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HomeMy WebLinkAbout0002 MINTON LANE - Health 2 M1�i1�'�il �,a 1705 Service Dd West Barnstable A= 174— 007 —008 (formerly 174-007-009) l No. 4210 1/3 BLU PO n oi, ESSELTE 10% a o 0 0 �tj 7 crpn y 176S .&erv�a— ,� o 4 - J.200.,r) R 'R t } b C ��� - its �'o ��J •1�� ���►�.�rv��' �nr��el 7 . . r rA ci-&^1rr ' l • •r,Y ry.e f 1 F, 5 1 A 1 .j COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION h I b' TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: o? Owner's Name: Owner's Address /A/ Date of Inspection: Name of Inspector:(please print) Company Name: rs�nvs,► Li9R/o�Sl.�/�•�cox/sr. Mailing Address: s-&y D c a 57we-e- G�r�1.LiC y�//EP y /�'yl�ft Telephone Number.. 5-49 8•-;,7®--��y�, 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 mys 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: �ses Conditionally Passes Needs Further Evaluation by the Local Approving Authority_,• Fails i z:2, t Inspector's Signature: � .�i�su.� ,r 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. Notes and Comments ****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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .2 A� Owner: L111 jaz� Date of Insp 'o : 9- i i—o 6 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: L- 1 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: W 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. 1,f 0 The septic tank is metal and over 20 years old*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: do Observation of sewage backup or breakout 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: /`� 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 02 1 � 1,0 n Owner. Date of Inspection: C. Further Evaluation is Required by the Board of Health: 90 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: N 0 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: (10 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. ,�LO The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 14 U 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 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: Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Insp n: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _ ./ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or caged 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''/z day flow ::� l�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number 0 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. Ary portion of a cesspool or privy is within a Zone 1 of a public well. �Arry 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 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.) AIV (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 t,��e�system is within 400 feet of a surface drinking water supply t/the system is within 200 feet of a tributary to,a surface drinking water supply _ i, 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: --:2- Bjlull-disc lla� Owner: Date of Inspe ti `1-1)—at, Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Plumping information was provided by the owner,occupant,or Board of Health J 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? V Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _-Z'/ Was the facility or dwelling inspected for signs of sewage back up? v — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? ✓ 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? fWas the facility owner(and occupants if different from owner)provided with information on the proper ai mntenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n Existing information.For example,a plan at the Board of Health. _ _ etermined 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: -2- -11"� A Owner: Date of Insp ion. Q-i(- o Co FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms): 33 v Number of current residents: -2- Does residence have a garbage grinder(yes or no):/Lv Is laundry on a separate sewage system(yes or no): A6j[if yes separate inspection required] Laundry system inspected(yes or no):_f U Seasonal use: (yes or no):A/0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): bb Last date of occupancy: 0oLJ COMMERCIAIA NDUSTRIAL Type of establishment: ' Design flow(based on 310 C 5.203): and Basis of design w(seats/ rsons/sgft,etc.): Grease trap present e r no):_ Industrial waste hot ' tank present(yes or no): Non-sanitary w disc ed to the Title 5 system(yes or no):_ Water meter re s,if available: Last date of cupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N ONE *c*,'l A8 C F' Was system pumped as part of the inspection(yes or no):V b If yes,volume pumped:_gallons-How was quantity pumped determined? Reason for pumping: TYPE JOF SYSTEM eptic 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): Approximate a e of all components,date installed(if known)and source of information: �F7 Were sewage odors detected when arriving at the site(yes or no): 410 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a2 __ iv Owner. Date of Insp ion: 9—//—o!, BUILDING SEWER(locate on site plan) Depth below grade: cP Materials of constriction:—cast iron PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) Depth below grade: Af Material of construction: rete--metal —fiberglass fiberglass—polyethylene —other(explain) — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: •;O/.cov' G Kc. x-8 Sludge depth: NdNr- Distance from top of sludge to bottom of outlet tee or baffle: )VA Scum thickness: z I Distance from top of scum to top of outlet tee or baffle: g �r Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: /H'e#5 4eRE- w:7-A K•v L s-� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 1?IPc.0A..., -c-r4J To per,•, s ir• T�iyk F vFx� GREASE TRAP:_(locate on site plan) Depth below grade:Material of constmc— ' n: c crete_metal—fiberglass—polyethylene—other (explain): Dimensions: Scum thickness: Distance from top f 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c? 1177_ � tAl. 3e-r.►�a- -Pi �'� Owner. Date of Inspecti : 4— i/—o Cv TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: '1V0 Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: /�(if sent must be opened)(locate on site plan) Depth of liquid level above outlet invert: !�;'7- Z USG 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.): PUMP CHAMBER: VU(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.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: „2 'V� A Owner. . Date of Insp"od: 4 —t 1—o 4P SOIL ABSORPTION SYSTEM(SAS): ate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number leaching galleries,number: loathing trenches,number,length: leaching fields,number,dimensions: n,f `7 x �l 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: V 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:kalocate 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /h� Owner. Date of In ecti n: q-,I—o Co 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. f� f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ':9 Gf/ I Owner. Date of Insp 'on. 9-11-0 C SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7 Y feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) 1E,---A-ccessed USGS database-explain: You must describe how you established the high ground water elevation: TOWN OF BARNSTABLE RaC SEWAGE# LOCATION V17:I,AGE • [�. Qorr�` as c._ ASSESSOR'SsMAP&LOT INSTALLERS NAME&PHONE NO. Ceps ' �a8.84G :SEPTIC TANK:CAPACITY /SOD tea./ --- - { ` �►wl'/�rA�prS : size 7.' I,EACHII�iG FAClL1TY::(�) ( ) NO.OF BEDROOMS UII DE OR OWNER pres-Z ATE 1 `� 1 l I PERMITD COMPLANCE DATE + Separation,D n the ( . Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Pnyate Water Supply Welland Leaching:Facihty (If any wells east on site or within 200 feet of leaching facility) - . . Feet Edge of Wetland and Leaching Facility(If any wetlandsezist j witbin'300 fcet of leaching facility) Feet Furnishedby . Ai- Az aa' - A3 = 3i c /qy ,SO' l� From . O y TOWN OF BARNSTABLE LOCA''JtON p? d2ft6r.� SEWAGE# .VILLAGE �f/• 4*iy,,e:Z�ASSESS0R'S MAP&PARCEL /74/ p 7 00 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ote-,R S(size) -7?c NO.OF BEDROOMS OWNER. -a�. PERMIT DATE: — I ,?--y `7 COMPLIANCE DATE: CQ o• IF 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY -ko yr ,43 31 43 3 VY n - o- Y � 13 _ ��� TOW,,W BARNSTABLE LOCATION SEWAGE# � i VILLAGE SSESSOR'S MAP&PARCEL INSTALLERSNAME&PHONE 0. SEPTIC TANK CAPACITY LEACHING FACILITY:` pe) (size) NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY --Ak R�7 g'�f C.2/, V y l�l I O OF BARNSTABLE �"°``'� ��O LOCATION 40J // f/ SEWAGE# t/ VILLAGE k1 , A,019f7-,Rli 1Q' ASSESSOR'S MAP&LOT -- :— INSTALLER'S NAME&PHONE NO. ��f�L ffG 69/' 7. 02-6-66 Z SEPTIC TANK CAPACITY ��> �p/ LEACHING FACILITY: (type) /�1 �! /�� �`S (size) �•� �� NO.OF BEDROOMS 3 BUII.D oR OWNER Z,7 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 A Z uz �~ 76- 1 z ,•/l ^-- TOWN OF BARNSTABLE '` LOCATI SEWAGE #ON ' ,.ter _ VILLAGE & L Sarn s4cLS/G ASSESSOR'S MAP & LOT_, INSTALLER'S NAME&PHONE NO. AAC i©t o fl, Cbas 3 Yd g.S 42G ,SEPTIC TANK CAPACITY /S'OD !906/ LEACHING FACILITY: (type) _-r/VJ/-1rodors (size) '7 NO.OF BEDROOMS 3 BUILDER OR OWNER 9r-c_s4 iq G Gya 1 ctcr s PERMITDATE: —COMPLIANCE DATE: G -',CD 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 Al Az A = 31 ' ct,,~Cty 93 = qS' AL4 " 5-0 ' A Slq = 7s' B O a 7�< " OWN OF BARNSTABLE LOCA SEWAGE # ` VILLAGE 14 13-PA SIBS/c. ASSESSOR'S MAP &LOT_ INSTALLER'S NAME&PHONE NO. Abr-}o l o}j, Cenc j SIaB•8 4.pG. SEIYM TANK CAPACITY /�'DD cja,/ LEACHING FACILITY: (type) �N�e L-Ir4d ors (size) '7 x if NO.OF BEDROOMS lI 3 g DER OR OWNER 9r-c s4;c :c Qo ldcr S q PERMITDATE:_ _t.� - oI 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 2W feet of leaching facility) Feet Edge,of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by Al Al as 0 A3 - 31' ' CkLAAACtj 83 ys' 4 A4 = $'p' A Fron-) ,By 75' B , U 4 3 r ' Pno, �� Fee I/ THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS r' ation for i� ogaf stem Cottgtruction ermit Application for 4 Permtt to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /_o t ' f°r Owner's Name,Address and Tel.No. �� p�.cFS ft� px.e�e►.rt`�-S Assessor's Map/Parcel �d 7/ M 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Q :9r)-&6 e66 Dow.✓ e.s/E —771 - y35p 342 - Type of Building: Dwelling No.of Bedrooms Lot Size y3, 8 sq. ft. Garbage Grinder(�) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ® Description of Soil 5- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o itle 5 of the vironme al Code and not to place the system in operation until a Certifi- cate of Compliance has been issu b is oar(ofeal / f Signed l� cJ Date Application Approved b Date [Z Application Disapproved for the following reasons Permit No. *' Date Issued �� . ti .-- 'y Fee THE COMMONWEALTH OF SACHUSETTS Entered in computer: Yes * �R PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE.,-MASSACHUSETTS Tipplication for Migpool *v em Cou,5truction Permit Apphcatton for�Perrmf to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assesso r's Map/Pa rcel ul ­�, ._��-Z�� 7-7 o-6b 3 £ JInstaller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �prhe /L ' 41,1-a / C/',/ `7 J ' .53yf Cz - 01s`1/ / f Type of Building: ' ' Dwelling No.of Bedrooms Lot Size `/� d/ sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .3° gallons per day. Calculated daily flow gallons. Plan Date Number of.sheets Revision Date p Title Size of Septic Tank Type of S.A.S. ® Description of Soil s t U7� ll 'L Nature'of Repairs or.Alterations(Answer when applicable) Date last inspected: Agreeme t e. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions oQAtle 5 of the vironmen 1 Code"and/not to place the system in operation until a Certifi- cate of Compliance has been issue y t�`►is Board of ealt (� Signed ( (, ( b r � `- Date Application Approved b _ Date 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 (4<Repaired ( )Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. P;Zee dated h( Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date /- , :) %'? _ q Inspector ? -------------- ------------------------- No. '°'� "� ", Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS M=64pogal *pgtem Con6truction Permit Permission is hereby granted to Construct( kf Repair( )Up rade( )Abandon ) System located at "7"'' — ���" and as described in the above,Application or Disposal System Construction Permit. The ap' licant recognizes his/her duty to comply with'Y'itle �and the following to tiprovisions or special conditions. Provided:C.-nsti'uction must a completed itb three years of the date of this tpe t. �., Date: n 9 / Approved by �\ \ T.O.F. AT EL 2-0 X. SEPTIC PROFILE TEST HOLE LOGS o ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: ✓' "�- �`L-fir l`� I ')MINIMUM .75' OF COVER OVER PR WITHIN �' OF FIN. GRADE ECAST t I „0 2% SLOPE REQUIRED OVER SYSTEM nCo I ' _� 5 WITNESS: �i'..s►� ►. .>�,r RUN PIPE LEVEL tir -- 1 FOR FIRST 2' t l�Y�/ DATE: J f I PROPOSED t'oo __ - - -: - , v5 4- TGALANK (�, " �cL � __ INVERT A PERC. RATE = v ,.� D�,,4- N I 2 �� ~ s . CLASS --" SOILS P# � (_7K SLOPES CRUSHED STONE OR MECHANICAL L DEPTH OF FLOW A COMPACTION. (15.221 [21) 0�V TEE SIZES: (!% SLOPE) (A% SLOPE) � Cr � � G Cr INLET DEPTH OUTLET DEPTH = q y LOCATION MAP. ,- - � n v L- 17 I ASSESSORS MAP PARCEL FOUNDATION FACILITY to SEPTIC TANK — D' BOX I LEACHING ? I� r%� FLOOD ZONE BUILDING ZONE: C , SETBACKS: FRONT { I�� �I� � I �,,:ivY-f✓ �;,F.d+G. .. vim{ I:N , SIDE r REAR - f PLAN REFERENCE: , tiv 14,4 ,� _•__. ___ 1��, � � ,<, NOTES: 1 �'` `•,,•� 1. DATUM IS � Or 'l-4 ✓ �t<: -�r-!,.�':� ";�a..-r i : z« .a:.�. . r _., 'r ;,•v r.: :� _ 1 2. MUNICIPAL WATER IS SE .TIC_ DESIGN: (r,ARAA('E nlsPosfR is _ . MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. DESIGN FLOW BEDROOMS (_�_ GPD) = ��=_` GPD 3 ti 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H � > 4' - USE A ___ GPD DESIGN FLOW SEPTIC TANK: ' GPD ( ) �- GALLONS 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 5. PIPE JOINTS TO BE MADE WATERTIGHT. N- IaF+, rn 1— US" A GALLON SEPTIC TANK Igo ENVIRONMENTAL CODE TITLE V. = 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING. SIDES: G P D 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. r `* --- - BOTTOM: 40 -„G - ' - - " — ( -) -- 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT TO-AL: S.F. GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED ,.? 5 ^��rl C�� vim - �•r /, , ;,. l FROM BOARD OF HEALTH. N" `` (�" ` 11� //y..,. \ `e.,`• o `/CJ \ ) `�, ._ . y\\ .,,,•,._ „r"" +"'ram 1 {I?al ,ao( i,l,�-t�t '�►�bt �11. -+. 0 5 Nrtcc ,� Q, SITE AND SEWAGE PLAN OF IN THE TOWN OF: F!^ BOARD OF HEALTH _ PREPARED FOR: �r APPROVED DATE MA .�` ,; . �' V o s 1� , 1 y / le 0 � 7 Feet ?E-r 1-1-T o G_ Y..y , ,.. t A, SCALE. -R---`_ DATE. _-� down cape engineering, Inc. ARM CIVIL ENGINEERS 001A H. LAND SURVEYORS ' PHONE 508-362-4541i A ..____-•--Y __-___- �..__-----a FAX 508-362-9880 `` "�, i; 7 ( PT t,:, w=,r l{2�t rt t,or 939 main st. yarmouth ma — 1 JOB# -A<_ - 4 Z ,�,�. h,> v ti.r--� ► �►-I ) 0JALA, .L.S. F. DA T. t .A ..�',..,.,,.... ). .. ,,. _... ,..._.�Sr� �&.,-�tlL` $�"i,.-, ..�.. '�x..Zz-a,.,. � ' ` '; ........ .....-.R.---