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HomeMy WebLinkAbout1567 SERVICE ROAD - Health 1567 Service Road _ W. Barnstable F/R 17d 005009 - - - t p r c. No.-w---7-V- ---- - Fee-4 -------- - - BOARD OF HEALTH TOWN OF BARNSTABLE Application rVeil Cootruction Permit Application is hereby made for a permit to Construct (.o�Alter ( ), or Repair ( )an individual Well at: &) . �(�2/1S f Rc F Location — Address Assessors Map and Parcel 9Jea6 4F 7E2 /C�t --------- - ------------------------------------------------------------ Owner ddress ---------------------------------- --------- ---- Installer — Driller Address Type of Building Dwelling----------------------------------------------------------------- Other - Type of Building ----------- No. of Persons---------------------------------------------------- �/Y/ 77 ��y✓SB//h %/p AJ Type of Well------------- - - ---- -- Capacity-- - - - - - ------ Purpose --— of Well--------------- - ----------------------------- ��Xisritiy 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 until Certificate . Compliance has been issued by the.Board of Health. SignedEfollowing ----------- --------------- D -------------- Application Approved By =-- ©- -- --------— --- ----------- date ApplicationDisapproved for t :------—------------------------------------------------------------------------------------ --------------------------------- - -- - - - ---------------------------------------------------------------------------------------------------- date Permit No. �- -- ---- Issued ------ - - -- ------ -------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS TO CERTIFY, Th t the Indi idual Well C2strZ, ted ( ), I ed ( r ired ( ) by------ — Q - `�'------ - - - --- -- ce )?,n at 7 -- - -- - - - ---IL&- --------------------------------- Installer has been installe in accordance with the provisions the Town of Barnstable Board of Hea rivate Well Protection Regulation as described in the application for Well Construction Permit No. 9- (Dated -- - t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- ---- — ---- Inspector------------------------------------------------------------------------ _ T A ---, e - �5 BOARD OF HEALTH TOWN OFBARNSTABLE Applicatiotf ArVell C0115tructionpermit r4• , Application is hereby made for a permit to Construct (Ci�,<Alter ( ), or Repair ( )an individual Well at: 'S( "p!!iCE Address w , C.n�S%ROE ----- ------- -- -- --- ---------- —-- — ---- — -- —— — -- --- —--- -- Location — Ad�dr/ess Assessorsrs Map and Parcel f�Af7�'U C � i�E 7E 2---N,r/i�i rh a`u1J--------- -1`r�-�----�t✓�--U�r"�--------��--'-�==-------� Own / er ddress Installer — Driller // Address Type of Building ._- Dwelling------------------------------------------------------------------ Other - Type of Building --- --------------------ll No. of Persons--------------------------------------------- f79 6S TI C' �lj C3y/SU/?i %/Aj 1 -----------Type of Well------------------- -------------- ------�--------- Capacity------------------------------------------------------------ - Purpose of Well--------------- - ----- - -�E-XIS711Vy 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 until a-Certificate . :f Compliance has been issued by the Board of Health. Signed - / Z� -- --------------- --------- --- ------- ----------- -------------- / 9 date Application Approved By— -- --=- - - - — --- —- -------------- date Application Disapproved for the following reaso :---------------------------------------------------- --------------------'-------------------------- ---------------- 1 i Y date ,Permit No. - (- -��- ---------- Issued-------------------------------------------- — date iw�we -,�...•,. c.....w......�..-c_._::... ...:.a;.a.... .�F+R-+vsrreertw+.�n. , - _ for _ - . ... < BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f ComPliance THIS IS TO CERTIFY, That the Indi idual Well Co str cted ( ), 1 ed ( r iced ( ) l by-- - --C 1 V - - uf ---------------- - ---—- Instaall�erJ ,� . . at- - - - -� -" � ----------I------------------------- has been installe in accordance with the provisions df the Town of Barnstable Board of H9tDated nvate Well Protection Regulation as described in the application for Well Construction Permit No. - ------------------------ ..Tl-E ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. iDATE- ---- —---- -- - ---- - -= Inspector-------------------------------------------------------------------------- x�.+.:�>..�..�..�..>..,�.�o.��-..�r—.n�w�. .a%�•F.:� i�i!►r she+}aw_e!+eWw 4r+P�av�s a.r�i.�Crw r�rr+•*w+i..ret.r.�s.+.ow.aw.+�:a+arraYr�J+ie>ws�ar�r.:,�sa.dac�x'a�re ras+or-T- ..._._. ti BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con5truct ion Permit No.V--FL- -- Fee-=-------------- r JJ Permission is hereby granted---- - �v1! ----- ----- �--J�1- ,' !'.:------------ to Construct ( Alter ( ), or Re air an I�di'v dua Well at: No. '- Street- � ---------------------------------i } as show n plic ti for a Well Construction Permit i 9 j Na. -1 - J1_��__-L2 - - -- Date ---- � r � ------------------ �-------------------------------------- � I DATE--, 11 Board of Health _ � ------------------------- T I� TOWN OF BBARNSTABLE LOCATION /"7 �5flvIce 1 SEWAGE # '7—y�� VILLAC E W. &r45�gdle ASSESSOR'S MAP & LOT-ZZy INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) .Z��/l "6�Q°S (size) /d X 30 X42 NO.OF BEDROOMS 3 BUILDER OR(5�WNE S PERMITDATE: //-97 COMPLIANCE DATE: C� - Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 5 '� _ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) DSO Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by z 76 �zll No. �—�1 4 Feed THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for &.5po5ar *pgtem Conotructfou Permit Application is hereby made for a Permit to Construct( )or Repair(Y)an On-site Sewage Disposal System at: Location Address or Lot No. 15'Jjj�l/ G�y Owner's Name,Address and Tel.No. Assessor's Map/Parcel /3�-�, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 Type of Building: Dwelling No.of Bedrooms Garbage Grinder(� Other Type of Building & d1 ,e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ile gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when ap licab ) /7`<L 7 r 7 ze� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this B ealth. / Signed Date Application Approved by Date / 9 7 Application Disapproved for the following reasons Permit No. 12 Date Issued No. r _ Fee j�C� THE COMMONWEALTH OF MASSACHUSETTS ` ( / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Mopooar *potem Con!truction Permit Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at: Location Address or Lot No. f jC' `fJr1//G�Y Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/-�'3qy Type of Building: 7 Dwelling No.of Bedrooms J Garbage Grinder(_401 Other Type of Building wt°�e,% eotre No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //601 gallons per day. Calculated daily flow 33� gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs orAlterations. At►swer when apglicabl ) /7-4- -77 Z 4VLe Date last inspected: / r Agreement: }� The undersigned agrees44o'Lsure the construction and maintenance of the afore described on-site sewage.disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of-Health. Signed Date Application Approved by, Date Z /�1 Application Disapproved for the following reasons Permit No. 2' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance TTJ�IS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( V<on by ,/�� xP 4p�/ CD//y Installer at 44 er41%CP /4� � �l�/r!S Q � has been constructed in accordance with the provisions f Title 5 and the f�r isposal System Construction'Permit No. dated Date .`1 ` X Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. / No. � I I —————————————————— /��" Fee �i.J� � � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 30igpoal bpztem Congtructton J)ermit Permission is hereby grant to 1&-le,O111, /15T to construct( )repair( van On-site Sewage System located at No.# /a 7Srrv%Gr° rof. Street and as described in the above Application for Disposal System Construction Permit. No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction mus be completed within three years of the date below. Date: Cl Approved by Board of Health f i NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAINS) I. kejel'),4- J �d��`D� , hereby certify that the application for disposal works construction permit sinned by me dated �` ���� concerning the property located at ZrI 7 56M111're—/W meets ail of the following criteria: YP! ^ere are no wetlands within 300 feet of the proposed septic system were are no private weiis within i 50 of tile^r000sed septic system —fie observed aroundwater table s i- -eeL or areaier heiow Lhe bottom of he teachinv_ aciiir_�; 7�iere s 4no increase in tow ardi.or ar.ae.. ,., in use or000sea nere ",o Variances -,-,quested or:e.ded. SIGNED : DATE: �7G 7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [.Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. s H w,y.�s .t�gjom -.:Er s.'- z'.v �w" �.z,�15'a ,'` �F a[ .✓ r3 i .r 2E' is ti -s '�' .` _ q health folder Bert F i 1 � V �r N S 1? \ j Zi J PJ /yv M� 3` l i t l t TOWN OF BARNSTABLE LOCATION, /J U7 S�r�//C� /� SEWAGE # VILLAGE Qotr�syg6l� ASSESSOR'S MAP 8c LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII,TTY: (type) .xw/`�l�•+c�orS I� (size) -�d k 3 J�oZ NO.OFBEDROOMS_ -3 BUILDER Ok6WRj� 1,�t-_53 PERMUDATE: //-97 COMPLIANCE DATE: g `] Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 's Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) DSO f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within'300.feet of leaching facility) Feet Furnished.by O ' qra�► I, 4� Q�"6L To` le/% R • i/ N i Commonwealth of Mossochusetts r ��Executive Office of ErMronmeniai Affai - D.' .Jolir►Grad UG Title V Septic Inspector Department of 1997 N P.O. Box 2119 �I '��n�.� Environmental P cr.p.� a eatickett,MA 02536 64=6K'133 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR ORT A CERTIFICATION Property Address: 1567 Service Rd.W. Barnstable Address of Owner: to Otis DCVA. (If different) ~ Date of Inspection:7131197 10` SN Name of Inspector:John Gracl Walter Hess:Box 777 W.Barnstable s Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes This Inspection is based on criteria defined in Title V Conditionally Pa es code 310 CMR 15.303.My findings are of how the system is _ Needs F her Valuation B the Local Approving Authority performinq at the time of the Inspection.My Inspection does Y PP 9 tY not Imply any warranty or quarantee of the IongevltV of the X Fails / septic system and any of its components useful life. Inspector's Signature: �/. / Date: 7131197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) _ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1567 Service Rd.W.Barnstable Owner: Waller Hess:Box 777 W.Barnstable Date of Inspection:7131197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health, safety and the environment. 1} SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due,,to an overloader or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1567 Service Rd.W.Barnstable Owner: Walter Hess:Box 777 W.Barnstable Date of Inspection:7131197 D) SYSTEM FAILS(continued) x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 1557 Service Rd.W.Barnstable Owner: Walter Hess:Box 777 W.Bamstable Date of Inspection:7131/97 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. NaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. x The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/15195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1567 Service Rd.W.Brn astable Owner: Walter Hess:Box 777 W.Barnstable Date of Inspection:7131197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available: nla Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:u gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: rda OTHER: (Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped In March by MacComber System pumped as part of inspection: (yes or no)No If yes,volume pumped: 9 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1007 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address: 1567 Service Rd.W.Barnstable Owner.: Walter Hess:Box 777 W.Barnstable Date of Inspection:7131197 SEPTIC TANK: x (locate on site plan) Depth below grade:4' Material of construction:x concreate_metal_FRP_other(explain) Dimensions: L 8'6'H 5'7'W 4'10' Sludge depth:1' Distance from top of sludge to bottom of outlet tee or baffle: 26• Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 0 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic to nk and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: nla Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na (revised 11it5195) 6 � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address: 1567 Servlce Rd.W.Bamstable Owner: Walter Hess:Box 777 W.Barnstable Date of Inspection:7131197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of con struction:_concrete metai_FRP_other(exp[ain) Dimens ons: Na Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate cn site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) n1a ' (revised 11K5195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1567 Service Rd.W.Barnstable Owner: Walter Hess:Box 777 W.Barnstable Date of Inspection'7131197 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible:excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: nia Type: leaching pits,number: 1,000 gallon H2O pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number, length: Wa leaching fields,number,dimensions:n1a , overflow cesspool,number:n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit is past the effective depth of leaching.The system is in hydraulic failure.Pit was full. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: nfa Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: nla Depth of solids: n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 11!15111) 8 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1567 Service Rd.W.Barnstable Owner: Walter Hess:Box 777 W.Barnstable Date of Inspection:7131197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' LOA 4A �c M �7 AC � 34 a DEPTH TO GROUNDWATER Depth to groundwater.12 feet method of determination or approximation: USGS Maps and Charts 12+Feet (revised 11115195) 9 I ASSESSOR'S MAP NO�' j 7 'PARCEL 3 73 � LO CA.T�ION � 57e rr,/c SEWAGE PERMIT NO. VI L'�AG " INSTA IIER'S NAME f ADDRESS Aj t C-j(ejC S.AAJ �S U I.l D E R OR OWNER DATE PERMIT ISSUED D A T E CO .MPIIANCE P/FZ�7 E i p� 6 No...... E?..p � Fim ............. THE COMMONWEALTH OF MASSACHUSETTS ', BOARD OF HEALTH .: B,¢ aL. .... ...:. ...................oF. . Applirativit for l9iup.uual Works Tomitrnrtiun Permit Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal System t: ............ -� t .._.... - - - --.... --Location-Ad r ss r Lot No. W 1..:..:-..-.. .. L• Owner 1/t�! Li. t�'�!1C!_V!5.��7_J!_►...�A� S�d.��. �tlSi�SS Installer Address Type of Building Size Lot�f/ ....Sq. feet .-� Dwelling—No. of Bedrooms._...__.._�.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .........................................------• --•-•---•-•-------.-•---•---•--•-•---..-._- --•------------•------------ -----•---•------------ WW Design Flow..................J5.................gallons per person per day. Total daily flow.............33�J-__._...__-._ .___..gallons. 11 W Septic Tank—Liquid capacityJO!d!..gallons LengthA!n. .". Width.--_/Q... Diameter................ Depths._-7._.. � Disposal Trench—No........ Width g Total leaching area._____ ...sq ft. Total Length............ ... Total leaching area.......---....__ Seepage Pit No........l..___._� Diameter./a.-.- .... Depth 3 g q `� ..__ De th below inlet_�_�. Z�o7_ s z Other Distribution box ( V) IDosing nk ( ) `-' Percolation Test Results Performed by.... 1�... ! !®E. v ............... Date__...f1 __.._....... a Test Pit No. 1...__.2_.....minutes per inch Depth of Test Pit.....14'Q...... Depth to ground water........................ f=, Test Pit No. 2---!!�Z.....minutes per inch Depth of Test Pit....1 ........ Depth to ground water...............-...._... ....p . •-• i r ----.---- � "CD �4NDescriptonooi------1J__-- 4------•T ! _ `S/ : : SC1B�S %GEf0 : ' J 7Z)P 91`<<1 . � �' C � -24 . •• ••----144 i �Sy4 C1(�= - - 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 TITL% 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation tuitil tificate of Compliance has , be� iss t✓-�bo �a a-l-t-h--. Sign .� -= ------------------------- -�-��-�---�---�--- Date Application Approved By............................... ® --- • Z1----gam- Date Application Disapproved for the following r sons:.....................-.........................................................................-_---...:.___=-- .................................-............................................................-....................•.............................................................................•------- Date PermitNo.....•............................................................. Issued_.............................------•---....._.....----- Date No......��� .' �3 s Fss/ �� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... /J''�A,2.VST I L ....................................... Apphration for Disposal Workii Trittotrurtiott Vrrnti# Application is hereby made for a Permit to Construct ( � or Repair ( ) an Individual Sewage Disposal System t �a7 Af6 E-,5 o ............... . •-........----.... ...................................................... .................................................................................................. Location-Ad`dr ss or Lot No. ............�- .y..! .. yv M Ev ...........................................................................................—..... W Owner Address Installer Address _ Type of Building Size Lot.,:� T ....Sq. feet ., Dwelling—No. of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . W Design Flow.................45-5..................gallons per person per day. Total daily flow.............3..C).....................gallons. WSeptic Tank—Liquid capacity/2Q.9...gallons Length'-_(o"._ Width.4.'-/O". Diameter................ Deptl>,5. '-.7.:'.. x Disposal Trench—No..................... Width&_............... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No......../............ Diameter.�Q.-0__..... Depth below inlet.(4....o........ Total leaching area..Z(,7.....sq. ft. Z Other Distribution box (/) Dosing tank ( ) Percolation Test Results Performed b .... .. Date.....1�41 ..6.9 Test Pit No. I...:� ......minutes per inch Depth of Test Pit..../-I .._.... Depth to ground water....... ........... ...__. C:, Test Pit No. 2.. ......minutes per inch Depth of Test Pit.... Depth to ground water........................ G; :; D ...........................•-- O Description of Soil.:�l.Q_, G.......Tl// .,, r��CIL •T. l Z .......G c���}.M. �....L�,4k!. . '.. x ............................•--•--•••--.......-- 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 Sanitary Code— The undersigned further agrees not to place the system in operation until Certificate of Compliance has been issued by the board of health. C Sign „`� �p'�-'• .............•--...................__.....--•---..�...-•---------......._..........- -•-•--......Date.............. Application Approved By.. . .......-- •-••--..... Z q-gam .................... Date Application Disapproved for the following re ons:............................................... ._..__.....__ .............................•---•-•----•-•---•......---................-•-•-----..............----•-.....--••--.........-•----......--•-•------•-••------...-------•-•---------••---•-------•--......--- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ 1.. �"`j lV............... OF...... . �" .. .. .................. (9rdifirttte of Tomplittttre THIS IS TO CFRTIFY, That the Individual Se Ka Di constructed or Repaired by tart..- ,P/1/� ..�.,. --. -- `� ..,. . ....................... In�- D at.. ..../. ------�� nn ��dd t�'.•-------------••---•-------...._..---.......------•--•--•-••--=----------- has been installed in accord rvelvitl4he prov�is5ifris�L`i `� 'rI� 06)( Vhel�tate Sanitary Coded Q' ted in the application for Disposal Works Construction Permit No......................................... dated_-............--..__._.......................... THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL NC ION SATISFACTORY. DATE........... •. •••-1..................................................... Inspector.......`............. THE COMMONWEALTH OF MASSACHUSETTS r74 _5 BOARD OF HEA TH 6-3'�� ........................ �..�. "•.`^.'.............................OF.B ... _....:.......... No......................... FEE.. ........... Bin�ron�tl or�� C�ott�#�ixur#ion �rrmi� Permission is hereby granted.................................. ........... j............. to Construct � ) or RepairL_(Z>V an Ind&idual S sa9 /stem T'p atNo... ......................................... Street as shown on the application for Disposal Works Construction Permit No.............:..... Dated..._. ..... ...... .............._...... •.......................................•- B rd of ....... . DATEI..l..... Health .............................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SOIL EVALUATOR&PERCOLATION TEST FORMS Page I of 4 �1HETq,,_ Town of Barnstable (' ■ARNBrABIX = Department of Health, Safety, and Environmental Services MASS. 019. Public Health Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 FAX: 508-775-3344 Soil Suitability Assessment for Sewage Disposal ASSESSORS MAP N0 /f2i/� PARCEL -- 3 Z NO. Date: Performed By: -( L Date:/ 2 6 76 Witnessed By: Location Address Owner's Name / /(1r es G�� f Lot#: Address,, h Assessor's Map/Parcel: �U`/ Telephone# NEW CONSTRUCTION REPAIR Office Review / Published Soil Survey Available: No Yes ✓ p �yp AW10-4C1 Year Published /9�7 Publication Scale /,"2SODo Soil ma unit Drainage ClassGlCiG W� ;AIU Soil Limitations SG/l4b5-RY 5-e l-2e S0�2°46,,,— Surficial Geological Report Available: No t/ Yes Year Published Publication Scale Geologic Material(Map Unit) Landform Flood Insurance Rate Map: A/0, 25000/ 00/5 C Above 500 year flood boundary No Yes Within 500 year boundary No ✓ Yes Within 100 year flood boundary No ✓ Yes Wetland Area: 726-,STS /Uo7 !/v 41a9/Ud National Wetland Inventory Map(map unit) Wetlands Conservancy Program Map(map unit) Current Water Resource Conditions(USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: 6,&VAdtt/ TCle- 47 �r WIWA� &� 3 ��2 6 � y>�/�2/Gt�iG� TfI64-,C- /yJlf/� 6/3T/v/I/�lJ FiQ�1 ,1j��7P�V DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORA Page 2 of 4 Location Address or Lot IJo. On-site Review 2 . Date:. 'Z /3- 9G Time: 14!3a Weather Deep Hole Number .sue: . .:..:.. . ... Location (identify on site plan) Slope loh► Surface Stones Land Use !��ivr tG�? Plus, OAks . Vegetation 6 .,:. 'W w6C// /Ydd�fli Hiwy . Landform SITE �L�� Position on landscape (sketch on the back) SG� Distances from: Drainage Way feet Open Water Body /D4 feet P /�j0 feet Property Line feet possible Wet Area Drinking Water Well ./�d '. feet Other DEEP OBSERVATION HOLE LOG' l colorSoil Other surface(Inches) Depth from Soil Horizon Soil Texture (Nunes((( Mottling (Structure,Stones,Gavleljrs, Consistency, °� S (USDA) WOO D Ap L64/4 GoA�"� " 3D 5141VO �l �l «. SSG 5141� 5,4,rb loyR���3 #Il x&D 00— 2.� GS�N y F���� fAnl Pj�L?l Sr9/✓D n/g/ 5 a�� 32'I /Zo mrx C—D loy Leo 68as NO DepthtoBedrock: r6 Parent Material(geologlcl �� d Weeping from Pit Face: De th to Groundwater: Standing Water in the Hole: EAtimated Seasonal High Ground Water: DFP APPROVED FO01•12/07/95 FORM 12 - PERCOLATION TEST Page 4 of 4 Location Address or Lot No. � •�� �� � COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test* Date: ._/Z.1/319I-/- Time:. . Observation Hole # Depth of Perc46 Start Pre-soak Id; 30" 5-0 End Pre-soak �Q ¢S:Sv Time at 12" ��; -1 ;hq Time at 9" Time at 6" � Z3.1 4-p Time (9"-6") 00%/8%46 Rate Min./Inch In; �7-559c, Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed Site Failed ❑ Performed By: �o�N_ /� Ze Witnessed By: �lji2� � ,r33,��iey � /d �� ?�c Qd)f s/6 • Comments: �Uf.�..E�.7 ��i.� ..,1'an-..,..�.......M._....:..... ...�M.._�.�,���.-.� �.,�.k.. . ... ..... DEP AMOV®FORM-JIM/95 . .' DORM 11 - SOIL EVALUATOR DORM Page 3 of 4 Location Address or Lot No. Deter�ninatio�i for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole......Q. inches ❑ Depth weeping from side of observation hole ...d inches ❑ Depth to soil mottles . .D inches r-6ssT—,S1Z ❑ Ground water adjustment ................... feet Index Well Number ................ Reading Date .................. Index well level.. 37 P �Adjustment factor .......... . Adjusted ground water level ..... .... G #� 6"OvzW f162. /y.95 IVa7 6rvC4 viv�E �y IT /s / 2E r P/rS 4--r- e5�- , 7 - rd 77 Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? E- If not, what is the depth of naturally occurring pervious material? Certification I certify that on 6 `�✓`� (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me n 017 t with the required training, expertise and experience described in 310 CIVIR Signature Date DEP APPROVED FORM-12I07I9S • SOIL EVALUATOR& PERCOLATION TEST FORMS �,t►tE� Town of Barnstable Page 1 of 4 t i al Services • eA M�� Department of Health, Safety, and Environment �E019. Ake Public Health Division 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 FAX: 508-775-3344 Soil Suitabili Assessment for Se e D *isp osal ASSESSORS MAP NO4 Z a r�•$ PARCEL -3-3 NO. ,y, 1 / Date: ��"✓� -�� Performed By: �AAIAI Date: C Witnessed By: Location Address Owner/'s Name L0 f-r /a/ Lot N: !`J-E f /�G�✓A,rj/ Address,and �Y ,es Assessor's Map/Parcel: Telephone N NEW CONSTRUCTION _2!!�' REPAIR Office Review / Published Soil Survey Available: No Yes ✓ Year Published Publication Scale /%ZS4od Soil map unit Y /n�YP 6 Drainage ClassyU!tabR4/a9&G Soil Limitations 6d4U61ZVf 5;6661966- Surficial Geological Report Available: No ✓ Yes Year Published Publication Scale Geologic Material(Map Unit) Landform Sfl/VJ vy/c y Flood Insurance Rate Map: 2.1�000/ d 0/S C A U6, 19' 1`�g Above 500 year flood boundary No Yes V Within 500 year boundary No V Yes Within 100 year flood boundary No V Yes Wetland Area: i9 �rl�TGfl�/J vt�O .doLr O(�'S�' .9Ti�il/ /V67' fit✓ U National Wetland Inventory Map(map unit) O/Z �i/l!'�N /d� �� � ��'¢�� Wetlands Conservancy Program Map(map unit) Current Water Resource Condition`s(USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: !'QWAIJ/W)9r l)- 6:4' 3 7 PCR 964 ma LZ- ®I�EP F�Girv�C>'fi� ��AT DEP APPROVED FORM-12/07/95 FORM I I - SOIL EVALUATOR F2 R 4 Page /f/ / fzF� Location Address or Lot IJo. C,1es� n-site Review Time: �® A Weather CZ,07/J Date:. y Deep Hole Number 0� �3"9 �. Location (identify on site plan►/�?�/Slope (o ) /,0 o Surface Stones �J3 ,l�B� v�V Land Use Vegetation Landform Position on landscape (sketch on the back) Distances from: Drainage way feet Open Water Body /SD feet �t . feet Possible Wet Area iZ.S'feet Property Line ether ' Drinking Water Well 15,' ' feet DEEP OBSERVATION HOLE LOG Soil Other Depth from Soil Horizon S�IJSDAIra Mlunsellol) Mottling (Structure,stones, Consistency, % Surface(Inches) or-/ �d-'�� .�o ���,7J GlJ/ � � r- oCt1��S�a� ,r jr J'l!_' %b12/73 40 ' z nO 75 A eoYR/�/ a��t�S DepthtoBodrock: AID� ��'L- 4n�9%/U 7�1f - Parent Material tgeologlc) �,u� weeping om Pit Face: fr De th to Groundwater: Standing Water in the Hole: Eptimated Seasonal High Ground water: DEP APPROVED FORM•12I0719S f FORM 12 - PERCOLATION TEST Page 4 of 4 Location Address or Lot No. _ COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test* Date: . Time:. . . Observation Hole # Depth of Perc /,1 Start Pre-soak 23: 45 AM End Pre-soak A10,`�' Time at 12" ✓� �� 3 Time at 9" Time at 6" i Time (9„_6") ; 2 S%1 Rate Min./Inch Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed Site Failed ❑ Performed By: ../ lw/0, Je qtl�— Witnessed By: RM,,60 AW)ZK �� T • Comments: ..... .. .. .. ........:.�:.. . .........:.�..:....... :.,...�.... :::v .�..:.�.-�. Der APPROVED FORM•11/0705 r - FORM I - SUIT, LVALUATOR NORM Page 3 of 4 Location Address or Lot No. Detertninatio�t for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole ... P inches ❑ Depth to soil mottles inches /00 01-11-es ❑ Ground water adjustment ................... feet Index Well Number ................ Reading Date ................. Index well level .. Adjusted round water level ......... ............ ....... . . Adjustment factor .... ...... . J 9 �Qavy�lU�?C� G✓ N°7 E�Co LrN76 A , Iq T - 3 7 Pit ¢ 667To,14 a,49' 7-e5T 1,0/7"s 77, Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorpStion system?L�� If not, what is the depth of naturally occurring pervious(material? Certification I certify that on G' 9�� (date) I have passed the soil evaluator examination approved by the De" artment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature _ - .polle—� Date 1Z DEP APPROVED FORM-12/07/95 mom« � 1 i � `� S# AO N. LOT 7. Plot A,;:PL/CA AJ T* ' BAY BE RAP. Y AIOA$r- .d w . . fir�j `�yG4-,r�r�V.tw+a� �r ,,�""'��� � .,�.rM`°�,�..�..�.«.� � �: �,it a ��f,ef�'� rt� �'�� �� � ,�►` u�' �./E(,t,�' �,•r�f,,`/ d f - psi ► } C} ? % %- GV 9L L. let/y'r G C,Q '-/C A.' 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