7 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date__. ( - r Inspector
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Xigpogar bpgtem (Congtruction Permit
Permission is hereby granted to Construct( )Rep a' Upgrade( Abandon( )
System located at �" �6'7 t5 -
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 ermit.
Date: M Approvedby
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10/9/97
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NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated `®` 1f14PT ' concerning the
property located at `dF i? f�'/¢ �' klWW ,Me meets all of the
following criteria:
/There are no wetlands located within 100 feet of the proposed leaching facility
✓ There are no private wells within 150 feet of the proposed septic system
Y There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
1/ If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) �®
SI
GNED:: �' DATE: 401 .
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
.may
L O C kT ION (�Y _. SEWAGE PERMIT NO.
V-ILLACE
k ' INSTALLEIt's NAIVE i ADDRESS
n
0 UILDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
10d,
6/ /8 4 :83-16Z
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HOUSE G ARAG E
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THE COMMQNWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town pp West Barnstable
Appltration for Disposal Wiliks Tonoirurtion Prrutit
Application is hereby made for a Permit to Construct (X ) or. Repair ( ) an Individual Sewage Disposal
System at:
West Main Street (Route 6A� .................Lot 2
................----•--............._... ...- ........ -... •-•----•---------..........._....---........----
Location-Address or t No.
Anthony Mucclarone P. 0. Bo '365 , rankling 1�1A .02.038
................................ ._... •- •-----------------
W ddress
Inst
5--J uS��... ' `l _4..�Q���...1�19.......�Address
ress
all
dType of Building Size Lot._3.3.,,6 3 6±......Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures --------------- -------------------h6 r.QQm---------------------- .
W Design Flow.... .1.Q................................gallons per NotXoX per day. Total daily flow---3 q................................gallons.
WSeptic Tank—Liquid capacity.1-01..0gallons Length---8-!.6!!.. Width4_110.".. Diameter................ Depth5.1.411.....
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No....I--------------- Diameter.......8........... Depth below inlet..6............... Total leaching area4 2 5___g a.W
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed by...GlieX_-r Q1.e...&...Ha].rian,....ZIlC...... Date..._V.191$2.................
Test Pit No. $.... eSS_minutes per inch Depth of Test Pit----14.4"�.'... Depth to ground water....N�an_Q-........
fT Test Pit No. 2....tha11.minutes per inch Depth of Test Pit.................... Depth to ground water.---....................
rx2 ..Q-------------------------------------•-------•----------.........------------••••----••--•...................................-------••••-......----•------
0 Description of Soil................................................................................................................................. ......................................
v See....?14 ..p. an.....--•----------•----.
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 TIT LE, 5 6,,the State)&odD1x}YCode— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of licalth.
Environmental \ Signed-- -- ----•.
---------- . ------------------2- -�------•---•• --••-
r / Date
Application Approved By...........:-- ......... ........................................... ..-;- ,lczZ. Yat
..k--------
Application Disapproved for the following reasons---------------•--•------------------------------------------•---------------••------........---................
...................................-.....................................................................................................................................................................
Date
PermitNo.......................................................-- Issued-.......................................................
Date
A,
No....g
—q. :- ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............Town West Barnstable
...................... .....OF.................................... .......... ........................... ....
Appliration
...
for Disposal Works Tonstrurtion Frrmit,
Application,is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal
System att-----'
West Main Street (Route 6A) Lot 2
....................................................................... .. ..................................................................................................
6 Address
' Anthony MucciaYVA P. 0. Box 365' O*ta'hklin, MA 02038
............................ .........................................!.........................................................
- __ A -, (—Ad,-,5s
(4 w"r ICA...................
.C)Lcurl oa
. . ...........
Ksta�ler
Address
Type of Building i 3 9 636
..........................Sq. feet
Size Lot-3
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. oi'-persons............................ Showers — Cafeteria
Othfixtures ...................................bedr.o.om........................................373U---------------------------------------------
U per day. Total daily flow__________________________..._____..._-- ns.
Design Flow............................................gallons per YpXr
j:4 Septic Tank—Liquid capacity.1.0.0.0gallons Length Width4.'1.0'... Diameter................ Depth.._.______._..
Disposal Trench—No..................... Width..I?................. Total Length.. .............Total leaching area.4,,---------fq- ft.
Seepage Pit No ........... .........
............... Diameter.._._.._.___.____.__ Depth below inlet___._.__.._____.................. Total leaching area.. ...
z Other Distribution box (X ) Do tank
ere e & Halnon. Inc. l 9/82
Percolation Test Results Performed by..........?rt K......1.................................................. Date........................................
Test Pit Nol Less ft
�--4 .-minutes per inch Depth of Test Pit---i44......... Depth to ground water....XQ34.9..........
04 Test Pit N f�
44 o. 2----2...6....minutes per inch Depth of Test Pit____________________ Depth to ground water..____._.._._______._._.
9 ......................................................................... '...q.............................................................
0 Description of Soil....................................................................................7
WSee plot plan V.................................................................................
U .................................................A....................................................................................................................................................
.......................... ....................................................................................................... .....................................................................
U Nature of Repairs or Alterations—Answer when applicable........*........................................................................................
....................................................................................................................................................................................
Agreement:
The undersigned agrees to install the afoiiedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
.................................................... .........
*Environmental signed
.......................
D
Application Approved By...............................
- ---------Date
'Application Disapproved for the following reasons:_'�5_1 z......... .. ... ....................................................................................
..........................................................................................................................................................................................................
Date
PermitNo................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF.....................................................................................
tiff
THIS IS TO"CERTIFY, That the I 'Se e Disposal System constructed or Repaired
by...................................................................... --------*-----------*-----------*---------- -------------e----------------------------
staller
at.................... Environmental
... .......I.. ......................................................................................................................................
has been ins 11 1 ance wi the rovisions of TITLE 5 of The State MW Code as described in the
application f osa#QJVorks Co 1 ernd<114---------------------------------------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHAANBT 164"STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI,JFACTORY. A,
DATE...................................:.....6 ......... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... .......OF
FEE........................
Disposal Works TWng-truction nutit
Permission is hereby granted......................................I.................. . .. .............................................................to Construct or Repair an 4 Disposal Sy
at No...............e �i
.j_.v.............................................I.................................... .................. �6'�..................................................
as shown 0_10�10po_ztion fordjigposa;a�G94ructiod�76rrslw�X'61ov..................... Dated.________...._._.___._.___..._:_.__.......
41
--.:t...........................................................
DATE............................................ ;aid of Health
..........................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
r
,
CAPE.WATER TESTING LABORATORY
South Wellfleet, Massachusetts N663
Telephone: 617-349-3 900
DATE. .................F=: .:` 's:.. ."....1 Y 3........................
TO ........... ..........1:_: :: '? . ? : ....:: ::............ .........................................................
On the basis of a sanitary survey and a laboratory
examination of the sample of water taken from a .wtiI
...........................................................................................
located on the premises of................. s , z. xt; . x ► .............................................. ..........
located at ................11w.LA.A,.:....�.�� ...��� �;��1
:�:�:� :�- >it ........ this supply is approved for do oses at
on. ............ ......:...... ................................
PV�N OF Mq,SS
the time the examination was made.
ti
RICHARD M.
STURTEVANT y
�� / c' S3
Signed / q� �o. E....
11
Richard Sturtevant
Registered Sanitarian
Cc�11�.i��:ea
ptl f; 2
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