HomeMy WebLinkAbout0741 OAK STREET (CENT./W.BARN) - Health 741 OAK STREET
W. BARNSTABLE
A = 215-016-001
r
No. 4210 1/3 BLU
O O p p
~, M
CERTIFICATE OF ANALYSIS Page: 1
y'rtA_.CFSLtS�~�.
Barnstable County Health Laboratory
Report Dated: 12/8/2005
Report Prepared For:
Order No.: G0533946
Julie Rose
741 Oak Street
W. Barnstable, MA 02668
Laboratory ID#: 0533946-01 Description: Water-Drinking Water
Sample#: 33946 Sampling Location '741 Oak St.W.Barnstable_,MA Collected: 12/6/2005
Collected by: J.Rose Received: 12/6/2005
Routine
ITEM RESULT UNITS RL MCL Method# Analyst Tested Note
LAB: Inorganics
Nitrate as Nitrogen 1.2 mg/L 0.10 10 EPA 300.0 LAP 12/6/2005
LAB: Metals
Copper BRL mg/L 0.10 1.3 SM 3111B LAP 12/8/2005
Iron BRL mg/L 0.10 0.3 SM 3111 B LAP 12/8/2005
Sodium 52 mg/L 1.0 20 SM 3111E LAP 12/8/2005
LAB: Microbiology
Total Coliform 0 CFU/100mL 0 0 303 AF 12/6/2005
LAB: Physical Chemistry
Conductance 350 umohs/cm Lo EPA 120.1 DCB 12/6/2005
pH 6.4 pH-units 0 EPA 150.1 DCB 12/6/2005
Sodium level is above the,maximum contaminant level.—Those on_a low sodium_diet,may_yv to consult a phy
C
Approved By:___
(La irector)
Z�=a ^ �—
Q
fi
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CD
.. ! to .. . ..
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Pb: 508-375-6605
,211/o/,�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Q
'� d DEPARTMENT OF ENVIRONMENTAL PROTECTION
ASSESSORS MAP NO: DL
a
PARCEL N0:_(�( ( o
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: QA oe 5 T
Owner's Name: C S-rx ;:;e
Owner's Address: -751/ e%f, - g,--
Date of Inspection:
Name of Inspector:(please print) C'
Company Name: ,�7yr�s e�9�y�✓se .� GG�ST - ;
Mailing Address: riv fi e,k/> e
ri
Telephone Number: ��D ZY—-:,,7 >
c;
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information r orted �.)
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on y � r-
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a D P
rri
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
impasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Sign ature:- Date: � � o�
a4
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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
v 1 CERTIFICATION (continued)
Proper ty Address: wne ST
Owner: C-li-54--f
Date of Inspection:
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 CUR
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
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:
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:
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:
2
Title 5 Inspection Form 6/15/2000
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: e: �.
Date of Inspection:
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 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 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of l l !
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ ckup 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
gged SAS or cesspool
tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
tuiool
d depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
t/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
�,f tunes pumped
�V- y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
�ater supply.
y 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 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
_ the system is within 400 et of a surface drinking water supply
r
_ the system is within 200 f la tributary to a surface drinking water supply
the system is located in a 'tro en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a public wat supply well
If you have answered"yes"to y 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.
4
Title 5 Inspection Form 6/15/2000
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: -7
Owner: C1S52 .c.PaES
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes —
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks
4/ Has the system received normal flows in the previous two week period
t,- Have large volumes of water been introduced to the system recently or as part of this inspection '
lL— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up"
Was the site inspected for signs of break out
-4 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 bafflesor tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum s
v— 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
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 approximation of distance
is unacceptable)[310 CNIR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:Owner: K_:�g X_ bES
Date of Inspection: 2 LLD
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example:.110 gpd x#of bedrooms): J�4
Number of current residents: -2
Does residence have a garbage grinder(yes or no): Q
Is laundry on a separate sewage system(yes or no):,o [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):e
Last date of occupancy: ��o f�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flo (seats/persons/ qft etc.):
Grease trap present es or no _
Industrial waste hol b present(yes or no):_
Non-sanitary waste charged to the Title 5 system(yes or no):_
Water meter re gs, ' available:
Last date of occupancy use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records ,2 00-7—
Source of information: .ySTL� Gf/ Tis Tl.� �./'yE.rT AG4�'r a 2
Was system pumped as part of the inspection(yes or no): V j
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE STEM
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/Altemative 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 age of all components,date installed(if known)and source of information:
Affy aV A, f
Were sewage odors detected when arriving at the site(yes or no): 1�0
Title 5 Inspection Form 6/15/2000 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
ld �A-�i✓�T9�LE'�lyi�►-
Owner:_e'er S.of-A
Date of Inspection:
BUILDING SEWER(locate on site plan)
r�
Depth below grade: 2 Y
Materials of construction:_cast iron _40 PVC,L/other(explain):
Distance from private water supply well or suction line: Z.5-p t
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:�
Material of construction:_ oncrete_metal_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: CQ 1,fi /0'o o qAc-
Sludge depth: fYL.v�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: /ir
Distance from top of scum to top of outlet tee or baffle: /0"
Distance from bottom of scum to bottom of outlet tee or baffle: ^'
How were dimensions determined: T/,'syaL �iEolr�wr4
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage etc.): /J /
xac crzs�cz►.-csl ?i (� e�'/rZill` �Pedy�P
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_ra tal_ erglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of ouXeeaffle:
Distance from bottom of scum to bottotee 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.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
Owner: 6,5*Itw 'C/a s-5
Date of Inspection: ro �2 ga:;oe4
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: 1/B gallons/day
Alarm present(yes or no):NQ
Alarm level: Alarm in working order(yes or no):
Date of last pumping: 2 9r—0-2--
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: f/ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: L-
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: (locate site plan)
Pumps in working order s orno):
Alarms in working ord es or no):
Comments(note co lion pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7// g Z2 � 57--
lyz
Owner:
Date of Inspection: !�/.Z�/�4/
SOIL ABSORPTION SYSTEM(SAS): ovate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative 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:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater' flow s or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site pl
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: G'E ;00-4
Date of Inspection: 674A �y
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.
10
Title 5 Inspection Form 6/15/2000
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
xw
Owner: Gem S.'�-ice .C.PaE�
Date of Inspection:1,/,z r//�
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 6 -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)
yChecked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
:i:�Ccessed USGS database-explain:
You must describe how you established the high ground water elevation:
-T-^0Qn /2.2
Title 5 Inspection Form 6/15/2000 11
f
TOWN OF BARNSTABLE.
LOCATION �4 � � '� SEWAGE #
� ri VILLAGE ASSESSOR'S MAP & LOT-2/0 61
0 INSTALLER'S NAME PHONE NO: � ��S
� { �1
y 4 SEPTIC TANK CAPACITY
LEACHING FACII:ITY:(type) -�( ' (size)
/V9,A( rt:k IV NO. OF BEDROOM _PRIVATE WELL OR PUBLIC WATER l l tk,4
° SNP 6s"'7kr BUILDER OR OWNER .
DATE PEP-MIT ISSUED: �� �/
--�--
DATE COMPLIANCE ISSUED: ` a-�`` � "
VARIANCE GRANTED: Yes No
A At, E)aQK
3 5 ' A , �� y
3 e
��k
TOWN OF BARNSTABLE_
LOCATION��-¢ � �' SEWAGE # L d
VILLAGE- ASSESSOR'S ASSESSOR'S MAP & LOT2/O� al
INSTALLER'S NAME & PHONE NO. C0�
SEPTIC TANK CAPACITY C7CIL
R �//
LEACHING F.ACILITY:(type) ( (size) �cai[(o t;)p
NO. OF: BEDROOMS-r) _PRIVATE WELL OR PUBLIC WATER -
BUILDER OR OWNER ��5�� 9:L2:f
DATE PERMIT ISSUED: I� �/�� MV
—T
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �`/'�
i� CDC 79
g
y
Caw: � ado Pik ��
•�
No.qZfj 7 Fmc._R o °'—..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Diopo!3Ml Marks Tiamstrurtiou liPrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ✓) an Individual Sewage Disposal
System at: A r�� �/� S�
.......... J ..-...-..---•--••------------------•---......------... .-•-----------•----•--....-----.....-----....
...
Location-Address r Lot o.
c ... i� _
QG._. _.��...... ......... .
ddress
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------.}_----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ---------------------_---- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- -------------------------------------------------------------
W Design Flow.................................. ...... .gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity_ -Qallons Length________________ Width................ Diameter_............. Depth................
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by.......................................................................... Date...------------......----..............
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...._...................
1:4 ----------------------------------------------------------------------------------------------------.........................................................
0 Description of Soil........................................................................................................................................................................
x
x ------------------------------------------------------------- -----------------------------------------------
U Nature of Repairs or�Alter tions—Answer when applicable.-_-._.�k _______________`.._.-� _�Q_-__----- ._..1._I�_..
® ----------------------------------------------------------------------------------------------------------...........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp ce has been 's ued by t d of health. r
Signed ..... ......... ............... ..... .................... �. .................. ..'i
Dace
Application Approved By ............ .................... Dale1.. 't�
Application Disapproved for the following reasonr: J
.............................................. ..... '..-..-------------------..............------------- ------- --------- -----------------------------------..._...... .------........
Dale
q Da
Permit No ....... I 9 79-6........................... Issued .. .- " �'� / 'r✓j�
Dare
a15.
.. Y.. Fnx.. ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ,
, pphration for Bi-nVniittl Workii Towitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ✓� an Individual Sewage Disposal
System at:
............... ------------------------------------- ...------------------. ----...---------------------------....----
Location-Address or Lot o.
._ rc�. ------------------------------------------------- .5�..._..Q �`. r.......................................... _
Owner ddress
.............................. ----------------•--- -------••-------•------------------••---------.
.
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms......... -----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures -----•--------•---------------•----•------------------_--..---------------------------- ---------------------------------------•---------•-----------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity..1041allons Length................ Width---------------- Diameter-----.---------- Depth................
x Disposal Trench—No. .................... NAidth.................... 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 by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------.--_-----_---_-_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit....,_....__._._.... Depth to ground water......_.................
a -------------------------------------•-------------------------•-------------•-----•--------.................................................................
0 Description of Soil........................................................................................................................................................................
UW -------•---•-- ------------------------------- ------------------------•---------------------•-------..._._.... - - -----------------...._..jj.
Nature of Repairs or Alterations—Answer when applicable.--.----& - _____--.__(___._ X- ----_----
= ----------------- -----------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5,of the State Environmental Code—The undersigned further agrees not to place the
IR7system in operation until a Certificate of Comp a� ce has been 's ued by th -bo rd of health. {{ -� r
Signed I.rz (�(4 l r
-- ------------------- ---------------------------- --
Date
Application Approved By' ` .. - - ------ /. ?...
-./-c -:- y-
Date
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------
----------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................
Date
Permit No. ............yj......... -P-6 Issued .........f...�_....- 1 I.-I....-...�..�-.rJ............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ger#tftra e of C11umplianre
THIS IS TO C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ✓)
by .... ------------------------------------------ ---------- -----------.--------------------------------------------------
lt„tauet
at ......... .........0...,_. V - Cj
i ---- - - -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ._.; /..-.. ------------------ dated ------/.. ...�..r. -�_--.`CAI
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFA TORY.
// ,� .-- ----------- Ins ectori,f'.�/�
DATE.....1.. � ... - � P ""y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE 7zt_
No............1 ...... •2 b FEE..... ' M
Digtnii 1 IVunrk Tuni#rudion f amit
Permission is hereby granted..... C_J rl_...._..
.` �
to Construct ( ) or Repair ( an Individual Sewage Disposal System
Street qq
as shown on the application for Disposal Works Construction Permit No.A_�_.__ ,__ Dated.._, .
Board of Health
..........................•_--_...-_-
DATF........... -�_-=-�-y--=-��---f �
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS �..
Date:
TOXIC AND HAZARDOUS MATE PALS REGISTRATION FORM
F�NAMEOFBUSINESS: �v�r®�
BUSINESS LOCATION: , 0/1-K 5-r e V-n
MAILINGADDRESS: R 5r� L,., /✓p �� Mail To:
TELEPHONE NUMBER:
Board of Health
m�� � .� 0 ��7 Town of Barnstable
CONTACT PERSON: t n/�l �4 P.O. Box 534
EMERGENCY CONTAC/T��TELEPHON,EVUMBER: �'l 5A 30- Hyannis, MA 02601
TYPEOFBUSINESS: H�S� r��
i
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES y NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS: ?-�
TELEPHONE: (401 -5 4- ? O -:7 ct
i
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
1 - Z� Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
G Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
I
.'LL - -
tl
No - -- Fee--
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZIpplication-*rVell Con6tructionPermit
A *Iiiation is hereb made fora e it to Alter ( ) or Re air ( )an individual Well at:
-- (V9 ST'-(.�._(Litrfg7�tra),
----
L ation — Address sors ce
--- ------------------- ----- --! �v__J to-----ram,---- --�i�h---C��D/
Addre
L• WI_Sr_ �J'-'��'� Owner /' ss --- ---- —
Installer Driller Address
Type of Building [��Dwelling - � - -
Other - Type of Building------------------------------ No. of Persons-----�------------------- ---
Type of Well -- { - --- ---- - Capacity------------------------- - - - -—
Purpose of Well-- ^�--- "�-------------- —
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation untLaCertificate f Compliance has been issued by the Board of Health.
Signed - ------- --- �'%' ----
date
Application Approved B - - -------- ------ --
date
Application Disapproved for the following reasons:-------------------------
--------------------=--------------
-- —--- =- -- —-- ------------------------------------
odate
Permit No. ---- Issued--- -- - ------- -------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (i�, Altered ( ), or Repaired ( )
/ -- —� Installer
J'
at --------------- -----
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit NWC --1-°'��Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------- —- —-- Inspector-- ----- - --- - —----—-
IM
9 ,9
No.-------------------- Fee-- ------------�------
BOARD OF HEALTH
TOWN OF BAR-NSTABL �
zipplicat ion for Vell Cootrurtionpermit
A pli ation is hereby made for a e it to struct_ );'Alter ( ) or Re air ( )an individual Well at:.
, 71
r f';'L�cahont Address _ sors p d P�`cel
664
10 Ito
_W1 T_� � Owner — ------ — -- �I�y �-- lr_�/O�ss
--------+----r-- -- - --
Installer Driller, Address
Type'of Building I
Dwelling----
t l
Other-_,Type of Building --- -- ------------ No. of Persons---- ( -----------— ---- =
Type of Well-� -- - Capacity--------- ---- ----- - - - - ---
Purpose of We]l-- amv_t ` ___�--__� T ---=-
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board:of Health Private Well Protection Regulation - The undersigned further.agrees not to
place the well in operation unt' a Certificate f Compliance has been issued by the Board.of'-H)�ealth.
Signed — - ------ — _11T 17 ----
date
Application Approved By- � -- - _—_ ---- ^� `
47
date
Application Disapproved for the following reasons:— ----------------------------=----
-- —--- - —-- - - ---- ;----------— =------------
date
Permit No. ----- Issued-- - - -— -----------
date
Jr9 i9�.l34Ne�iiOe9iTiAois!misKa.h•1r4i45ARi9L..G?LFifiiC30ilSTif6icQisc�niitr'wfdfm9s�i4b'3o,REi4P.Sires}�iTi�3lgCb4aQ1rJY3®A.:till?cl4iRi�b?i.QcSitilc42E?cT�RafB�dpvtitw4i!e4le+�M�e;
BOARD OF HEALTH
TOWN OF BARNSTABLE
�lCertifirate Of �tCompriarice
THIS IS TP CERTIFY, That the Individual Well Constructed 4 , Altered ( ); or Repairea".
by— Ole ---____----- Installer
a.
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in .the application for Well Construction Permit Nc$"0'-f f-AI Dated � -----
THE ISSUANCE OF THIS'CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ - = Inspector--------------- ----
'SPd9iyi!!s�ii,i?i�iw6♦.sOfiV;d+liS.i�"6!MYIBV&S(W.ij4¢]E�i42�it,115%kf0'1'8,TA48�aFb1434iQK9Bii'viPo..K,Yi9,til5T6fDii!Fig!6``b'!i!@8R97iV�T1iM&0548!!i.?d'.ti.1437G.!$R$9Birtti 13!lYsPpi93984A!�±is41:4$.WTG!13�i!ir28T1StTim
BOARD OF HEALTH
TOWN OF . BARNSTABLE
Well Con5tructionPermit
No. ==--- .4 a� Fee- =" '
Permission is hereby granted
to Construct ( Alter ( ), or Re air ) azt' divid a ell at
No.
Street
as shown on the p lication fo,rpa.Well Construction Permit
No.-�'' _ - ---- Dated ----
�.
-------------- ---------------------
Board of Health
DATE=— __
T.O.F. AT EL. 131.0' SEPTIC PROFILE TEST HOLE LOGS
/-,ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE)
OG
ACCESS COVER (WATERTIGHT) To ENGINEER: EAGLE SURVEYING
r,
129.0 WITHIN 6" OF FIN. GRADE
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM WITNESS: ED BARRY
E L. 128.0' 4/14/94
128.0' FRUN PIPE OR FIRST LEVEL
VEL 2" DOUBLE WASHED PEASTONE DATE: P
PROPOSED 150.E - PERC. RATE _ < 2 MIN/INCH /Ne eRLOCUS
GALLON SEPTIC 3 MAX.
126.75' 125.5' CLASS I SOILS P# 8203
127.D' TANK (H- 10 } GAS RwZE 6
BAFFLE 125.17' �� 125.0' C7 C❑ CI
( 7 % SLOPE) 6" CRUSHED STONE OR MECHANICAL 124.67 0 Q E:� 0 a O a 0 4 AROUND
SERVICE RbPO `•_,
COMPACTION. (15.221 [21) �$g 2' CD � � � 0 122.67' 1 ELEV. 2
Q ELEV.
DEPTH OF FLOW = 4 (2.4 % SLOPE) ( % SLOPE) 0' 1,33.0' 0" 128.0'
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE
INLET DEPTH = 10"
TOP AND TOP AND WEQUAQUET
OUTLET DEPTH = 14„ SUBSOIL LAKE
SUBSOIL
`t.v-1 36 130.0' 36" 125.0' LOCUS MAP SCALE 1" = 2000'
FOUNDATION--- 14' SEPTIC TANK 65' D' BOX 14' LEACHING MED. SAND
FACILITY
SOME SILT &
STONES MED. SAND
EL. 115.0' 84" 126.0' ASSESSORS MAP 215 PARCEL 34-2
SOME SILT
ZONING DISTRICT: _R-F
EXISTING AND ROCKS
WELL YARD SETBACKS:
�`M FRONT - 30'
SIDE - 15'
CLEAN MED. REAR - 15'
SAND PLAN REFERENCE: 527/84
' FLOOD ZONE: C
EXISTING
WELL
PR
WELOSED
156" 120.0' 156" 115.0
C3 NOTES:
P� -'- � / LOT 8 NO WATER ENCOUNTERED
BENCHMARK Q �/ o /
<
CATCH BASIN A,� ; �26 SEPTIC-,DESIGN:-- (GARBAGE ')!SPOSER. IS ,NOT ALLOWED ) 1 . DATUM IS BASED ON BARNSTABLE CIS
ELEV = 127.0 -
Ni< EXIST. DESIGN FLOW: 3_ BEDROOMS (110 GPD = 330 GPD NOT AVAILABLE
HOUSE - ) 2. MUNICIPAL WATER IS
USE A 330 GPD DESIGN FLOW3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
-� 128 SEPTIC TANK: 330 GPD ( 2 ) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10
5. PIPE JOINTS TO BE MADE WATERTIGHT.
USE A 1500 GALLON SEPTIC TANK
'o! 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
�30 LEACHING: 6.
CODE TITLE V.
rx C'ID� `�/� � ,-� SIDES: 2(12.83 + 25) 2 (74) - 112 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
83 x 25 = 237 USED FOR LOT LINE STAKING.
12.
Q��o ,�� �/ ,, BOTTOM: ('74) 8. PlPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
`.132 �'� �� -.��`EXISTING TOTAL: 471 S.F. 349 GPD 9• COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
LEACH AREA USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
/
EQUAL) WITH 4' STONE ALL AROUND FROM BOARD OF HEALTH,
i 1 10• CLOCATI❑N❑❑FS ALLHALL UN DERGROU NDIB& OVERHEAD IUTILITIESE PR?I❑R
/
/ TO COMMENCEMENT OF WORK.
PT 0 /'� ,# 43,5�3 sFt LEGEND
SITE AND SEWAGE PLAN
1
S,# '/ �<< PROPOSED SPOT ELEVATION OF
LOT 9 OAK STREET
1 C-) #2 100x0 EXISTING SPOT ELEVATION
IN THE TOWN OF:
LOT 10 o� 1��0 100 PROPOSED CONTOUR (WEST) BARNSTABLE
VACANT
o^� 100 EXISTING CONTOUR PREPARED FOR: MARKWOOD CORP.
-a, UTILITY POLE
C_ GUY WIRE 40 0 40 80 120 Feet
LOT 11
BOARD OF HEALTH
APPROVED DATE MA SCALE: 1" 40' DATE: JULY 7, 1999
off 508-362-4541
fax 508 362-9880
l�H 9fy �\N OF M
1�� JJ� �� HJ J
down cape engineering, Inc. o� ��' o� ARNE q�y
L\HIvF. H c
s OJALA `{^ H. ✓
CIVIL ENGINEERS CIVIL - U OJALA
No. 30792 yo NO.26348 Q
SURVEYORS '�oF ISTER 1� ,9F _
F
N 939 main st. yarmouth, ma 02675 - ------ ---- I
99- 161 -9 AR OJALA, P.E., F.L.S. ATE