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0045 ADRIAN WAY - Health
45 .Adrian Way. Barnstable A = 317 083 oe 4 1 TOWN OF BARNSTABLE LOCATION �� ( �`G� L) y SEWAGE# q VILLAGE c. f-n S �. ASSESSOR'S MAP&PARCEL 0 INSTALLER'S NAME&PHONE NO. ��01( 2194 66 ( SEPTIC TANK CAPACITYr-%JJ%k %M Q / A a J a$o® (Y'k 0' ,w LEACHING FACILITY.(type)tA G.Xis rn%Ots �q (size) %A%y 0 'A NO.OF BEDROOMS OWNER PERMIT DATE: 1 a t 1 I COMPLIANCE DATE: aLq / g 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 I�A —S e. ?LCN-A i CT lCr .r A ,3 l �cu P GG AoZ: L(b � 3 = ► 6c W3 �G �, ,oL No. Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Misposai 6pstem Construction Permit Application for a Permit to Construct lv) Repair( ) Upgrade( ) Abandon( ) ❑Complete System []'Individual Components Location Address or Lot No. y j k rV , CJ ay Owner's Name,Address,and Tel.No. Assessor's Map/Parcel t� o� � " i oVC,.r��� � Installer's Name,Address,and Tel.No.S-a�a�� d vh� Designer's Name,Address,and Tel.No. 5cn� V)� 03C;AC, ZIK 3 Type of Building: Dwelling No.of Bedrooms - Lot Size S s S F LC Vc sq.ft. Garbage Grinder(N Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd r Plan Date Ca 1 1 Number of sheets } Revision Date Title Size of Septic Tank �X1.5� (GO 0 14 e-W Type of S.A.S. Description of Soil VC ks" C Z�LO G-W. Nature of Repairs or Alterations(Answer when applicable) 6® Cc a. O(Ay 5 e(Jk1 C a nS C n f r�-e � (_S-Kr `r.R_ A- � tJ�G d Le �(1C r�SC lS�1n L `�kci 1,uk+'U� d36 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 Certificate of Compliance has been issued by this Board of Health. J Sign Date / L /I Application Approved by Date 0 71 Application Disapproved by Date for the following reasons Permit No. r' Date Issued 1a`f '�� AP 9 / No Fee 1 ... %�/. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plication for Disposal *pstrm Construction 3permit Application for a Permit to Construct(, Repair( ) Upgrade( ) Abandon( .) ❑Complete System [�ehdividual Components Location Address or Lot No. l's A&�G�,n (� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 20 los Installer's Name,Address,and Tel.No.S�� a�u o vt7� Designer's Name,Address,and Tel.No. .5cc�4A M Prc,,,.�. QpW� C.G.P \t\ Type of Building: Dwelling No.of Bedrooms 2 Lot Size ;` Ste,S ACE r� sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date (�T� ( / Number of sheets , Revision Date ., Title Size of Septic Tank Type of S.A.S. Description of Soil7� Nature of Repairs or Alterations(Answer when applicable) AAA t V1,5(�, P.ra�r ci Qoc Date last inspected: Agreements j The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in r accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. . .:'. Signed. s Date/„?/ Application Approved by Date Application Disapproved by E Date for the following reasons Permit No. f Date Issued s2 f rK 3 ------------------------------------------------------------------------------------------------------------------------------------ -- �- �' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Ceftificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed qvl< Repaired( ) Upgraded( ) Abandoned( )by ,r 4 'at a A;- tV has been constructed in ac`c9rdance with the provisions of Title 5 and the for Disposal System Construction Permit No.a of$_3 � dated 7'f n Installer <,CC7�( Designer .#bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date .�- ;,�. (p �/� Inspector �l.�'`�•____ � �.ti7..._ ----------- --------------------------------------------------------------------------------------------------------------------------- No. Dcq 51 Fee / 50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct Repair( ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co m eted within three years of the date of this permit. �---- k Date 2 - "f Approved by i r' \ t' i\�` -i '`J 'r ��` 1,,-+,_,'._..�,__,�' �,w-..._�.'`�-,., `. —I 1\ � ti ,f�� I� (°' .l`� (� � i r � '''�'� fi✓` '\ -� L It ,I�, --•\ <„JI 1 \ ( ; %,. / , r / S / I t � �' \,\_ ',.,1`\'�\ �1 ,!`t\ \ �i ,.M 'i�`/ I � ' � � � '1 I L �' li �`"' /"-f- � y/i !f f f, �f k �� \i�.\�.1��\I\' \I�\t.\. �1tt' ` f C `1 LOCUS MAP \� `�`,a��S/ ' \`{• ,l f �) ASSESSORS NM 3 7 PARCEL 63 1. f".. a Ny +,•.> :� +`.�`l'� \�.\_ -� >\\ 4. I \I j \� W°.a,L w.au ZONING SUMMARY LS ! _uC NAWEE 't ..-•.\ { (, ZONING wsm Rr-z m C7 sm , f \\ \\\ uw.Lot sa u.xo sP. o , NIN.Lot„aoNrAGE ZO• 1 ,,.� I `-�.�•h I ti c I S ,, \ .Inour sEiRAac n• i"--•. ( j^� `:� >� ^-�_.,\\. `'\ _, �\ � �^�, V: W....W....c..NDG IS L�cNT w• o,13 LOC oL OTNINN HE AQUFER Z NOTES �`L�, / � /v,. `.�� ~\ \•\ �,. :- l ( �' �\ J �/ � P I a r 2 � .!. �1} �1 ,.worr�e x.w ee �-.;, / i � \l �<( , -> � ��.ry -. .' / 1 , j! !J(!� � 'I`)� 4 u.ww,Pec wm m�E�/.•Pw.w,. ' 4# ^Z /J } . \1 �' fr._� ✓ % `L NO LOT 5 •;, 239,503 S.F. .... __.u�J Nc. Pvc �-, ro� /�_✓' ` 1 I.�, \ nms,«a , R xa%ar.,�AP,m 1�.` I '`.• 5.5 AC. r ` J • 'PRva� _ ._.•s{ ( ar ua s,uac w.m omce d �n I �' uc.,nw.w acNm a r,lx SYSTEM PROFILE �'\: < 5 -] SITE PLAN IXYTWC J 6EGROOM \_,_. 1 Or ePww :<;xn�`�=o �,` :\�`'�_ �'_\ J•�:.-��'_� ��./�,'—I r✓,f > �5 ( ; l a�'r�l I�;� i �r �,`\� #45 ADRIAN WAY BARNSTABLE, MA nr GIO VANNALEDDY �iGUNW110N— 2)' —SCPRC TINN— 9R' IX511NO E%ISIwG ` ti __ I\_ / ��' ��'/ �J .s[�/ / 1 E%ISt. LEACHING FlEID � •g -,...i'^��Y .f f' r / . .'-- f o j ) � GATE: JUNE I.2018 �`�,�,/ (.�j i,y/� S ) �/J ( J w � sm�r_zo• WR CIKM flal"*r4'<r ~ `? l / lr� f.,1 -.''�\ 1 rti �-,_m,��. `-.�� ^ -,.., r. / / \ -,r'- ✓^-.�_ G-1.-15 ( \/f l i f < �.�—r�` r .✓ ( I 1 \ �� -..�_�, O1 0. ) land serve �� •; xlv, :•,`\` "'\ ,J J i' '�" ..,�-��,\,..` DATE AN0. WA4l P.E.P.I.S ]e Mvin SM1set(MA 6.,r3 \ t •r'� P rwww,rrPwer azs>rs DCB # 8-l76 q .) vi II goom MAW R 1 i y ` r r, L _ - s , 5 ,,• G �s'SB Y ' y •� hF ; a _ - I i _ y � ,w. r - _- - � ,jam �. �. - ka - -_,_ -_ _� w W Page: 1 of 1 CERTIFICATE OF ANALYSIS Aw �^, Barnstable County Health Laboratory (M-MA009) • "ss,�F,v��^ Report Prepared For: Report Dated: 6/18/2015 Sheila Vanderhoef Order No.: G1587287 P0 Box 164 Cummaquid, MA 02637 Laboratory ID#: 1587287-01 Description: Water-Drinking Water $::A Sample#: Sample Location: C45 Adrian Way;Cummaquid Collected: 1, ,06/09/2015 Collected by: customer Received: 06/09/2015 Routine ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen 0.25 mg/L 0.10 10 EPA 300.0 LAP 6/10/2015 Copper 0.11 mg/L. 0.10 1.3 SM 3111 B LAP 6/12/2015 Iron 0.14 mg/L 0.10 0.3 SM 3111E LAP 6/12/2015 pH 6.0 PH AT 25C NA 6.5-8.5 SM 4500-H-B DCB 6/9/2015 Sodium 7.4 mg/L 2.5 20 SM 3111B LAP 6/12/2015 Total Coliform Absent P/A 0 0' SM 9223 RG 6/9/2015 Conductance 120 umohs/cm 2.0 EPA 120.1 DCB 6/9/2015 Water sample meets the recommended limits for drinking water of all the above tested parameters. • Approved ` � Attached please find the laboratory certified parameter list. pp BY (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Town of Ba-�nstable. P# � Department of Regulatory Services EX Public Health Division Date_ s6_1 ems$ 200 Main Street;Hyannis MA 02601 _ Time D MGM Fee Pd. Date Scheduled i —� - oil' S zitability Assessment fop Sewffe DisposalPerformed By Witnessed By: i/t i LOCATION & GENERAL INFORMATION Location Address•.'40 W A lr .1 Owners Name (�} • Address 46 Cad b QO AtA {}yQu/Wl O sfi� 6 7� l rr Assessor's MaplP�tt el: `L JV.1 + Engineer's Name N1Gyo.! d J � NEW CONSIRU01ON REPAIR ^ j Telephone# Sa8 � � 1� I k Land Use t """ 10 E�l'\ � Slopes(96) � � Surface Stones Distances from: Open Water Body S� ft Possible Wet Area ��ft Drinking Water Well>/S ft Drainage Way , ft Property Line --ft Other / ft SKETCH:(Street name,dimensiotis'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) S> SEPT1L .� . yJT KIE- P19-79 Z 0 a 7�7 n y �. - - ..-.v-.-� -.-a o+ -- '- c�- w•-'-'.�.-vim-+v -�.-..Y � � _... i • h I I I i I II I �ue,/ Depth Bedrock tu / l Parent material(gedlogic) l��'C��` d � I p '"^""`'--'� , Depth to Groundwa.tdr. Standing Water in Hole: N i Weeping from Pit FACE — Estimated Seasonal Thigh Groundwater A D RMIN TION FOR SEASONAL HIGH WATER TAA�LE a Method Used: !' In, Depth Clb erved standing�.n obs.hole: in. Depth to soil mottles: Depth toiweeping from side of obs.hole: ! in. araundwater Adjustment t� ! Adj.GroundwaterLevel.,,,,e, _ A .factor.,,,._....- . i Index Well# � Reading Date: Index Well IevG1 - - di PERCOLATIOON TEST . Date— Ton . Observation / I - Hole# i t � t Time at 6" _._.��-- ..-------- . . Depth of Pere � L •' ' Start Pre-soak Time.@ d _1 `� Time(9"-6") End Pre-soak 1 wl e Rite MinAnch ! I Site Suitability Assessment: Site Passed Site Faileds Additional Testing Needed(YIN) Original .Public lie lth Division i Observation Hole Data!TO Be Completed on Back ***If percolafiion test is to be conducted within 100' of wetland,you must first notify the Barnstable C4z. servation Division at least one(1)week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# L - Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenc % ravel b`'_ `� v .A Loam tl.T44 I'Dv, 3 N 3 32 CMW DEEP OBSERVATION HOLE LOG s Hole#_ De th from q , Soil Horizon , Soil Texture Soil Color -.red :Soil 1. ' Other Surface(ir- ' i ' ' (USDA) (Munsell) 4'. Mottling.•(Structure Stones,Boulders. Consisienc4 %Gra el PIP I.A 3 lll///��� �t�32:` DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsistenc Grave 1,0wvw s1�6 2 DEEP OBSERVATION HOLE LOG Hole#-' Depth from Soil Horizon Soil Texture Soil Color? Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. n isten ravel) bt'> 13 tl v A wv►, � �n .�31�/ Flood Insurance Rate Map: / Above 500 year flood boundary No= Yes ___/__ Within 500 year boundary No Yes Within 100 year flood boundary No _ Yes 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? VLS If not,what is the depth of naturally occurring pe ious material? Certification _ I certify that on b (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required t ' in expert se and experience described in 3,10 CMR 15.017. Signature ° Date l 4 Q:\.SEPTlC\PERCFORM.DOC q-03 Massachusetts Commonwealth of Ma �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 45 Adrian Way Property Address John P. &Sheila D. Vanderhoef Owner Owner's Name information is Barnstable Cumma uid MA 02637 June 27, 2015 required for every ( 4 ) page. Cityrrown 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 A. General Information filling out forms 7!# on.the,computer,. . / _4 7 7T id Y.'.:3 a`;Q r.* ma's[. use only the tab 1: Inspector: M key to move your cursor-do not David D. Flaherty Jr., IRS, REHS use the return Name of Inspector key. Flaherty Environmental Services Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 City/Town State Zip Code 508-362-1657 SI#4711 Telephone Number License Number B. Certification 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 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 June 28, 2015 lnspg&Vs 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w ,•'" 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owners Name information is Barnstable Cumma uid MA 02637 June 27, 2015 required for every ( q ) page. CityfTown 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): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 45 Adrian Way Property Address John P. &Sheila D. Vanderhoef Owner Owner's Name information is Barnstable Cumma uid MA 02637 . June 27, 2015 required for every ( q ) page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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, 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 t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owner's Name information is q �required for every Barnstable Cumma uid MA 02637 June 27, 2015 page. Cityrrown 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 (S'AS)'and'the SAS-It 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 clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume.is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal-System Form-Not for Voluntary Assessments 45 Adrian Way Property Address John P. & Sheila D.Vanderhoef Owner Owner's Name information is C bl arnstae umma uid MA 02637 June 27, 2015 required for every B ( q ) page. Citylrown 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. El ® Any portion of cesspool or privy is within 1 00 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 16,000 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 - ❑ El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone li of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, ' or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M ,•''V 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owner's Name information is required for every Barnstable (Cummaquid) MA 02637 June 27, 2015 page. Cityrrown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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 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 break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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. ® ❑ 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: 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 45 Adrian Way Property Address John P. & Sheila D.Vanderhoef Owner Owner's Name information is i bl t Barnsae Cumma ud MA 02637 June 27, 2015 required for every � q ) page. CityTrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No. Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d private well 9 ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of designflow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No s Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owner's Name information is every Barnstable Cummaquid) required for eve ( MA 02637 June 27, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: v Source of information: owner, last November 1000 gallons 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) ❑ 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. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Adrian Way Property Address John P. & Sheila D.Vanderhoef Owner Owner's Name information is ( q )required for every uid Barnstable Cumma MA 02637 June 27, 2015 page. Cityrfown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: new leaching system installed with existing tank in 2004 per BBOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . Depth below grader 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, venting through dwelling adequate, no evidence of leakage Septic Tank(locate on site plan): 1.5 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Forth: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 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owner's Name information is ( q required for every C,umma u ) Barnstable id MA 02637 June 27, 2015 page. Cityrrown 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 31" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? dip stick, tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping should be performed every two to three years, inlet&outlet tees good, tank seems structurally sound, liquid level appropriate, no evidence of leakage a 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 Date of last pumping: Date t5ins•3113' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Adrian Way Property Address John R & Sheila D. Vanderhoef Owner Owner's Name information is Barnstable(Cumma uid MA - 02637 June 27, 2015 required for every q ) page. Cityrrown 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.): Tig ht 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 17' I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 45 Adrian Way Property Address John P. &Sheila D. Vanderhoef Owner Owner's Name information is required for every Barnstable(Cummaquid) MA 02637 June 27, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)"(locate on site plan): off Depth of liquid level above outlet invert Comments(note if'box is leverand'distnbution to outlets equal,-any evidence ofsolids carryover, any evidence of leakage into or out of box, etc.): dbox seems level, no evidence of leakage Pump Chamber(locate on site plan): Pumps in working order: _ ❑ Yes ❑ No*. Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owner's Name information is bl t Barnsae Cumma uid MA. 02637 June 27, 2015 required for every � q ) page. C41rown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (4) ❑ 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.): (4)flow diffusors with stone in a 12'x 40'x 1'configuration, soils sandy with some loamy sand, no ponding, no signs of breakout or hydraulic failure, stone is clean, vegetation typical (lawn) 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•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Adrian Way Property Address John P. & Sheila D. Vanderhoef f Owner Owner's Name information is every Barnstable Cumma required for eve ( quid) MA 02637 June 27, 2015 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 45 Adrian Way Property Address John P. &Sheila D. Vanderhoef. - Owner Owners Name information is Q �required for every Barnstable Cumma uid MA 02637 June 27, 2015 page. City/Town 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-ttte�area betaw,--' - ❑ drawing attached separately 11 �S76 L 61 8 �z 83 ,6 ,r �- - rag ' 3 >/o0'� t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r - Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 45 Adrian Way Property Address John P. &Sheila D. Vanderhoef Owner Owner's Name information is � Q )required for every uid Barnstable Cumma MA 02637 June 27, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >10 Estimated depth to high ground water: 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: 2004 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: system design plans show groundwater past 10' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 �M 45 Adrian Way Property Address John P. &Sheila D.Vanderhoef Owner Owner's Name information is Barnstable (Cumma uid MA 02637 June 27, 2015 required for every Q ) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Page: 1 CERTIFICATE OF ANALYSIS tt' Fri Barnstable County Health Laboratory -- Report Dated: 12/1/2005 Report Prepared For: Order No.: G0533839 Sheila Vanderhoef P.O. Box 164 Cummaquid, MA 02637 Laboratory ID#: 0533839-01 Description: Water-Drinking Water Sample th 33839 Sampling Location 45 Adrian Way,Cummaquid,MA Collected: 11/30/2005 Collected by: S.Vanderhoef Kitchen Tap Received: 11/30/2005 Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 3.9 mg/L 0.10 10 EPA 300.0 11/30/2005 LAB: Metals Copper 1.1 mg/L 0.10 1.3 SM 31.11 B 12/1/2005 Iron BRL mg/L 0.10 0.3 SM 31 1 1 B 12/1/2005 Sodium 13 mg/L 1.0 20 SM 3111E 12/1/2005 LAB: Microbiology Total Coliform Absent P/A 0 0 309 11/30/2005 LAB: Physical Chemistry Conductance 130 umohs/cm I.0 EPA 120.1 11/30/2005 pg 6.1 pH-units 0 EPA 150.1 11/30/2005 Water sample meets the recommended limits for drin'king'water of ill the above tested parameters. Approved By: ( rector) ca C:.n 0 < t ` t V3 +.I -0 z - v3 i t y CA) rri i RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i f Page: 1 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Dated: 12/1/2005 Report Prepared For: Order No.: G0533840 Sheila Vanderhoef P.O.Box 164 Cummaquid, MA 02637 Laboratory ID#: 0533840-01 Description: Water-Drinking Water Sample#: 33840 Sampling Location 45_Adrian Way,.Cumma uid MA q_+ _ Collected: 11/30/2005 Collected by: S.Vanderhoef Well Head Received: 11/30/2005 Routine ITEM RESULT UNITS RL MCL -Method# Tested LAB: Inorganics Nitrate as Nitrogen 3.8 mg/L 0.10 10 EPA 300.0 11/30/2005 LAB: Metals Copper 0.16 mg/L 0.10 1.3 SM 311113 12/1/2005 Iron BRL mg/L 0.10 0.3 SM 311113 12/1/2005 Sodium 13 mg/L 1.0 20 SM 311113 12/1/2005 LAB: Microbiology Total Coliform Absent P/A 0 0 309 11/30/2005 LAB: Physical Chemistry Conductance 130 umohs/cm 1.0 EPA 120.1 11/30/2005 PH 6.2 pH-units 0 EPA 150.1 11/30/2005 Water sample meets the recommended limits for drinking water of all the above,tested param ters. Approved By: (L D rector) rs Cz C i f CI-) 1 a > tV y s I CA) 71 } RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 081 J rJIN1N.i �^T'M O1rwTFR. oiA vnwn�Y ¢�cxA ♦ � C'Y.L w I . J MAIM FLOOQ FLM! 196� SCJ.FT. ' 4�,ao2idni waY B�RNSTOFjLS� Md. i \ UPPE2 LE`:EL PL,SN Leo®�n .. O 0 wewccc/sroxu�n _ �owe2 L�-vEL. PLotd awl s4. cacNn_space smo G q=1=0 4F5 4,DPJ6"J 7 W4- ( JAN-31-02 THU 02:45 AM FAX: PAGE 2 m"e appucation to tocat rire wepartment. Fire Department retains griginal application and issues duplicate as Permit. APPLICATION and PERMIT Fee: x storage tank removal and transportation to approved tank disposal yard in accordance with the provisions t M.G.L.Chapter 148, Section 38A,527 CMR 9.00, application is hereby made by: • Tank Owner Name(please print) --�(t��e1 P� U1.�Cie � X Addr@SS T-1JJl�.�Oak" WA j -SANS�-ft��Q twe y'g°r�� + !J Snae� CQY Staff 8n I I Company Name_Advanc,a Fnvi r nmP p y � � Heal Co.orindlvidual I I Address -L—Gr-eat western RdAddress ,tnr Signature if ag i for permi Signature(if applying for permit) ' C I GI Certified Other O IFCI Certified 0 LSP# Other Tank Location `-f KD2fCA U L-AY ft!/US jlrr ►V Ut S SW address cky Tank Capacity(gallons) _ z O U U _Substance Last Stored �u�•� rank Dimensions(diameter x length) t R0 L k/v p aemarks: �, )�e2G2uu�►� S�v26 ��� i =irm transporting wasteAdvanced Envf ronmerttal State Lic.# hLV5083856100 lazardous waste manifest# E.P.A.# tpproved tank disposal yardJatnes .Gx'an t o. .1 -Tank yard# 008 ype of inert gas Tank yard address Je(at rn f f c t--,r ��ab�y „]„�AW Ai , it or Town / FDID# �` " ` Permit# ) _ ate of issue ��Vo l Date of expiration g safe approval number: Dig Sale Toll Free Tel. Number•800-322 484a gnature/Title of Officer granting permit r removal(s)Bond Form FP-29OR signed by Local Fire Dept.to UST Regulatory Compliance Unit,One Ashburton Place, ..Y.� m 1310,Boston,MA 02108.1618. @vig8tl 9/96t TOWN OF BAIMTABLE 5C. 45 ADRIAN WAY , CUMhiAQUID_BARNSTABLE2004-087 ,,LOCATION SEWAGE # VELLAGE CUMMAQUID?BARNSTABLE ASSESSOR'SMAP& LOT 317-083 INSTALLER'S NAME&PHONE NO. ELLIS BROTHERS CONST _ Cn _ UhZ--Z237 SEPTIC TANK CAPACITY I ®a O EX (5 t 1 N LEACHING FACILITY: (type) C b ill Fgu 5 6ti-5 (size) l )< '(0 l Ff 6:-o NO.OF BEDROOMS JT ` BUELDER OR OWNER JOHN AND SHEILA VANDERHOEF 3/8/04 PERMPTDATE: COMPLIANCE DATE: r 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 o 1 � �f �oC, f r �cc 37. 5 — ,;gs"s TO 4 4 4�,` 4 - 5' 107e �. 1_ z L-7` (6-3 6—� — 1040, _ - 03 lot r � ® s c Q No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ge, l� J PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS �Y RpPlication for Mi5pogar *pgt M (Com5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.Nq. -7i�3 /ft^�2fA w!' wdf G'Si+or ./79 A. ,�/�A+�.�/ -�-Sav/•r l/�ON ��� t Assessor's Map/Parcel , ,, 'f�3�dt�r1a G�vrr1 , 317 �� 083 - � Installer's Name,Address,and Tel.No. Designer's Name,Address sa�and'Tej.No. 0 L�Vr� �AoS. Go.✓1 L+� ' �„_ 3� b or��jQ�7V �l�Nti' S see 3 , Z 3 cZ.vT .�+s,� ✓ . .SAS f- De.�,•ais.� /y!�, v2G5�� 39 o1?y Type of Building: /' BED"''•` ` �-�CA Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 33 Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets a Revision Date Size of Septic Tank ype of S.A.S. Description of Soil C, 40p, -.row .Z-0 PAI � J Nature of Repairs or Alteratio (Answer when applicable). •/X/ 14 p.Bak -,1-" .54 15-2X0 44 1/1, �11� Ll/ � ids A//i11�Ly►/L✓ SINE MUST Date last inspected: S HE ALLA TION AIVD�ERT� SUPERVISE Agreement: SYS ' �9?Vh; —r WRITING The undersigned agrees to ensure ons lion and maintenance of the a A , A I LVer?li g g fdees'cyil7e ;on� te� �s�oyal system in accordance with the isions o tle 5 of Environmen I Code and not to place the system m otion until a Certifi- cate of Compliance has is ed oar"f Health. Sign Date Application Approved by Date Application Disapproved for the following re Permit No. Date Issued THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M ACL DATA No._�Al F �, ( s�K 'THE COMM NWEALTH OF MASSACHUSETTS Entere&in computer: - "�- PUBLIC HEALTH DIVISION -TOWN OFBARNSTABLE., MASSACHUSETTS yYes i Yication for OzaY $tett C0 erfite; , A lication for a Permit to Construct pp ( . )Repair( )Upgrade( Y)Abandon( ) O Complete System O.Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Pazcel` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel;No. / �- ) �/ �3 /l/(7 S. N.S cs --d-•.S i2 _. vZ y 7 .� .3/C�/C,.. j J Z 3 c .vTc .t r s mac✓. 41' 2 N'yr '/I S f �eK.c�i fyl•Q Gy 3y Type of Building: Dwelling No.of Bedrooms Lot Size ' S sq.ft. Garbage Grinder(10,12 Other Type of Building /i No.of Persons Showers( ) Cafeteria( ) Other Fixtures 4. Design Flow 3_3-c�) gallons per day. Calculated daily flow __S U gallons. Plan Date. /— Z-- — a 5' Number of sheets cl;� Revision Date Title/liE% /�/✓�/f, �:�s�f /� ��d/L%/Iti Gfi. _1' ,e,,,� Size of Septic Tank e,"A�s ' " k Type of S.A.S. Description of Soil, -- �vl G ,Z-J a �/� ��/a 4, Nature of Repairs or Alterati l(Answer when applicable) ti I/ ' 6 FI . -5-1 5✓0 Ci/4 G WAq 1,r ny p 3� Date last inspected: CRDANCF To p��STRICT Agreement: The undersigned agrees to ensure tfhe•cons�ction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the/Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y_this:Board of Health. Signed > ,ra4 v0 � 0 i1L Date Application Approved by _ f� � .!; Date Application Disapproved for the following reas Permit No. Date Issued t v THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Comp rice THIS IS TO CERTIFY,that the On-site Sewage Disposal System s (' Ttegaired( )Upgraded( �) Abandoned( )byCLAT1(��o fl�� T�[ �;� at - 2- ;'</�.aA �� s/`4�.1 ,o STEM Chars-beeti constructed$A40gdance with the provisions of Title 5 and the for Disposal System Construction Permit No. �A C� ' ..' dated' i vilftl/kni Installer ;e../ s r s;z.v , Designer h ! y ;.; "�'R�CT The issuance of this permit shall not be construed as a guarantee that the system will function asldesigngd. � Date ] t0 / 14 - Inspector �` - No. 1iN�i(/�fL/� ———-^�------—.— -�--�. ------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE., MASSACHUSETTS MiZpo5ar *pgtem (tongtruction Vermit Permission is hereby granted to Construct( )Repair( )Upgrade( 1,)Abanl�trS(GNjN System located at .— /Il✓� .� �� i�n��.r;^�/' r_.SETA T ENGINEER�j���� f IIJESy N �S�PFR s rIST .. r RITI and as described in the above Application for Disposal System Construction Permit. The applican eco�fil�s%h i�hQito comply with Title 5 and the.following local provisions or special conditions. Provided:C-onnsst/ouctilgn must be completed within three years of the date of erm t. Date: Approved by P FEB-U1-u2 FRI 03:32 AM FAX: PAGE I Po sox 94 J.Dt 3249 Main SVeet Barnstable MA 02630 ��� Phone:(%8)362-3312 Wotmf Fax(5W)362-362.84" ftx m317 ro: Y.�d� From Pax: Pages: pho»m Date: C Re: Q Urgent Q Par Review 0 Please Cosrlmer8 0 Please Reply ❑Pleme Recycle .as,. ..�;k f ..� .s.6. Y;w' h,;:n"f.•. }'• r` rtX, ;' ,SY.,• N,T�. e t� •1 • ggr, as - •'`! lei i'•r?:. � cif:.'.;..: .:'e:r::,., '•al;l.��.,.. b ice!:'r yyyy� i'.✓a'. ; ^��5,!'•i% ��`,'`�F�'i;.�d„sir"��:i i..�.�%' ji``�:+'i .%4� f Feb-01-02 09:49A ADVANCED ENVIRONMENTAL 5083856622 P-04 e2re1�«ae2 19:5© 151Idt1aj/bt7 JM•1LJ w•.r�.. ..._. •., ...�. ��•. 11.►�/�IrI.LL "�.ranu.�P1c��.rM1.. t�uo.ioaoocc t'.V[ F FAX:+at#Rsapp)tcaeton ea taeal p"Wptusmem. Pits Dopevimnt retain'~atioal sWitation sr,0 istua•duplieatt as parent. 00, CP �e�malGtras3+tt i ( eput' lo;-- APPLICATION and PERMIT eu: -M or storago tank remoral and traftportalion to approved tank disposal yard In eceocdanpe wah the pr4QviS+0r!8 i1 M.G.L.Chaptsr tee, SeCtlon 36A,527 CUR 9.00,appliCadon is he►Sby rnR&by � 1 T�nK 0WA61 Name{0Ie282 PhAtl,-S- Alt i #"kfl _ X Cumpany Name Adxutr•aA PAurar Rent,.a Co.or Ift*iftff1 .v aoerasaP_. - Aaa.0 N Sivitwo !a lot peun SiSnawn(If applying low pe"ill t C.nirl�e Other .IRCI Celtrnad Z)UP i •otne� _ Tsr,k Location e4S P,DZ:r A" 1,AM Y NS t rYtl� ranw CAMMY t4a40041_.. .... UCH U rse+w 3v4alenea Lim Sureddr Ta�Jc Cu11Mt 4nS Id anlawr><Isngtl+} r-�) I'l(J L A n 2"1 ` �en>t♦ettf: � �f�.� N{tD _ STe.�R�tt� �".4vJ�L _,._ .... ...._._ -- :-,;rarss,�oewnp�+sata#evaliCed E�iranmant,:ai 9teua�k.a ,�Y50838Sb1 p — eue,00ua waste e+m+ileatf L;.P Is a I W,Owad Ianor giBms)yaraj mes r:G1 ane�s'�•,Tmi� Tanh love a , AAA _... _... __...- Yaa 01 OW oat .__ ._.,Tsrdt ywd ad*%" u •� --_ _ sty o+To.n ts�tpr,v`-- F0101_ f t 1� Pe„nit• —_.._ g a.Ia ailplOrl:nun r 2 oo t ti i V 5 . Oi Is Toll rreo T.1.N%;%-4s+-fall N.2.42j d ' I juturs 17•un of Otkaar ar"rq pMrRi --,--•--_.�_ i ••e"ava0l 29M Forrtl FP-2WFI ttpnod by Local lira peer.to UST Aegulamry Ca1lpllante Veth.One A.hbuow Place en 1310,9oaton,MA021WviliG. .�aM dial Feb-01-02 09:49A ADVANCED ENVIRONMENTAL 5083856622 P_03 02/81/2002 10:bU Lbl tJb41/bCl icu�LJ vR.ur w iti �O71l1Fbd4tdl/�+� �:%P(QO06fR6Ld� �� RECEMT OF DISPOSAL.OF UNDERGROUND STEAL STORAGE TANK Psa)y 20) rL ry p f NAPE AND ADevA"ko—=R ANK YARD 23 RI'8dv1l1 , APPROVED Te*raid cedes►$02 CMA SAIS(4)M~ a✓0 T I I cm"undej�+e Ity of Isw I h p8isa+Ny to um"rom rid steel s W* m M•aoa�Ish YWT by R^^ v1°' pertr�erlhip 1XJ/2.tM/N� snd acoopted eenut N conaonnenoe w111t t►pw�,esem 19►s P�wnnen Re9uils9at 602 CZAR 3.00 PpManx t°�praA�l��w+d SW Storage Tw*d1amwOnp ya►de_ A vom psmdl was ieauod by LOCAL 140 aR Pk*06pO^+"B"4- vmtm �_ to wnaW ad6 tii*.to via Yard. Reams nk yard owner or am*m Ssu�lM0012e0 P*Masmadvw 1=6J � a Aso v _. E / q Thin 3Fgne4 t*Wpt of dh poaat moat W v3jgM d to the IerA head of the fire depaMnenl FOIDif O.L.-. _ !-^. .� .— pursuant to 502 CMR 9.00. EACH TANK MUST HAVE A RECEIPT OF 13111106 L Feb-01-02 09:49A ADVANCED ENVIRONMENTAL 5083856622 P.02 0?/81/2082 10:50 161736417bb JaMt::� ka c I w iIw r..oc uj TANK DATA Galioaa 07600 Prevism Cant=" �?0!4 Qua ua Dtsaneter 'ADO �• ..n�) Data Beedved �- Deparumt Peralt a Scrlal 0(if avadame) Tank 1 ).0(Form FP--290) Owner/Operator to mad revbed copy of Notitkato>a Fan CM9%or FP290R)to :UST Compliance, Office of the State Fin Monks%P.O.But 1025 State Road,Stow, MA 01775. -1 own of Barnstable °� E o Regulatory Services Thomas F. Geiler,Director • URNSTABM • �$ , ; �� Public Health Division 1,9 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 i Installer& Designer Certification Form Dater —� Designer: Sfr6-AN R, /_�PLS��ti Installer: ��I &05. cop�;(- Address: 60— §Z6 Z�Q.31 Address: Z S �41AIKS/ IA.o- A( T On 3'- C`( S &ZOS C-0-/J 5 7- was issued a permit to install a (date) (installer);• septic system at YS gq eW UJA based on a design drawn by (address) n'&4 ¢..-- dated (designer) l� I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations.. Plan revision or certified as-built by designer to follow. J 11 A,UA-C4�4)qa� I ;� 'M (Installer's Signature) (D signer's ignature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTA 9LE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT=CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form _ V ',_, Town of Barnstable P# nlb,A VS t C� Epp THE Tp�� Department of Regulatory Services r anrwsrAec� Public Health Division Date z MAss. a 1 C; 9 039. ��� 200 Main Street;Hyannis MA 02601 • `K `hArfp��n Date Scheduled I ' ► `' Time Fee Pd. 00 Soil Suitability Assessment for Sewage Pisposal ' Performed By: Witnessed By: `J�'1V' �i.• .1�tAn!�^ . ��-S - LOCATION& GENERAL INFORMATION Location Address — Owner's Name f I1 Address lyr Apf. Assessor's Map/Parcel: 3�� Qff/ Engineer's Name NEW CONSTRUCTION REPAIR __,Y\ Telephone# 'Land Use ' 1, r r`F "' Slopes C/a) Surface Stones Distances from: Open Water Body It Possible Wet Area N ft Drinking Water Well ±I. V ft Drainage Way A1 a'T' ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) vvx:awn»wm.o��e.OR�w...a.l ]sVnlm?T+m.nn.•«•.Rsyp`4:a. wv+v.m.mwn. . hs <2 G.W' 'E.W. "Ll . +s.r `-:�t+.+�6 i.+'.'^ +.-.•s.:.-`.nr --.-...- ...-,.'i.-.-.1,..�..- ,+r'.-.o..l "`.. ..�_g - - -' "a�' ,49 t _.` _ V Y Parent material(geologic):5,4 t di a`t Depth to Bedrock rf�6 Depth to Groundwater: Standing Water in Hole: I y 4F"IV4- Weeping from Pit Face A llk Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time VO V; Observation Hale# 71-1 Time at 9" - 3 Aq! I le- Depth of Perc � Time at 6 MIA— Start Pre-soak Time cr 0 Time(9"-6") *' Fit a h+ End Pre-soak t'. 5 • r Rate Min./Inch1 Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original:Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:HEALTH/W P/PERCFORM DEEP OBSERVATION HOLE LOG Hole# c� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Consistent %Gravel t /�' �� L l OoI ;''a A A 1 4111 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel A' li Si tlaihn 14 N41ors . � q f DEEP OBSERVATION HOLE LOG Hole# Depth from Soil.Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Map: , Above 500 year flood boundary No_ Yes Within 500 year boundary Tdo_ Yes _ Within 100 year flood boundary No_ Yes 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? • If not,what is the depth of naturally occurring pervious material? Certification I certify that on C�: / 6)Z(date)I have passed the soil evaluator examination approved by the, Department of EnWronrnen al Protection and that the above analysis was performed by me consistent with the required trainin ,expertise�expe-'en d cribed in 310 CMR 15.017 Signature _ _.S`_ Date Q:li EALTH/W P/.PERCFORM Town of Barnstable P# ON of SHE rpk Department of.Regulatory ServicesV /x) BARNSTAHM Public Health Division Date a MASS. a 9c� i639. ,m4' 200 Main Street;Hyannis MA 02601 "lEn�r s 3ate Scheduled ► G Time l(/� �M Fee Pd. D ! � Soil Suitability Assessment for Sewage Disposal i / Performed By: / y R /� 5, Witnessed By: `/�'lV l'1 LOCATION & GENERAL INFORMATION Location Address y; Owner's Name _ Address Assessor's Map/Parcel: 3 pp33 Engineer's Name_ NEW CONSTRUCTION REPAIR _ Telephone# Land Use KE Slopes(%) Surface Stones f� Distances from: Open Water Body ft Possible Wet Area /V /+ It Drinking Water Well ft Drainage Way IV dR€' ft Property Line 5-0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) a. gMV4 !t . U Jro, 7 .}} di' Parent material(geologic) . n Depth to Bedrock °" Depth to Groundwater. Standing Water in Hole: N64F Weeping from Pit Face IV - Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used:' Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time I-10:im Observation Hole# Time at 9" f �^ id Depth ofPerc CI f Time at 6" /l' Start Pre-soak Time a Time(9"-6") End Pre-soak n / +, Rate Min:/InchIt d3h 6 x.Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) ''Original: Public 1-lealth Division Observation Hole Data To Be Completed on Back --------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:HEALT H/W P/PERCFORM DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel l r Cra C t s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel n � t I*. l)ar 3/r � quo ca a 7. 4 r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) t; DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Flood Insurance Rate Map: Above 500 year,flood boundary No_ Yes Within 500 year boundary No— Yes _ Within 100 year flood boundary No_ Yes 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? If not,what is the depth of naturally occurring P vtous material? Certification / I certify that o /O : /,I- oz(date)I have passed the soil evaluator examination approved by the ction and that the above analysis was performed by me consistent with' Department of Etia-iromnen al Prote Y P , the re hainin , xpertise a d expe''en d scribed in 310 CMR 15.017. Signature il . Date Q:H EALTH/W P/PERCFORM } �T+y � � -----� Health,�department�Hea[th�System y Map/Parcel 317083 pt KFNOM114 01 Tag N r 00240 tang 01/01/1980`:Location B �Tes Not ficatioyDate 09/10/1999 i r Status Dates` Remo M 'oUfication Date: i Test 10/30/2001 y Fue Stored D Fuel StoWrage eason H f Capacity Construction teakDe action atho �c etection �StorageTank nl fob 002000 SS ..__ �Add�tion I�petalf"s �z�fhf -. rt; f` 4. N —4 co IROHMENM Aj)V ANTED p.0. Box 472 outh Der is, MA 02660 (508) 398-2400 !� AX (508) 398-2441 ✓ GATE PHONE r NO. rus�on�raseR en - �1. AGDRESS �r� FAfG OU f L pNAEv7. MDSf.RETD CHAR(3C. re5 ;'1 AMOU11T SOLID B'� Z . �RiGE D-,CF1IPTiGN -- Lef - Z < _ . .1— Te7F ns,7 CAP V'VJ nn•oT nnn:/4TIAO G LO CAT IO NO SEWAGE�PERMIT NO. VILLAGE • • �/� ,(�� IN TA LLER'S NAME Q ADDRESS O U I*L D E R ON OWN ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 23_ 7 17. --,... �� .3 �.. - - '� .� . , �; f f 7Nd0'VaZ ,.... Fps.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --Tow ................OF........ �b /�./►✓..�. ,�Q-l��:,��. _ .._ �.;:r.; Appliratiun for Disposal Works Tunutrurtion Vrrmit a . Application is hereby made for a Permit to Construct (//jor Repair ( ) an Individual Sewage Disposal System at: a .... .. �.. _. � Z!►!�1.�.. , ............. -Address or .... - _ L _... ........ .... Owner , ddress ----------- -----•------- •-•------------------------•---.------1---- Installe Address Type of Building Size Lot.5n.-��...............SkT--feet U Dwelling—No. of Bedrooms...........` ...........................Expansion Attic (rub) Garbage Grinder (�a®) '4 Other—T e of Buildin No. of persons............................ Showers — Cafeteria � u��a' Other fixtures -----•----------------------------------------- ...... --------------•---------•� ........... W Design Flow......../ZLI.........................gallons per. per ay. Total daily flow............................................ WSeptic Tank—Liquid capacitylO�!v.gallons LengthO..X_"'_. Width.f _%4-_`.r Diameter................ Depth- x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........:'........... Diameter...8.:'......... Depth below inlet......_-?__r_._... Total leaching area.c�COIV..sq. ft. Z Other Distribution box ( Dosing tank Percolation Test Results Performed .... Date......!_/:.V?AP....... Test Pit No. 1....4:.`I--.minutes per inch Depth of Test Pit____-�Ln....,_.. Depth to ground water....A,trz.e.Z__. Ic Test Pit No. 2_.__"_-_.2--.minutes per inch Depth of Test Pit... `....._... Depth to ground water...!® ±_ ..... Ri ------------------------------------------------------------------------------------•----------------------------- ------......_._....---------'--•-.......... 0 Description of Soil.........�. ��'e�......... �/9 !' ........... ����'� .....--•-�2.c'���lY....._..����9�!/ x v ........................... t�2 �u.,41--------- i4_�.�. ... -------- --------•------------------------------------------......................... W x --------------------------------------------- - ,¢g.Avpic4abe Nature of Repairs or Alterations-Answer when ...................•--.._...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igne ........... ................................................................... .......................... Date Application Approved By....•--- ,------•------------------ _` ?.�s........ Date Application Disapproved for the following reasons: ---------------------------------------------------------------------•----------------..........--''" -----------------------------------•----....------•-----.......----------•-------.....---•-•---------•-----•---•----•---•--•••--•---••-•-•-••-•--•---•••------•-----•-•---•......--•---......---------- n _rT 7-Y Date PermitNo......................................................... Issued_.,----------------------------------------------------- Date ` . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applirtt#ion for Bispnottl Works Tonstrnrtion ami# Application is hereby made.for a Permit to,Coyistruct ( or Repair. ( ) an Individual Sewage Disposal System at Lien-Address -•_• ------------ P .....i........................... ........... �. ✓�1✓ r ........ Address �----."� ._......_ ---- :.........:.. ..--••........................ .... Installer �r Address >w Type of Building Size Lot._ ::._5.............d3 Dwelling—No. of Bedrooms.__.. .....:.....................expansion Attic (cud) Garbage Grinder (44) Other—T e of Building No. of persons............................ Showers — a YP g •-•-•----------------------• P ( ) Cafeteria ( ) dOther fixtures -------------------------------------' --•----•--•----.........-'•••-..... ............_._. W Design Flow.......1°_/`l..�.........................gallons per, p r day. Total daily flow w•--•......._ .. gallons. 1.W Septic Tank,Liquid capacity�0_A.gallons Length._-._..j__ Width.-._:_kd_.-_ Diameter:................ Depth.-_ ..-- x Disposal Trent- No.................... Width..........� Total Length................. Total leaching area.................... ft. Seepage Pit No f._........ Diameter...a.........i De t-lT,below inlet......46.......... Total leaching area.+ ..sq. ft. Z Other Distribution box ( Dosing tank ( )' aPercolation Test Results Performed by: o! R�+ .__: .�__ f " 1 0:-`-t.... Date....../1/i >1 ,.a Test Pit No. I....G.`.' n.minutes per inch Depth of Test Pit _i.. Depth to ground water.... !►.t�+ ... rX4 1 +;w Test Pit No. 2---' ._1`:_minutes per inch Depth of Test Pit..j!`.�i........... Depth to ground water_-- o `..... .............. ---------- O Description of Soil......... ..>. ..-91t�:__ ..._ .!� t ,Mf.l . ......__,ems ?` l�r _.._._.. :�_`.�.`":..... �"'�+ !l,F V .........-•----•---•----•--•--- :*De'u ......... $N ............................. 3- '--------•---•........ W ----•-'-••-••----•----------------••----•• • • . • ' -�j� V Nature of Repairs or Alua i�nswel & ............................................................... ---•..........•••'••-_..'•-'••-•-----•-------•-••-•-•---•--•----••-•.....--••-------•-•-......••-••••---•--------------=----••••'•••---------•-•-••'--•-••--•-•-----•-...........-•-----•••-.......----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in-accordance with the provisions of TITS 7 5 of the State.Sanitary Code— The undersigned furtheragrees not to place the system in operation until a Certificate of Compliance ha beeniissued,ty>the board of health. Signe .................................... ............... ................ ..... Application Approved Date .PP PP B Y = . ............... a, Application Disapproved for the following reasons:..................Z -------- . ............................•--......---..........•-•-•--------•..._.....-------:_._.......----._._...•-------------......-----:...----------------------- --------................................... Date PermitNo........................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH a .........................................OF...................................................................................... f�le�zrtt#ae ,af f�unt�littnr�e I IS TO C TIF , That the Individual Sewage Disposal System constructed Repaired ( ) bY..... , ... ................................ ........................................................................................... a Instajler • ��3�. r�!•,�- ,.. i--•Y-:T--. r - ------ y - Asl-i lUhas been installed manrovisions o ! > o ' Sta nI r e. end in the a lication for Dis osalWorks Construction Permit �'�_ _ ____________________ dated--. _-. PP P THE ,ISSUANCE OF THIS-CERTIFICATE SHALL NOT BE CONSTRUE® AS AIARAN E THAT THE SYSTEM WILL FU TION SAT • FACTORY F DATE ..... ....................•l•-••-•• inspector.............-------- ......... ....................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0�?........... Fim r-?....... ............OF............. nn ��r#ilan �rmi� i - •.� Permission is ereby granted. r - .....-- f -•---- \ ................ x{< to Con ,r Repair ( a divi�l ewage Disposal Sys'fem j I' as shown on the application for isposal Works Construction Permit_ -___ t .,77 aed. .rr_ DATE. f l ...._ ....... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS " �- ' _ sC N F'. L4'N 1J Cii9RN S—T•A B:L-E M A S5. iY Book ABIf P S6.c '?` _ 71.64 - Q 3. 74•78 E ' •` t•!'1.. ` .11L' , 'ice , • '- #„ � M` T .. LOT .5 yell -, f 450- 64 4 i5b•41 . 16.E7 r Ae= No TOWN Or BARNSTABLE �AG . wPp' ►N Z�� UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS 11 n ASSESSORS MAP NO. PARCEL NO. �® ADDRESS' ALQ VILLAGE 1-a I L_ A lei ��- ���- �l E CONTACT PERSON 'J H � PHONE NUMBER —0�jc� LOCATION OF TANKS: CAPACITY: TYPE OF FUFT, AGE: TYPE: LEAK OR CHEMIC ' DETECTION SYSTEM! DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. DATE O`F FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF- THIS CARD. k i �,�, U 1` •�1 \��.i rt I �` �� 10/2 163 / /' IP�RIVATE I �4 ELL L I ' l / \ 150 ET, WELL RADIUS ( I I / 10� � ' 1 0 5.5 ACRES DRIVEWAY � I j 1 I I � l / I � I ( ( I I l / I I I 1 / I / / & NCJRTH 915 f 1 I I 1 1 l / PARKING Q� 92 9 941 1 I97 9I8 91 C 92 I I 9ll 4 FLOW DIFFUSERS- �� \ 1 I I III I / GARAGE WITH 4 FEET OF LOCUS MAP 45 ADRIAN WAY (NOT TO SCALE) DOUBLE WASHED 1 \ �A4 I I I I I I I 1 CL STONE �34• \ \ �� TE O \ -DBOX N // // / / 'bI I 1 R❑U Reoa n ' \\ STA E / / / / ( ,�, RDI O \ / / / E G \ / u&H. / t Rock Rom V-Y 96 - — \ --�� / / 3 BEDROOM • d TE E SINGLE PE 1 - � � � FAMILY 97. - - - ..-. _ xisting DWELLING CLEANOUT - - 0 G � 98 - - _- - Ta _ _ 32.5 FT P P-10 0 To of Bottom Ste -Deck Assumed SUBSURFACE SANITARY SEWAGE DISP❑SAL SYSTEM 99 - - - - - FOR 45 ADRIAN WAY, BARNSTABLE, MA LEGEND 1 \ r / MAP 317 PARCEL 083 OF+ygs — — — CLE_.AN❑UT // / S❑IL TEST'PIT ❑WNER+ J❑HN and SHEILA VAN der ' SEAN qN EXISTING LEACH PIT j / / 1 H❑EF PERC❑LATI❑N M.' APPROX L❑CATION /� �� ( 1 PLAN # 004-001 O TEST OBR N 015 TO BE PUMPED AND FILLED .� a WITH CLEAN SAND / �/ ( 11 DATE, JANUARY 20, 2004 ® WELL �sTER� 1 q N 101 // I PREPARED BYt f PSEAN M.E A❑X 103BRIEN -- EAST DENNIS, MA 02641 Proposed Contour r / I ± (508) 394-0977 1 / I EMAIL+ 75 SC LE 86.5 FT. I I I sob17@coMcast.net Exlsting Contour SEAN M. ❑'BRIEN R.S. #1015 N❑TE+ THE CERTIFICATI❑N SHOWN BY THE ,. REGISTERED SANITARIAN IS AN EXPRESSI❑N OF PR❑FESSI❑NAL ❑PINI❑N UPON THE1 INCH - 2 0 E E T 102 103 i // / ANDS INFORMATION ANDI THAT IT T KNOWLEDGE 1 — 104 0 C❑NSTITUTES NEITHER A GUARANTEE N❑R / A WARRANTY. s Profile - 45 Adrian Way , Ba 'rnstab ( e GENERAL NOTES AND SPECIFICATIONS 1. This plan Is Intended for the location and design of the sewage disposal system only. 2. This sewage disposal system is not designed for garbage disposal units. FINAL GRADE EL 9e3 4•PVD von 3. All system components shall meet the construction standards as outlined in 310 CMR 15.000 FDM DRM eon FDUL GMDE EL 94.0 (Title 5). 4. The topographic survey was conducted by the sanitarian on December 14, 2003 TW TANK EL 9e36 MUM OR INSTALL RISER •' ''•wff 5. This plan shows features which were visually apparent at the time of the topographic survey. CONCRETE WER NUTLET INVERTS °a mrre COVDR .an.e.ona vaya W SIME EL 92. i r2 FEEEETLGUT FOR .. ....., 6. Deviation from an approved plan is only permissible only with the consent of the sanitarian 4•Au=J!snL 41 PVC Pn•c ! a•,.-;ec "` and the Board of Health. 10 INCH 4•ou sOLro mL Pve PeE ;a?" LLLLLLLLLLLLLLLLLLLLLLLLLL.LLLL�„;r: �'ST' EL 97'19 LLLLLLLLLLLLLLLLLLLLLLLLLL.LLLL a;': 7. All large boulders, trees, topsoil, subsoil, fill material and organic material"shall. be removed 14 INCH INLET TM- INV.EL 9233 BOTH Dry,EL 92.0 INN.EL 9x5 SAS EL.�LO from the leaching area and for a distance of 5 feet around the soil adsorption system to the 3y4•TN I V2•DDAAE vAsr[B STONE s rtEs Pws depth of the parent material In accordance with 310 CMR 15,255. GAS BAFFLE D'BNK TO BE SET ON LEVEL CNNPACTED BASE 8. Any large boulders which are removed from. the proposed soil adsorption system shall be ' replaced with fill meeting 310 CMR 15.255 specifications. SYSTEM PROFILE NOT TO SCALE 4.y,� ° BY V OF D0M 9. There are no potable wells located within 150 feet of the proposed soil adsorption system. �„E S SET�OF SAS r _ 10. There are no. existing or proposed catch basins, subsurface drains, or dry wells located EXISTING 1000 GAL TANK EOTMnVE LENGTH SF , TESTHIM within 25 feet of the proposed soil adsorption .system. TO BE EQUIPPED WITH EFFLUENT FILTER BOTTOM EL Bz3 11. There are no Zone II boundaries for public supply wells located within 400 feet of the . proposed soil adsorption system. 12. There are no wetlands located within 150 feet of the proposed soil adsorption system. S❑IL TEST LOGS JANUARY 21, 2004 13. The Installer shall contact Dig Safe prior, to construction to verify utility locations. 14. It shall be the responsibility of the Installer to notify the sanitarian of any discrepancy Tys*��•+ TEST Oar•P between observed.fleld conditions and conditions as described on this plan before proceeding ° ° EL 9Bn EL 943 EL SU with the Installation. ° AR SSW*Loa Myr3M AP Sw*Lwn,MT4/3 TEST 1°�•' 15. The existing leaching pit and distribution box shall be pumped and removed along with OF MAS „n EL 94d I2n EL gas contaminated soil located within the proposed soil adsorption system. Sq S Loan Sae,oyr3r3 B Loay sow,Dyrv. ° 963 16. This Is a repair of an existing system, no reserve a area has been designated. ?� C�, son.coneln sae emues DBn P 9 Y g g�0 S M N G� a71n a Ned1n sons I0yrw4 EL 9L9 +3►, EL 9a9 Den EL e9.s CONSTRUCTION NOTES O No RedwynwVftc a nm-Keanw Sae Uy - CQj O'BRIEN N ^+� • 0 2�eaymepwc The system shall be Installed with in accordance with 310 CMR 15.00 and Barnstable Board of No. 1015 'w"°t"• PEyCO,HDDN TEST Health Regulations. O 841+ LL een Test HOW old Pe Test PM Red TE�� C2 Nf�° Svnd =d a nahwty P.& SEPTIC TANK S No Beyosteae WH Wftmw 1. Existing 1000 gallon septic tank shall remain, Tank shalt be Inspected, pumped and cleaned to DnNd V.SUM-R.S. Q ego DP e4 GWlww oP voter ensure water tightness. 1e61 ce sRt Loa 25y6n ;t L a D.'"P'e`°'" 2. Inlet and outlet tees will be replaced with Schedule 40 PVC tees, outlet tee will be fitted '3ft a.93a <2 min/Inch Rate with a .Zabel effluent filter. • 5p4 co ok sob 3. Outlet manhole shalt be raised to within 6 Inches of grade. _� � Pak 4. All ,Joints and Inserts shall be waterproofed. FLOW HLCULAT ❑NS DISTRIBUTION BOX NO ER NOGRaVATER 3 BEDROOMS = 330 GALLONS PER DAY EHcouNTErEB' BDI E � 1. Distribution box shalt be set on a level stable base of 6 Inch compacted ?' - 1 3€' stone. _ I'Mn EL a30 I4,n E'er 2. Distribution box will be Shorey DB-5 H-10 load rating or equivalent 3. Outlet lines shall be level for 2 feet. PER( RATE < 2 MINUTES PER INCH 4. Distribution box shall be water tested..to ensure water tightness and even effluent distribution. LTAR .74 GALLONS PER SQUARE FOOT 5. All ,joints and Inserts shall be water proofed. USE .66 LTAR 6. A riser shall bring access to 6 inches of grade 500 SQUARE FOOT SAS REQUIRED SOIL ADSORBTION SYSTEM 1. Bottom of SAS will be excavated will be excavated to a level grade. Only clean medium sand USE: shalt be used as fill. 2. 3 Shorey FD 4X8-L and 1' Shorey FD 4X8-D or equivalent will' be used for the SAS. 3. Only Clean Double Washed Stone free of Irons, Fines, Dust and Organics shall be used for NO INCREASE IN FLOW USE EXISTING 1000 GALLON TANK the SAS. 4. A PVC vent with an activated charcoal filter shalt be Installed 5. One observation port shall be Installed to within 6 Inches of grade. 4 SH❑REY 4X8 FLOW DIFFUSERS WITH 4 FEET ❑F 6. A 40m1 flow barrier shall be Installed along the.North portion of the SAS between the elevations of. CLEAN DOUBLE WASHED STONE ON, SIDES AND ENDS, ONE FOOT EFFECTIVE DEPTH, GENERAL 1. Only Schedule 40 PVC pipe to be used on system. Bottom area 40X12 = 480 square feet 2. All disturbed areas are to be loamed, seeded and maintained to prevent erosion. q 3. The contractor shall be responsible for vertical and horizontal control of all system Sidewalk (40X2)+(10X2)Xl=100 square feet components. 4. The contractor shall be a licensed 'Disposal Works Installer' in the Town of Barnstable. TOTAL 580 square feet l 5. The Contactor shall notify the Barnstable Health Department and the sanitarian for all CAPACITY 363 GALLONS PER DAY I appropriate Inspections. 6. Distribution box and SAS shall be a minimum of 9 Inches and a maximum of 36 Inches below grade. NO GARBAGE GRINDER ALLOWED 7. Buoyancy Calculations are not necessary for this Installation. n 3.D9.44 .4 AI Lr Q7 . 5C Ac. E V. a0 7 4a. LOAM AN as APR , ELE`V: t ,a 3 tr NO LJA CR �VC tV rr-9 ,6 so; 7 i RESERVE E� ,,o ''•' �.o _ y o t a ,/",L.EACN �,P/,7 ,z s;s, .. •� �5. `� ` � -. -. ,. fir. NAaL IN TREE ;j ' • . . x To 30. 450. 6 4 J3u1Z-01/vG 5E770ACX-- A2Z= v�; �n-�I rr - SC;y.L _ 4 :t F2��✓T /_^.' 5/ D / TZE4 ram ' y '' ' SEPTIC 5 y5 TAM C0Ak5T/2UC?/ON SHALL COnJFo,,2M TO MASS /V .• C—NV/QO�I/MG-N7"�}L CODE T/7L,� 1T �� L C—A C N2,4 TE .. hi. la I �'EQU/2EL� L 4�'N A dF L.TA/ 1Z�C,UI-A7-/ONS 7-0� :. .mil?©po.5 713 E tc=s r G o .. 2 0/ 74/t/ 3 ,{Q M�n��10�' co✓�� �"b TEti11� T�^. �/�pL i2 Vi0LI �'D:/:E� {. ' _/ W/ TH/N �N- .�G� I✓iA!/�.y�� :.�T��1 LSE, �•.._: T4,p2E VFA-/T /wES Xo tisi,v 4 D/A. WATFA2- � y P/TGf/ I—� FcOw iivE— _� : /O L t{ �/-/ t�� *�• � �. t %4" F�aT i /4' �4 i/FOOT . M!n/ �i r ff ""_ JY GA L t_ /N✓ETc'T �' i< ; cli< �i {/N✓E.QT i' ! 1 c �T�' TAN '! �i a f Ale r)C4 ti,J J � ) I �ltlA T r 4 T/ice a # °A56r c?f= - �- ; :MA __ P A Al �5 .�f _ s�7' - 1`ti C QL/T 7� A ;27 G'EAG'r!/.Vt-,'. /7-` ` .t r 3ff`(f �'4I • I� :vim z�r� � L vim. 3000 P 076 P - V :a 10 77 -