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0060 PINE STREET - Health
60 Pine Street West Barnstable A= 153-029 __ . .. ....... Commonwealth of Massachusetts,.. _Title 5 Official Inspec ion' Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is W Barnstable MA 02630 8/10/12 required for every page City/Town State Zip Code. Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end.of the form. Important:When filling out forms A. General Information - on the computer; use only the tab- 1. Inspector: key to move your : q� cursor-do not Ricky Wright " use the return: key. Name of Inspector B & B Excavation,lnc. Company Name .14 Teaberry Lane Company Address. K r ,: Forestdale :.::::. MA : 02644 = . City/Town State al Zip Code 4 508-477-0653 S14595 Telephone Number License.Number a .1 B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ .Fails Needs Further Evaluation by the Local Approving Authority 8/10/12 Inspector's Signature - Date : - - The system inspector shall submit.a copy of this inspection report.to the Approving Authority.(Board of Health or:DEP)within 30 days of completing this inspection. If the system is a shared system or - has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be:sent to the system owner ...and copies sent to the buyer, if applicable, and the approving.authority. ... *""This report only describes conditions at the time.of inspection and under the conditions of use at that time-This inspection does.not address how.the system will perform in the future under the same or different.conditions of use. t5ins•11/10 Title 5 Official Inspection Form:S u ce Sewage Disposal System•Page 1 of 17 T. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y. ❑ 'N ❑ ND (Explain below): l5ins-11/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, t . safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water 4 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10, t e Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or y ❑ ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters s due to an overloaded or clogged SAS or cesspool K Static liquid level in the distribution box above outlet invert due to an overloaded • 40 _ ® or clogged SAS or cesspool • Liquid depth in cesspool is less than 6" below invert or available volume is less ® than 1h day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified• laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400,feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply P the system is located in a nitrogen sensitive area (interim Wellhead Protection El 1:1 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, '^ r d ' or answered "yes" in Section D above the large system has failed. The owner or operator of any e lar Y 9 Y P 9 m 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. i5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Pine Street Property Address - Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 . page City/Town :. - State Zip Code. Date of Inspection - C. Checklist .. : :Check if:the following have been done. You must indicate"yes" or"no":as to each:of the following: Yes No EJ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were.any of the system components:pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of El ® this inspection? Were:as built.plans of 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 breakout? ® ❑ 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? 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: ® ❑ Existing information. For example, a plan at the Board,of Health. 0 ® 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(5)] .::. D. System.Information ,., Residential.Flow Conditions: a Number of bedrooms (design): 4 Number of bedrooms (actual). 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms) 440 t5ins•11/10::; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 v .. .. ..... ... .. ...... ...... .. ..... ....., ...... ..... ...... Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gpd))� Detail: Sump•pump? ❑ Yes ® No Last date of occupancy: July 2012Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t: Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): e General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ :Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) I.E] Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Y 0 Other(describe): t5ins•11/10 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Approximate age of all components, date installed (if known)and source of information: Tank original to dwelling, leaching upgraded in 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 611 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years m Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No + 4 Dimensions: • 1000 gal Sludge depth: no sludge t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound ,no sign of back-up. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): °Dimensions: , ,Scum thickness Distance from-top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle . 1 Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or'Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition,of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) " Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appeared to be stucturally sound no sign of deteration ,or leakage. Pump Chamber(locate on site plan): s Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): R Y. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Pine Street Property Address P Y Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching was dry and appears to be in good condition. No sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool . Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 't5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M40 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of.ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.14 of 17 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in-the area below ❑ drawing attached separately O O - Al- 7 A 3 Ms/ " rr. 83 ' '/Ov 3 ! q7 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ® Surface water , ® Check cellar ® Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2000 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: ' Before filing this,lnspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Pine Street Property Address Estate of Jane McCormick Owner Owner's Name information is required for every W Barnstable MA 02630 8/10/12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary- A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a a 15 L if @s.T TOVViN' CF BARNSTABLE LOCr"ti'iiUNh` PT/K SEWAGE # VI-.LAGE_ U/ ly ___ASSESSOR'S MAP & LOT IL IN7,TALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ,�.� (size) 1.3 X 3 9 NO.OF BEDROOMS BUILDER OR OWNER . PERMIT DATE: 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 t x ,. � . � �` ,- ' �� • � 1 - � � ,, �� _ . . �N� `�f. � � . �` •S s - �� �� �� N O No. L� l� Fee�5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migozal *potent Congtruction Vermit Application for a Permit to Construct( )Repair V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. S Owner's Name,Address and Tel.No. ` P-L' � � CAR/ k Assessor's Map/ParcelW. Inc133 `0.2 Installer's Name,Address,and Tel.No. BR RY07T2—� Designer's Name,Address and Tel.No. i'''df}RSTcs�S�`a..G S Type of Building: Dwelling No.of Bedrooms e Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ITY 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 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 of 'tle 5 o nLalth. tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issue thi o Signed Date 'n 317� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. ' Fee_ F THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Diopont 6pmem Construction Vermit Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / I S , Ca Owner's er'ssNNa/me,Address and Tel.No. er Assessor's Map/Parcel / w w' � ` ) �"" ' "d e Cv1q�� Installer's Name,Address,and Tel.No. BPj1V1g1107T4 Designer's Name,Address and Tel.No. 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 /T" gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �bescription of Soil 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 of `tle 5 adLalth. ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issue this Signed Date Application Approved by Date ( a..-3 a- '?Ci Application Disapproved for th following reasons Permit No. ��^ 1.3 } Date Issued ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the+On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by 1 e/A A I A ` ,1�rl at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer 1 /h Ar�. The issuance of this e t sh 1 not b. construed as a guarantee that the system11 funcction.as dlesigri���� v Date � �I Inspector�K_ f% �1'� �,a, ��Ppi ; /R d� / V v cy----------------------------------- Fee c THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Di5po0ar *pttem Construction Vermtt Permission is hereby granted to Construct( )Repair(>t)Upgrade( )Abandon( ) System located at 4 P-,e. i ST ✓� �,��Q,e,Q�j. 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 permit. Date: C2 -- �C/ Approved by �7 F t/6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. 0,? CERTIFICATION OF SKETCH AYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) � I, 'ea/gR 4L/0rT — hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 60 p-rHE 5r, 13/1w meets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system e • There are no private wells within 150 feet of the proposed septic system , • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less'than five feet above the ma.:dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 fee:of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation 1 the&LkX. High G.W. Adjustment . D1F-ERENCE BETWEEN A and B SIGNED : DATE: (Sketch proposed plan system on back]. q:health folder:ce:t 1 - DICK Lo Oa o: Clk /60© N1� ,vim p,av> o � t l+ PVr ` TOWN OF BARNSTABLE LOCATION 6 pile- SEWAGE # -9q —qt 3 VILLAGE Ufl�ff N ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. R WY SEPTIC TANK CAPACITY 10� LEACHING FACILITY: (type) .7� -1�� 4 (size) 3 x3 NO.OF BEDROOMS i BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: I _ Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet I 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 7 A"vq 1.C) i , TOWN OF BARNSTABLE IN 00C,ATION �j� SEWAGE # ViWLAGE ASSESSOR'S MAP 6z LO' ,� !�� INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY < -S IA/ LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WE OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: — DATE COMPLIANCE ISSUED: "y�fi�v' zT ' VARIANCE GRANTED: -Yes No r Raw'- / a i Y T, i\ .1= I No.. '.�. Fxs... 4�_ere, THE COMMONWEALTH OF MASSACHUSE17S BOAR® OF HEALTH TOWN OF BARNSTABLE Allpfiratinn for Diopooai Works Tonitrur#inn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: W ✓�G��� Lo t ddr .......... --. Owner Address W Instal Address dType of ilding Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.____:................._...............____Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Buildin No. of ersons____________________________ Showers — Cafeteria Pa yP g P ( ) ( ) Q' Other fixtures -----•--•------_-------------•......................................................................... W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_........._.......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..............................................._.......................... Date........................................ aTest 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........................ Descriptionof Soil.....................................-......................................... V` •-•••-------------------------•••--•--••••-----._...•--...--•------•-----------••--......-••••----•-----...-•---•-•••-•-•••••-•••--••--•-----------•••••----.....••---------------...--•--••-----_ -----------------•---------------------------------------------------------------------...-------•-•----------------- •- ------- U Nature�of Repairs or Alterations—Answer when applicable__________ __ __ ________ __ _ :_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with • the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the `system in operation until a Certificate of Complia 7has been is ed b th b and of h lth. Signed ---- ---- -- ---------------------------------- ------------ ------------------------ ------- ---------------- - Date :Application Approved By ...................................... ------------------------- ---------....... ----- ---------------------------------------..---------------------------------------------- ------------------------------- ------- Date Application Disapproved for the following easons- ----------------------------------------------------------------------.............................................. --- ---------------------- ------------------------------------------------------------------ --------- ----------------------------------------------................--------........................... ------=--='--------...----------....... Dare PermitNo- ..........................................................--------- Issued ............................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tons rn.rfinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat: ; ...........�..- ....... ..� .......-- I o .. Loc ddrgss or Lot No. { ............• - ---- --•- ------ ------ _.-- •.... - ----.--•.-.- -----------_---------------------------------- -•^----^•--•--.............................. Owner ................•..__......_..--Address ess W T -e of ildin install' .�. Size .....- 5... feet . d Type �i g q Dwelling—No. of Bedrooms......2...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ga Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ODescription of Soil........................................................................................................................................................................ x U ........................•-------------•---....--•----•--------------•----•----------..........••----........-•------------------------------•---.....----•---••------•-....----••---•-------------...---- UW •--•---•-•---•----------------------------•-•-•---•---•--------------------------------•----•------------------------------------ Nature-of Repairs or Alterations—Answer when applicable..---_..---/() 1� ..(. 2 _. �� .�f... ..---•ee e- ------------••--------•--•------------•-----•-•----------•-------....--•-•---...-----••••------•---••--------•-----•-------------•.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewa e 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 Complia P1has been iss ed b, th board of h alth. Signed ---- ---- -- - -- ----- ---- ------.----------... -.. ----------------- ....................................... , �. ApplicationApproved By ...................................... ----------------- ------------------------------------------------------------- .................----------------------- Da[e Application Disapproved for the following axons- --------------------------------------------------------------------------------- ---------------------------------------------------- ----------------------------- --------------- ------------------------------I.................-- -----------------------------------........-----------------------------..........................----- -----------------------.......---...... Date PermitNo- -------------------------------------------------------------------- Issued ---------------------------------------------------...--------...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cfertifira a of C�ontylinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired at ............ ...... ----- -'...... ..�, .. ..�.�.. , r 3. /N. ice. ( 9f ':.. ............... 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 ......../. �-- .. p THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON*RUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......: ------------------------------------- Inspector ..-....... ..... ps, ^..-- -�.��.�.------�.��_ ���s+�' -- -------=----�.------------- -- i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Disposal Works Tonotrnr#iv Uprrntit Permission is hereby granted.......... • ...... .« ?��!a'� %.... to Construct ( ) r Repair (lam 4n Individual Sewage Disposal Sys em as shown on the application for Disposal Works Construction Permijt�Nro..,1' �G DateQd....+ '.-, .f1�4c .��..Z ....... Board of Health FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS / a. TOWN OF BARNSTABLE LOCATION 4 SEWAGE Vi�.LAGE�9 ASSESSOR'S MAP & LOT/— INSTALLER'S NAME & PHONE NO. _V)�,A_ ±je SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sue) A et, NO. OF BEDROOMS ___ PRIVATE WE OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No 40 N s J. 1 N SUBJECT TO APPROVAL OF Fxs QN&MMTIONTHE COMMONNPAWNA ••••••••• BOARD OF MMS_TH ..............................-....-----..OF.......................................................................................... Applira Lion for DiipnsFal Marks Touti atinn Pamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat: •-- . t..........................•• N .---------------........--............... atie dress / or Loo. ........... •••• ......... -_ ........................... .........._........••------•••-•-•-••••••-•••••-•-•••••-••••••••••••.............................. • caner Address W Installer Address Type of Buildi g Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )U '4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria Q' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank/—Liquid capacity./f. allons Length................ Width................ Diameter................ Depth................ x Disposal Trench— ........... Width____..._._________ Total Length............. .__. Total leaching area________....__.....sq. ft. Seepage Pit No......�------------ Diameter........�_l�__._. Depth below inlet____.__..._. Total leaching area.__-,��sq. ft. z, ther Distribution box ( ) Dosing tank 1-.4 ( ) ercolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2______________minutes per inch Depth of Test Pit--- _........ Depth to ground water........................ i ..-------••_..... _._. --______- fYi _----------- f....__ - O Description of oil... -• ..- Z = i° J x a w ,` ... d e r.-.--..._....Ail .� ,�'� ••--- .._..__ - ___________________________________--_______________________-_________________________________._._.__ _______ _ _ __ UNature of Re irs or Alterations—A saver when applicable..a_ ..c!� =----- ---•---- - -- - --••-.' •--•--_• ------1�..-•- -------------- --- ---------------------------- _._.... . greement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e provisions of TIT I.;;. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in eration until a Certificate of Compliance has been issued by the board of health. Signe •• --•-•• ..........:............•---.....------___•-•••...•--•---••-•--• -- ......................••--•-••- at, pplication Approved By........ j = =--------•------•-• --•t �� 7 ...... Application Disapproved for the following reasons_______________________________ •--•-•....................•------•---------...__....•_ Date-------.....-. -------------------------- •------------------------------------ ....... ------------------------------ ------------------------------------------------------•--------------------Da tetell------------ ..__ / � Da Permit No......................................................... Issued_. _!____-•^--_____ -__....-.._..._...... Date No. .. F>�8........3 ....-�✓` ..._ - .._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................. .......... OF......................-:.....-.....:.... .............................................. Appliratinn for DiipunFal Works Tumitrnrtiun rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 001 ........ __. ...................................... ' ---------•-•----•-----_-----•-_----••-••- �/� catio dress orr Lot No. ._..Y� ..__ .. ...................... ................._. caner • y Address W .......................... ................................................:................................................. Installer Address Type of Build g , Size Lot............................Sq. feet Other—Type of Building ____ Expansion Attic ( ) Garbage Grinder ( ) Dwelling—No. of Bedrooms............................................ `�p, ________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ......................................................._................................d W Design Flow......................:.....................gallons per person per day. Total daily flow.................._.........................gallons. WSeptic Tank Liquid capacity__"' .gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench No_____________________ W>dth__ Total Length_.__..._ Total leaching area............ sq. ft. 'Seepage Pit No.___. Diameter _..._._.. Depth below inlet_._... Total leachin area. .... l P - g :. sq. ft. . Other Distribution box ( ) Dosing tank ( ) Percolation Test. Performed by................. ~ ..........---------------------•---••••-•••---------_... Date-----.................................. � . Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2______________minutes per inch Depth of Test Pit__._,-...,..:..Depth t ground water........................ ------ O .: escription of oil...r .... ".... ... f"�` �j ................... W -- ----- -- --- f+ x U Nature of Re airs or Alterations—A swer when applicabe**:_ . _. � .. w r ........... greement ' The undersigned agrees to install the aforedescribed,Individual Sewage Disposal System in accordance with he provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees-not to place the-'system in eration until a Certificate of Compliance-has been issued by the board of health. Signe __._. w Da PPlication Approved By. "�" .. �•, �. � - Date ` Application Disapproved for 1he following reasons. ...........................Z................................................... 1 "{ ---------------------- -------•---------•----------- --- ---•- Date• -------••--- Permit No.---•............................................. Issued...........................................• === Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .......OF.... .. . ........:.............................. Xrrtif iratr of T pliFanrr T I S TO CE That th$ Individual Sewage Disposal System constructed or Repaired by------ ----------------•------------ ------..._._._...-•-•---•---..._........---•-----.....-•---•----.................. Installer at. ."i". "taw has been install d in accor ce,with the provisions of I F - 5 of The State Sanitary Code as described in the application for Disposal :orks Construction Permit N .� __ _ ___________ dated_--.- �`{�^;t� "...d." __........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE TH �HE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........................--------•-••-•............. ---=------.-....------ Inspector..........................................................................:......_. THE COMMONWEALTH OF MASSACHUSETTS ". BOARD OF HEALTH No......................... e FEE... .............. 'spo 1 nrkn Tun trnrffot4 Vandt Permission is.hereby grante. .,:. ----`-------------------•----. ............ ....---..._. ........... to Construct (.. ) or. R air pan dividua Sewage >, gosal t /,/� a ��treet as shown on the applica ion for Di sal Works Construction Permit YJ}�� _ _ _. ._�04 ted.. "� "'"✓ �" ......, .................. 4____ B '7' !---------------- oar It d h ' DATE....:. ..:..............•'.........;,: ..... r FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS M THE COMMONWEALTH OF MASSACHUSETTS FORM 30 l H � I�OBBS&WARREN f/ BOARD OF HEALTH CITY/TOWN W r ` C� DEPARTMENT /�/�/0 j / P nR ADDRESS TELEPHONE Address_ O_k Occupant- Floor _Apartment Noof Occupants W► .. -_ No. of Habitable Rooms______ _ No.Sleeping Rooms I., No. dwelling or rooming units No/Stori s Name and address of owner - Remarks Reg. Vi0. +� YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage �-I oul 2_,A Infestation Rats or other: m STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress: and Obst'n.: O B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen. Sanitation: Dam ness: C ) fv h a a Al WD ON V IC _", f i"C u1►] - Stairs: , Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: 'I I Al C7 Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks,Flues,Vents: PLUMBING: Sup ly Line: ❑ MS ❑.ST ❑ P Waste Line: H.W.Tarik s Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 11110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantrya - Den' Living-Room Bedroom 1 Bedroom 2 Bedroom 3 . Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. p M J _�, Airy n �td� , � 1 Went.,, lumb.,Sanit'n.: W-59 Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n.- General Building Posted ` , ) Locks on-Doorw A1/1') ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDI ON WHI , / ��' MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJUR. v � fc INSPECTOR c/��=TITLE r� / A.M. DATE TIME P. THE NEXT SCHEDULED REINSPECTION �,1 � � P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found'to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. i .................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ._&W..Y1.................OF:...... . C.xn.�..i�"��..�.�. --------- Appliration for Dhipmal Murks Tongtrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i ocat' n-Address r Lot No. - e Owner ` Address ✓ a - =f •�i r��/-- = c�, --14•:{•'`................. ..................................... Installer Address Type of Building Size Lot..�-_9.®o0._Sq. feet U Dwelling—No. of Bedrooms.......... .Expansion Attic ( ) Garbage Grinder ( ) 1.4 Other—Type of Buildingo. of persons..__._.Z.............. Showers — Cafeteria � Other fixtures ...Z.tJ .1-zc r ..V._r e? ..........................................•---•----• W Design Flow............:Q5 ________________... lons/per person per day. Total daily flow_...__.*.....:..___gallons. WSeptic Tank 7-Liquid capacity./1 _ allons Length................ Width................ Diameter................ Depth............._.. x Disposal Trench—No_____________________ Width........... of �t -----------------_ Total leaching area.................... ft. Seepage Pit No...... ............ Diameter./&&P': epth in ........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by............. .. .4.., .e.............. Date........................................ ,� Test Pit No. 1................minutes per inch Depth o Test Pit.................... Depth to ground water........................ w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth t ground water........................ ... . •--- ..........--•----- . x Description S --... .r1 � ; ��. . ... d ��._ -- _-- . --- ................................... Aso = - V Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ----------------------•.----••-•---..........---....-------•--------•---------------••--••-•--•-•-••------......------------------------------------------------------------------------••••••••••-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be sued by the board of heal X/1 + . D,e l Application Approved By.......... -1. . �. .. .---•.. ............... _ ,� --- `. Date Application Disapproved for the following reasons:.......................:........................................................................................ ..........--•-•..............•---•---•-------•--------------•--•--------........---------•--.....--•---...-----------••---•-•---•--•----..............----------------------•--------------------------•- Date PermitNo......................................................... Issued.....667 .........�-:•- Date -- -------------------"I----------------------- No .... - Flora... .................... THE COMMONWEALTH OF MASSACHUSETTj BOARD OF HEALTH �° "fi.: .... i.. ,►fit..►Y1 OF....... r '• e4, I Av ji ir4flon for 13ispusal Iforks T.onldrnrtinn Prratit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: f�--------------------------------------------------------------------------------- odation-Address r Lot No. uL W O ,py - Address wner (. � t Installer Address Type of Building Size Lot__ ".'?.!;Q9_.Sq. feet U Dwelling-No. of Bedrooms......... _______......................Expansion Attic (. ) Garbage Grinder ( ) Other='Type of Building ............................ No. of persons---------a................ Showers Cafeteria ( ) Other fixtures e!�r/ei t f' ------------------------ - --------------------•---------------------- W Design Flow.............. lons pei n per day. Total daily flow..... :OP"" ...............gallons. WSeptic Tank -Liquid capacity: _ _ allons Length................ Width................ Diameter................ Depth.....____....... x Disposal Trench—No_____________________ Width........... Apt! ot Total leaching area....................sq. ft. 3 Seepage Pit No------I............ Diameter_j� .�_'_- met__"_______________ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank . ~' Percolation Test Results Performed by---------.fn R_-......_ , ._ .�!_ Date__________ ____________________________ a , Test Pit No. 1----------------minutes per inch Depth Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth t ground water........................ O Description�qf Sol--------a-'".- "' ' �,!�"' ................ x = :.._ Y ------------------------•-�{----____---------------------------------_-_______--------____ UW -------------------------------------------------------------------•------=-------------------------•----------=----•...------------------=-------------------------------------=---------------•-_-- Nature of Repairs or Alterations—,Answer when applicable................................................._................................................ ......................................................• -••-•-- ........- -•-••• --•-••• --• -•-•-•--••-••----•-•-----•-••----•--•----•--••-••••••-••-------_..._. Agreement The undersigned agrees to install the aforedescilbed Individual Sewage Disposal System in accordance with the provisions of Article XI of the,State Sanitary Codq— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be sued by the board of'healt} ,?Signed.... ET.�t -. ----- D Application Approved BY ,: . . �'+ . • - •••• - ¢' -- - ��a "` . , Date Application Disapproved for the following reasons___________________ . `^' ..--------••-••-•••-•---•-•-•--••••••-••-•••-••-••-•=----•-----•••-••--•...---•-•--•-•-•••-••••••-•-•-•••--••-•••--------•-•----•••••---•--•-•-••-•---•-•--••-------••••......-••••-••-••••••--------•-- Date PermitNo............................................................ Issued.......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALT (it rr�i$ #� �� 'It�zi� li�nr�e k # THIS. S CZR4IIvY, What e Individual Sewage Disposal System constructed ( or Repaired ( ) by✓ {-;; - .......................................................... ;�' aller at - r ... has been.installed in accordance with`the provisions of Articl XI of The State Sanitary e as described in the «' application for Disposal Works Construction Permit N�.�__ . ..... �:"" ------ ----- dated.. lr'.--..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE. SYSTEK WILL FUNCTION SATISFACTORY. DATE....................•---•----............-------...........•••••--..__..._••---- Inspector.................................................................................... THE COMMONWEALTH OF'MASSACHUSETTS BOARD OF HEALTH N _73 �Q ' ..............oF. 1 ...............---.... FEE.. .... . / 'wi n �n #r Jinn prntif Permission is ereby grante '.',._ -a.._•-- !.................................................................................. Ito Construct or Re pal ) an�ndividu 1 ewage Dispos` 'System IF 144 Street as shown on the application for Disposal Works Construction P it_.,N ;n o r ,of Health w DATE :...._..... - _...............:.•-•••••......... FORM 1255, A0"BBS & WARREN, INC.,. PUBLISHERS - �- fOC1�'✓O f; T,i�� � i j, o 7' � s 0 L_ /' 10 -7 / 12 CERTIFIED PLOT _PLAN L O C.AT I O N. /-',,T`4 43 4 r- SCALE: /"o' 0. DATE — S R E F E R E N C E .64FI N C �o'r— ,q o ro� -•.f 9--�-;�7 v i HEREBY CE RTI FY THAT THE 8U1 LDING LAND S U rll V c U R SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT If CONF.ORM TO THE 0�FMS ZONING BY — LAWS OF THE TOWN OF W H E N C O N S T R U C T' E J JOSEPH M. MONAHAN,JR. N BARNSTABLE SURVEY CONSULTANTS, ' NC . gF40 cisTE�`yo� i WEST YARMOUTM` MASS N0su h '-t'=--- ir.rrrnrnri r.r rw. i� i r 10 Ar vf VJ vi -C wa ,( _ -- , /13 oDos t - - k SCALE: T ' h /f APPROVED BY: DRAWN BY DATE: DRAWING NUMBER II � 01,E CIO ral- A. its 'NYC g iA CL _ I 1-4 14 cos -- - o - - � r i 1 l TGt ULe-Y��'L Co`�+n � (9 0 SCALE: /tom// v /t APPROVED BY: DRAWN BY DATE: j q V O T oivse.- Vja4�k be v DRAWWQ NUMBER i I