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HomeMy WebLinkAbout0448 WILLOW STREET - Health 448 Willow Street . W. Barnstable P f1 G A CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Dated: 8/30/2006 Report Prepared For: Order No.: G0637979 Sarah Dowling 448 Willow Street West Barnstable, MA 02668 Laboratory ID#: 0637979-01 Description: Water-Drinking Water 7 Sample#: Sampling Location 4448"Willow-St.West Barnstable,MAT Collected: 8/29/2006 Collected b: S.Dowling Received: 8/29/2006 Routine. ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 8/29/2006 LAB: Metals Copper BRL mg/L 0.10 1.3 SM 3111E 8/29/2006 Iron 0.21 mg/L 0.10 0.3 SM 3111E 8/29/2006 Sodium 9.0 mg/L 1.0 20 SM 3111B 8/29/2006 LAB: lVierohiolo-y Total Coliform Absent P/A 0 0 309 4 r8l29/2006 LAB: Physical Chemistry cr- Conductance 80 umohs/cm 2.0 EPA 120.1 8/29/2006r' pg 6.6 pH-units 0 EPA 150.1 .t 8/2902006 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: &� (Lab ,tr tor) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ro a t d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED /� 350 MAIN STREET �r"� WEST YARMOUTH,MA 509-775-2800 AUG 0 4 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ivIAP MAP-130 PARC-024 Property Address: 448 WILLOW STREET PARCEL WEST BARNSTABLE,MA. 02668 LOT Owner's Name: THEW,KATHY '— Owner's Address: 448 WILLOW STREET WEST BARNSTABLE,MA 02668 Date of Inspection Name of Inspector:(please print) Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience un the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1.5.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ' ^ oil 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 i i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW,KATHY Date of Inspection: 07-19-04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information wluch indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CI\1R 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is inmiinent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 I , Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA, 02668 Owner: THEW,KATHY Date of Inspection: 07-19-04 C. Further Evaluation is Required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is witlun 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Tide 5 Inspection Form 6/15/2000 3 r Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW,KATHY Date of Inspection: ' 07-19-04 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 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—fVvPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW,KATHY Date of Inspection: 07-1.9-04 Check if the following have been done. You must indicate`Yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner;occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner(and occupants if ditherent from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 3Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW,KATHY Date of Inspection: 07-19-04 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): WELL Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establislument: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes;volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) hmovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1997 PEMIT#97-213 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW,KATHY Date of Inspection: 07-19-04 BUILDING SEWER(locate on site plan): X Depth below grade: 6" Materials of constriction: Cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 6" Material of construction: X concrete metal fiberglass polyethylene _ other(explain) If tank is metal Iist age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 GALLON PRE CAST Sludge depth: 4' Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 16 How were dimensions determined: AS BUILT 8a TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL,IN LET TEE,OUT LET TEE. NO SIGN OF OVER LOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of constriction: 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: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW,KATHY Date of Inspection: 07-19-04 TIGHT or HOLDING TANK: N/A (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/day Alann present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Continents(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.,): D BOX IS 16"X 16"0 20"BELOW GRADE,ONE LINE IN,ONE LINE OUT.BOX IS CLEAN&SOLID. NO SIGN OF OVERLOADING OR SOLID CARRY OVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 448 WILLOW STREET WEST BARNSTABLE, MA. 02668 Owner: THEW,KATHY Date of Inspection: 07-19-04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits, number: I leaching chambers,number: 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.) LEACHING IS ONE 1000 GAL.PRE CAST PIT,PIT IS 6'BELOW GRADE WITH COVER AT 16",30"WATER IN PIT,STAIN LINE AT 3'NO SIGN OF OVER LOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (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 or no): Cornments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Conuuents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD PART C SYSTEM INFORMATION(continued) Property.Address: 448 WILLOW STREET WEST BARNSTABLE,MA. 02668 Owner: THEW.KATHY Date of Inspection: 07-19-04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i SA f/ C Title 5 Inspection Form 6/15/2000 10 v Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMRITS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to NO groundwater 15 feet Please indicate(check)all methods used to determine dne high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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 IJSGS database-explain: You must describe how you established the high ground water elevation: TEST HOLE 3' BELWO BOTTOM OF PIT TEST HOLE AT 15' NO WATER /►� � wig' �£�� Title 5 Inspection Form 6i l 5/2000 1 l I No. Fee �jj THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for 3Di!5po9;a1 *potent Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System Aindividual Components Location Address or Lot No. T� A Cs Name,Address and Tel.No. Assessor's Map/Parcel �3d O 1/�r � } Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. T�pe of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 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)_ 44AZ eSUO Q f3� 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 is by this B and of Hralth. Signed Date S--a2 ?- Application Approved by Date Application Disapproved for the following reasons Permit No. C?7-- �/2 Date Issued TOWN Ul- BA1ZNJIABLE LOCATION �s� �/� / _ SEWAGE # �7—o2I3 VILLAGE /!'�.G ASSESSOR'S MAP& LOT 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �fJ LEACHING FACILITY: (type) f ea (size) NO.OF BEDROOMS�o _ BUILDER 0 WNE PERMTTDATE: S —g7_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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 'j f h � a. 0© No. � �` �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC'HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Mgaaf *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System [Xindividual Components Location Address or Lot No. .j'(Lf `491 W. rer's"N:yddress and Tel.No. Assessors Map/Parcel �'U �—O 7` `�' ' /4 . Installer's Name,Address,and Tel.No. 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 2 Showers( ) Cafeteria( ) Other Fixtures . Design Flow 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) /JvO 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 issupyby this B and f Signed =0��/Yo ® Date S'02_ 17 Application Approved by Date Application Disapproved for the following reasons Permit No. 9 7— �_3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (fompliance . THIS IS TO CER FY, that the On-site Se age Disposal System Constructed ( )Repaired ( )Upgraded( ) Abandoned( )by � iL at ha constructed in accordance with the provisi ns o Title 5 and the for Disposal System Construction Permit No. "� ated Installer Designer The issuanc of this ermit sh no be construed as a guarantee that the system kill f nction as designed. Date Inspector -- f3.7 ————————— -----------------.,,� ---�-7—� — ' No. 7 / — :1-13 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogaf *pgtem Construction Permit Permission is hereby granted to 'onsiruct VDepair( )Upgrade( andon( ) System located at Ivy 0 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 's/her duty to �I comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t s p rmit. Date: / Approved by li l TOWN OF BARNSTABLE LOCATION 41 f1T T SEWAGE # VILLAGE —��/��nn ASSESSOR'S MAP & LOT /tiALLSR'S 014CO tfog' 973'-,��as �HR'S NAME&PHONE NO. _SEPTIC TANK CAPACITY —57 Z,10 —Ir/c / S,-a Ir c/i e e� LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE=DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 94 o TOWN OF BARNSTABLE ;0 ATION'Ag r SEWAGE # VIIIAGE /✓ _ ASSESSOR'S MAP& LOT 36- 4 INSTALLER'S NAME&PHONE NO. &Zl� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1600 NO.OF BEDROOMMS-^ BUILDER ORMVVNE�I PERMTTDATE: �� _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ � � . � . _ _ . . , . ! . - � . »; � � � _ � � - � ��J�2T .k : � _�_ � . . . . . : . . . �*� ~ ` ��- . . . , , - . . w & \ \/ . ._ � _ : r , . �\��� w\ � - . � � � - � . . v .� . % : . �� / . � �\> . . /.#U��~\� ��� ��\� . � � �:�&�§��\ J . a 1\>���ƒ� . . . q� 7:��C � � � . »�2 �` ' �% � >%f �.� . . � . ��\�± ' , � �. • \ , � � � ���� � � � § 3 � \ . � ` � \� . � / ��/� � � ����z . TOWN OF BA~RNSTABLE �I,OCATIOIV' C ( SEWAGE # VILLAGE- =- ASSESSOR'S MAP & LOT INSTALLER'S NAME &,P10NE NO. SEPTIC TANK.CAPACITY' " LEACI3ING FACILITY:(type) zz Cn a (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER _ r BUILDER OR OWNER DATE PERMIT ISSUED: t _ DATE COMPLIANCE ISSUED: 7 VARIANCE GRANTED: Yes No /� .' ., � ' .: . c e `�� 1� =; �� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................O F..................................................... Appliration for Dispniial Works Tonstrurtion an it f Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: lt�..... .. . .............•----1! --------- . ....-- ' ----••----------------.........-•--------- Location-Address or Lot No. ............... - . ._. .......................... -•------.------------- -•---------- .......................... a ........ - -.C.----- ---------------- --- -eL -- = '�c....................... ....5?5-..............S/..Addr s — taller Address 0 UT. of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a 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 ( ) N Percolation Test Results Performed by.......................................................................... Date........................................ �.4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ (4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-_---:__-_--__---_-_--- 9 .............................-.............................................................................................................................. 0 Description of Soil....................................................,................................................................................................................... x Uw -•----•--------------------------------------------•-----------------------...... ...----• .� p Nature of Repairs or Alterations—Answer when applicable..____ __ __ ____ ____ ��QLI_... .(LrP. ... -.:---.-------_. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIU, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued b the board of health. p Signed---- .........XE A.. ...... ------------------------ Date e Application Approved By.............. . -- •... ------------------•--------- ...... Date Application Disapproved for the following reasons:....................... .............................................•-•-------.....--•--... ........ ...-. .........................•-------•-•----...------------------•------------••------------...-------------------------------------------------------------------------------------------------•------..._. 7.n Date L41Permit No......... .-... ------------- Issued. .---...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ....................0 F...........................------.........................._... Appliration for Disposal Works Tonotruriinn frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........ �,... ...... � - ............................. i Location-Address or Lot No. -..----- --•------•. .--•---...... -�- .......-•.. ................................................ a / Ow erC .. "-t. f / /� -..Ads ... staller Address T Building Size Lot............................Sq. feet e of �., Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 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............gallons Length-----------_--- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ---•----••--------------•-•---..........---•------••---...-•----------.......-------------------•---......................................................... 0 Description of Soil....................................................................................................................................................................... x c, UW •---••••---------------------•-•••---------•---•-••-------•---------•••-•--••--•••••---••---------••---••--•. - ------------- - Nature of Repairs or Alterations—Answer when applicable____��1 Pi_. ._______. (C✓r1/J-__� �, •__.,,( ._:-•_--_---_-.��0.-..1 = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI�� 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be9A issued by the board of-health. ...--- -__ �u�-.... r Signed -----......... - �1:... .:.. Date Application Approved By............0' �,r-: � : . = ?`--=•�?.G,:.___r.`�... ~ Date Application Disapproved for the following reasons:----------•----•---------------•----------------------------•------------•----------------...........•--...._.. •--•-•..............................•----.....--•------------.....---•----•------•--.........------------••••••-•---•---•-•-••••-•••...••••••--•-•••--•-•------•-------•-••......•--•--............••--- Date C PermitNo.........•--- _ L ..... ------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..�.:V...........O F......... . .,C s. ,.�.. L' ., t{............................. �rrtifiratr of fd omplianrr THIS IS Q CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by � � � `.c?..,= =L� - Installer at................... �'�,��.�_> t,L �� �>�e.zka' ` -------------•-------•--------------. has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---------Pi 2__._1-/_!K]�)----- dated_ -------_----------------------------------•- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... ..`.. .... . ................................ Inspector............. .............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t 1 ........ ! .r ..l. .1. .........OF..............IJ f .`: �C�: !`t................................ FEE-.,.�=1 t� t ...... Disposal Works Tonotrurtinn rrmit Permission is hereby granted-----' s _._.__ .�:.2:5_= -' ` - ._._.. to Construct ( ) or Repair ( --an ividual Sewage Disposal System A atNo.............. L. ...........................G'l':'`.'_ tr-.r c-�_.L:!1^�� _._ PP P � Street �{+ �- , as shown on the application for Disposal Works Construction Permit No.11___.t.:%j_:.__ Dated.......................................... -----------------••-•••-••-•........•••. --=-----------------------------•••••-••••...••-•--.......... DATE................................................................................- .• Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS