HomeMy WebLinkAbout0412 BRAGG'S LANE - Health 412 Braggs Lane
Barnstable P
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CONTRACT Customer Name(llt4�oisn -F`—C�sta{ U�Q S�t��€ Customer Signature .�.,-
SKETCH Contract Date 7 f31 13'7 Sales Representative Si
gnature.
ATTACHMENT Customer Phone &VAI M;fvty &ar 62.2rs,l b C f 2Mgq-I$y) Contract P�ice�A4,
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NOTES: w p 'Each box equals one foot unless otherwise noted.This sketch is a good faith
_'�`"Z4li4S representation of the work to be done,it is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets,light
fixtures,plugs,jacks and/or switches are subject to change if necessary.
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COMMONWEALTH OF MASSACHUSETTS
}:f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P T
RECEIVE®
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a+•n, 3
i t FEB 1 3 2002
�e TOWN OF BARNSTABLE y `
HEALTH DEPT.
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM r `
I *' PART A:,,'
CERTIFICATION
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630 s r }
=1 Owner's Name: ARLENE HINKLEY °
Owner's Address: PO BOX 1106 BARNSTABLE MA 02630°
Date of Inspection:2/7/02 '
14
i Name of Inspector: (please print) _ JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: �i, P.O.'BOX 2119 TEATICKET,MA.,02536
r Telephone Number: 508-564-6813 FAX 508-564-7270gi-
.�
CERTIFICATION STATEMENT
' I certify that I have personally inspected the sewage disposal system at isMthis�address and that the information reported below ;
7,
.i true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and N. t .
1 experience in the proper function and maintenance of on site sewageidisposal systems. I am a DEP approved system ,, ��r� s� '
p p p
' inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)�rThe system: a ,
X Passes `� x
_ Conditionally P sses r t"
Needs Furt r valuation by the Local Approving Authority #
Fails to
s ; Date: 2/7/02
Inspectors Signature:
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The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)-
1= 30 days of completing this inspect on. If the system is a shared system or,has a design now of 10,000 gpd or greater,the 4 �r�}
inspector and the system owneri shall submit the report to the appropriate regional office of the DEP.The original should,,,,-..
• sent to the system owner and copies sent to the buyer, if applicable,'and the approving authority.
Notes and Comments
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE .
SYSTEM'S USEFUL LIFE.
j: ****This report only describes conditions at the time of inspection"and under the conditions of use at that time Thk
ins ection does not address how the system will perform in the future_under the same or different conditions of use '
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Page 2 of 11 +F
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS � � '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
+ PART A
CERTIFICATION;(continued)
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630,
Owner: ARLENE HINKLEY Y
Date of Inspection: 2/7/02 '
W
}i Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: P
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310;a J4,' f
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.'
w
Comments: y, � 5
SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE a
j SYSTEM'S USEFUL LIFE.
• 1 ;
B. System Conditionally Passes:.
} _ One or more system components as'described in the"Conditional Pass"section need to be replaced or repaired.The system, a F
upon completion of the replacement or,repair,as approved by the Board.of Health,will pass. L `
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain:, M{
n/a The septic tank is metal and over 20 years old* or the septic tank.(whether metal or not)is structurally unsound,exhibits )' ? y
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 ass inspection if it is structural) sound not leaking and if a Certificate of Compliance indicator x �.
P P p Y g p
that the tank is less than 20 years old is available.
ND explain: n/a
€ n/a 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
a Health):
i _ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced.
' ND explain: n/a
n/a The system requiredpumpingmore than 4 times a year due to broken or obstructedpipe(s).The s stem will
Y Q Y Y pass'
{ inspection if(with approval of the Boa4o''f Health):
broken pipe(s)are replaced ,
_obstruction is removed
ND explain: n/a
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Page 3 of 1 I }A,
r OFFICIAL INSPECTION FORM -NOT FOR;VOLUNTARY ASSESSMENTS511
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
} PART A' S
# CERTIFICATION(continued)
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630' ��
Owner: ARLENE HINKLEY
Date of Inspection: 2/7/02
C. Further Evaluation is Required'by the Board of Health: �* s
` Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to ff.t ar Tea
protect public health,safety or the environment.
A "
j 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system,is-110
l not functioning in a manner which will protect public health;safety and the environment: tF `
_ Cesspool or privy is within 50 feet of a surface water ,t`
i _ Cesspool or privy is within 50 feet of a bordering vegetated•.wetland or a salt marsh
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• 2. System will fail unless the Board of Health(and Public Water,Supplier,if any)determines that the at
`k system is functioning in a manner that protects the'public health,safety and environment: _ .
} _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water i�s
supply or tributary to a surface water supply. jr "
_ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
1 _ 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'
i supply well".Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and k
e from m
pollution from that facility and the presence of amoni
volatile organic compounds indicates that the well is fre a
nitrogen and nitrate nitr=this
al to or less than 5 ppm,provided that no other failure criteria are triggered A copy�r
of the analysis must be form. �, w
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,i 3. Other:
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n/a
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Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIONi,(continued) � �3
Property Address: 412 BRAGGS LN BARNSTABLE,MA 026311
i Owner: ARLENE HINKLEY
i Date of Inspection: 2/7/02 s' t
;i
E; D. System Failure Criteria applicable to all systems: . ''A ,
S You must indicate"yes"or"no"to each of the following for alLinspections: P 4
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Yes Nok ,;
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool rr`
_ X Discharge or ponding of effluent to the surface of the ground orsurface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert'due,tto an,overloaded'or clo ed SAS or cesspool,,,
_ X Liquid depth in cesspool is less than 6"-below invert or available.volume is less than z day flow
X Required pumping more than 4 times in the last year NnT>due to clogged or obs cted i e s .Number of tunesx
q P p g y gg p�P ( )
Pumped n1a.
X Any portion of the SAS,cesspool or privy is below high groundwater elev ion. ' ' xF
: X Any portion of cesspool or privy is within 100 feet of a surface waters ply or tributary to a surface water supply"�t
X An portion of a cesspool or ri is within a Zone 1 of a ublic we a�
F - y P P P.,vY P
YS J{�,
X Any portion of a cesspool or privy is within 50 feet of a private w er supply well. k K.
.y
_ X Any portion of a cesspool or privy is less than 100 feet but,gre er,than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes ' the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volaf Norganic compounds indicates that the well is free,f '
from pollution from that facility and the presence faammonia nitrogen and nitrate nitrogen is equal to;Dr,
Y-. !
less than 5 ppm,provided that no other failure iteria are"triggered. A copy of the analysis must be r
attached to this form.] F
�f
_ (Yes/No)The system fails.I have determine that one or more of the above failure criteria exist as described in4310 �
CMR 15.303,therefore the system fails.The system wner should contact the Board of Health to determine what will be ;V',,.
necessary to correct the failure. J�`
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t 1 E. Large Systems:
To be considered a large system the s tem must serve a facility with a.design flow of 10,000 gpd to 15,000 gpd s
You must indicate either"yes"or"no" o each of the following `
(The following criteria apply to,lar systems in addition to the criteria above) 1 `
j�t
; l yes no
X the system is within 0 feet of a surface drinking water supply
X the system is wit 200 feet of a tributary to a surface drinking water,supply L,
X the system is cated in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
f Zone II of public water supply well
1 If you ve answered"yes"to any question in Section E the?s stem is considered a significant threat,or answered A, ,
" es"in Section above the large system has failed,The owner or operator of any large system considered a significant threat
1 Y
"NE"100
under.Section E or failed under Section D shall upgrade the system ih accordance with 310 CMR 15,304.`Che systettt awn�r
should contact the appropriate regional office of the Department
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Page 5 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
e
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E "
" PART B'k.
CHECKLIST . r
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Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630= �
Owner: ARLENE HINKLEY
Date of Inspection: 2/7/02
} ,
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?
a X _ Has the system received normal-flows in the previous two week period'? r
_ X Have large volumes of water been introduced to the system recently or as part of this inspection? , y
E 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?
;x 1
i X _ Was the site inspected for signs of break out? t
1 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?
1 `
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper mamtenance�
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.l of subsurface sewage disposal systems
v
The size and location of the Soil Absorption System(SAS)on the site has been determined based on: a
Yes no :;.
} X _ Existing information. For example,a plan at the Board of Health.
�l
X _ Determined in the field(if any of the failure criteria related to�Part C is at issue approximation of distance is M
unacceptable)[310 CMR 15.302(3)(b)]
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Page 6 of 11
( 7 z
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACK SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C';
SYSTEM INFORMATION
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630
Owner: ARLENE HINKLEY
Date of Inspection: 2/7/02 ' `
! FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3 :, k
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
5 Number of current residents: 2
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] �Y
' Laundry system inspected(yes or,no): NO
i Seasonal use: (yes or no): NO
' Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
` Last date of occupancy: n/a ,
COMMERCIAL/INDUSTRIAL j
Type of establishment: n/a i �x
' Design flow(based on 310 CMR 15:203): n/agpd 9r A
y Basis of design flow(seats/persons/sgft,etc. : n/a
m
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes;or no): NO F
,l Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a r
GENERAL INFORMATION yxi
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/aµ
Reason for pumping: n/a r4 ;
z TYPE OF SYSTEM a
X Septic tank,distribution box, soil absorption system
_Single cesspool r -
_Overflow cesspool ' ' 'x
.s_ Wz
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)
_Tight tank Attach a copy of the DEP approvals ' s :.
Other(describe): n/a
gApproximate age of all components,date installed(if known)and source of information:
23 YEARS WITH NEW SYSTEM THREE YEARS OLD. h '
Were sewage odors detected when arriving at the site(yes or no):NO
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s Page 7 of 11 w. ZZ
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , '
PART C:
SYSTEM INFORMATION(continued)
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630' + e
Owner: ARLENE HINKLEY,
Date of Inspection: 2/7/02
BUILDING SEWER(locate on site plan)
1
Depth below grade: 18" �
Materials of construction:_cast iron X40 PVC_other(explain): n/a _ h
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.)
TOWN WATER 14
I1 SEPTIC TANK: X(locate on site plan) s '
Depth below grade: 12"
` Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) 4 ''
Dimensions: 1000G L 81611 H 5 7 W 4 10 t �
1 Sludge depth: 1" baffle:33" �+ ,
Distance from top of sludge to bottom of outlet tee or ;
Scum thickness: 0"
� Distance from top of scum to top of ou
tlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: MEASURED +
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relate `
to outlet invert,evidence of leakage,etc.): bei' J4
r ' SEPTIC TANK AN
L COMP
ONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. 4,
S
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG.THE SYSTEM'S USEFUL LIFE. i
GREASE TRAP:_(locate on site,plan)
' Depth below grade: n/a t
t Material of construction:_concrete metal_fiberglass polyethylene_other(explain): n/a
Dimensions: n/a
''. Scum thickness: n/a
Distance from top of scum to.top of outlet tee or baffle: n/a
{ Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a r
Comments(on pumping recommendations, inlet and outlet tee or baffle,condition,structural integrity,liquid levels as related�£
' to outlet invert,evidence of leakage,etc.):
j { e t5
n/a � .
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR YOLUNTARY ASSESSMENTSF 4 ,
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM '<
PART C. z° ., r
SYSTEM INFORMATION(continued) ; r
f
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630 . �� �
Owner: ARLENE HINKLEY
1 Date of Inspection: 2/7/02 w.
TIGHT or HOLDING TANK: (tank must be pumped at time of in
spection)(locate on site plan) k
Depth below grade: n/ate
i Material of construction:_concrete_metal fiberglass_polyethylene other(explain): n/a
i Dimensions: n/a + ti
Capacity: n/a gallons . : &x
r Design Flow: n/a gallons/day
r Alarm present(yes or no): N/A ?,
Alarm level: N/A Alarm in working order(yes or no):NO "
Date of last pumping: n/a
}
;
'. Comments(condition of alarm and float switches,etc.):
4 n/a >s
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
! Depth of liquid level above outlet invert: LEVEL WITH BOTTOM;OF.PIPE V v
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage,mmto. ,x
or out of box,etc.):
4 wA
i D-BOX APPEARS TO BE STRUCTURALLY SOUND. ,
' PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):NO` yA
q Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and.appurtenances,etc.): ,F
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Page 9 of I I
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OFFICIAL INSPECTION FORM—NOT FOR�VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C . "
SYSTEM INFORMATION(continued)
77
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630 �
Owner: ARLE.NE HINKLEY
Date of Inspection: 2/7/02 '
PF4
d
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
j
If SAS not located explain why: ° tt
n/a ,
Type ..' � k�
1000 GAL 6' X 6' leaching pits, number: 1p
INFULTRATORS leaching chambers, number:'. 6
n/a leaching galleries, number.. n/a ", "
0 leaching trenches, number;,length: n/a 3
n/a leaching fields, number: ° n/a ,t
i n/a overflow cesspool, number:' n/a J .
t9 5
n/a innovative/alternative system
Type/name of technology'€ n/a .'
' s
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): I,
DID NOT EXPOSE.PROBED DRY.SYSTEM SHOWS NO SIGNS`OFxFAILURE.LEACH PIT WAS EMPTY AT z
TIME OF INSPECTION.BOTTOM IS AT 9'.RECOMMEND,RAISING COVER ON INFULTRATORS.
r '.
# CESSPOOLS: (cesspool must be pumped as part of ins ection locate on site Ian '
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a - wnfi ,
Depth of solids layer: n/a
Depth of scum layer: n/a '
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): f s
PRIVY: (locate on site plan)
Materials of construction; n/a
Dimensions: n/a t:,;
Depth of solids: n/a.. `
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
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Page 10 of 1 I f' ,
ayi
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ;#_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART C,c ;}
3 SYSTEM INFORMATION,(continued) IF
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630 �
Owner: ARLENE HINKLEY k
Date of Inspection: 2/7/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least.two permanent reference landmarks or benchmarks.`.
the building.
.
t Locate all wells within ]00 feet. Locate where public water supply enters g.
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' Page 11 of 11
¢4.
` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM °
PART C
SYSTEM INFORMATION(continued) r �
Property Address: 412 BRAGGS LN BARNSTABLE,MA 02630
Owner: ARLENE HINKLEY ° 4
' Date of Inspection: 2/7/02
1 a ,
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SITE EXAM ,y
r
° Slope
Surface water
_Check cellar
_Shallow wells
Estimated depth to ground water 12+feet - ,¢
4
I Please indicate(check)all methods used to determine the high groundwater elevation:
NO Obtained from system design plans on record-If checked;date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a2, `
y NO Checked with local excavators, installers-(attach documentation)' * :'
YES Accessed USGS database-explain: n/a ,
- µK 3
' You must describe how you established the high ground water elevation:. _
HAND AUGER- 12+FT.NO WATER ENCOUNTERED.
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TOWN-OF BARNSTABLE Ar' n
`,LOCATION - SEWAGE #
VII. .AGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. r-,\, `/�
SEPTIC.'TAN-K`CAPACITY (L03 G �— 6� <25�t 54
LEACHING FACILITY: (type) (size) .b? S NO.OF BEDROOMS
BUILDER OR`OWNER
PERMITDATE: COMPLIANCE D TE: '`I
Separation Distance Between the: nQ A- /bFeet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility,
Private Water Supply Welland Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) AM Feet4a`
Edge of Wetland and Leaching Facility(Ifanv mw4aV&exist
within 300 feet oJ leachin fac' ' f"' Feet
'Furnished bye
s� Dy
No. ^Z it Fee
Entered in computer-.
THE COMMONWEALTH OF MASSACHUSETTS
P
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
3pphration for )i-4po5al *p5tem Construction Vermit
Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. C ` (f� Owner's Name,Address and Tel.No.
11
Assessor's Map/Parcel
Installer's Name,Address,and Tel.
Designer's Name,Address and Tel.No.
. � h qr _A
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �Cx=c::> Type of S.A.S.
Description of Soil
Nature of Repairs or Alter tions(Answer when applicable) I
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 EnvironmCode and not to place the system in operation until a Certifi-
cate of Compliance has been ' ed by this and of a ��(
Signed Date t
Application Approved bydff.Z�t, Date /
Application Disapproved for the following reasons
Permit No. 9F-S 3 7z.- Date Issued r- 17
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GJ
GAL,
TOWN OF BARNSTABLE
LOCATION 5 SEWAGE #
VILLAG ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE N0. Sw M �R ✓�- 71
SEPTIC TANK CAPACITY �-
LEACHING FACILITY: (type)
NVIIX (size) (A' ;?C -5 i
NO.OF BEDROOMS !
BUILDER OR OWNER
PERMIT DATE: /�/y� COMPLIANCE D TE: f
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ! "ynQ �� eet
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 an s exist Feet
within 300 feet o leachin fac' '
Furnished by
No. - - Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Zigpogar *p!tem Cott!5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. O ner's Name,Address and Tel No.
Assessor's Map/Parcel �(v
Installer's Name,Address,and Tel.No. U \ Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Gender( )
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 0=<7 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable) Vd <-ff
Date last inspected:
'Agreement:
The undersigned agrees to ensure the construction and maintenance of tFie afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environm al-Code and not to place the system in operation until a Certifi-
cate of Compliance has been i ued by this and of a I t
Signed Date
Application Approved by - Date g
Application Disapproved for the following reasons
Permit No. 9�s Z Date Issued 7
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO C RT1FY,that the On-site Sewage Disposal System Constructed( )Repaired (V/)Upgraded( )
Abandoned( )by I�C_\ C-Ak
at has been constructed in ac ord A ce
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9'� 3 �— dated �7
Installer L d C% t cG.J'iX` Designer
The issuance of this pe t shall not a construed as a guarantee that the system will function as designed.
Date �
� Inspector
r
No. 5y — (� }
�� � --- ---------------------Fee Jv.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migpooaf *p!5tem ' on0tructfon 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 recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Con stru�ti n m�b�completed within three years o a date yf thisp�Date: s o Approved b jGs \
O .. ." i.
fl 10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only:
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated'R I (� S , concerning the
property located at cJ'nS tW—Meets all of the
+
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility _
1 ti
There are no private wells within 150 feet of the proposed septic system j
There is no increase in flow and/or changel!n use proposed _
1
�✓ There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of anwetlands,the bottom of the
proposed leaching facility will ngi be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following: +
A)Top of Ground Elevation(according-to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNED: DATE: js 7�
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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L O C A.T ION ' 4- SEWAGE PERMIT NO.
d l L L A G E 9S MAP NO: a�y (I U
INSTALLER'S NAME & ADDRESS
OR OWNER
DATE PERMIT ISSUED S_ 23 - 7f.
DATE COMPLIANCE ISSUED
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No.----------�7 Fps.... ..
THE COMMONWEALTH OF MASSACHUSETTS
. BOARD OF HEALTH
...................----.....OF..................-....------....... -----...--------.................................
Appliraation for Uiq nsalgWorks Tonstrnrtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy at
5. - 3 . ....� .:3..5 ..8---.ZPA.— F1.J l�el
Lota d ess of Lot No.
tr�t � ... .. lii z P�If ... rt.�...... Pdl ��: c.�� .
W , Address
....... . .&. .......----- ...,_..---
Installer Address gg ec��
d Type of Building, Size Lot__yl.._�S.92...Sq. feet
U Dwelling�L No. of Bedrooms.............. ._...Expansion Attic ( ) Garbage Grinder ( Ic))
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p
Other—Type of Building� yp g ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
Q' Other fixtures .
- ---------------------------------------•----••---•-------------------------......
14
W Design Flow............ .......................•_.gallons per person per day. Total daily flow__._....3.3.0........................gallons.
W Septic Tank 4 Liquid capacity.M ..gallons . Length................ Width----------------
Diameter---------------- Depth................
x Disposal Trench—No..................... Width..................... Total Length......--------------
Total leaching area....................sq. ft.
Seepage Pit No....I-_______________ Diameter.....1.0 '__- Depth below inlet....6.X ZQ... Total loaching area....pQ.4.4...sq. ft.
Z Other Distribution box ( ) Dosing tan ( ) - v 19C40�?. l /i5- / jq 7'$
W Percolation Test Results Performed by........ /W__.... ....................... 'Date.._ ......
.1 Test Pit No. I............:...minutes per inch Depth of Test Pit.. ................. Depth to ground water.........................
�X4 Test Pit No. 2................minoutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil .--• [,� + -.• �- T- .....
° I _ .....
x ------...It. '-.,� ......... / ---------------------------------` ....--------
U �i
W
= = =----------=.............................................
UNature of Repairs or Alterations—Answer when applicable.___....................................................:.......................................
---.............................................................••----------------................----.....-----------------------------------------.................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i l'i TIE 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.
Signe, ..... ...... .................................................................... ...........••-t.e...--.........
Date
Application Approved By-------- .---- . •- --.-_.J -_ _.'.71 '
Date
Application Disapproved for the following reasons---------------------------------------------------------------•-------------------------------------------------
........................................................•---........•-•--------------........------......------------------------------------•------------•----......-•--•---------------------...------
Date
PermitNo......................................................... Issued-- -----.........------
Date
`..:►i -F 4
NO........... � r Fss... -........ .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;.
........:......................OF.........................................
App ftratiou for UiiivviiFal Works Toni&dion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage. Disposal
SyAcqi at:
.......6AryluAA�fv..... ..............................
Loca'on- d ess N o-
`�+��'y {1 p �f �/ •or Lot t
!!!�1..W. i ._._ +C.'k.�/.��i! ..... ...".} �r 4 ==...... � -!_'!l M� i'� fi•=•- IC' ? ...._: Cik` :�° �II�l
owp�,r / dress
••-•--......_!l` �1'�..3/ . .......1 t U ±..----••--------•---......--• .....-- /" .l.Y a...
Installer Address qq
Type of Buildin . Size Lot__��`- U---Sq. feet
U ..........................Ex Expansion Attic Garbage Grinder ytp)
Dwelling No. of Bedrooms___..__..__. p ( ) g
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a g ...........
Other fixtures .•-- --"gallons per person per day. Total daily flow_.....; __ .......................gallons.
d
W Design Flow...____ _
WSeptic Tank--[Liquid capacity./47 ..gallons Length................ Width................ Diameter._.-__---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...I-•_____________• Diameter__.1_0-':... Depth below inlet....6t.X. --. Totals IQ2ching area___ 4.4...sq. ft.
Z Other Distribution box ( ) Dosing tan
Percolation Test Results Performed by._...._ �fE$ . ...................... T .
aTest Pit No. 1................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................_.......
O Description of Soil '""" f�-`" +„r�--•`.. .."-- W..:"
p �"� - s,F
x l
W ------------------------------ ...................................•••-•---------••••••-••-.......-----•......•.
U Nature of Repairs or Alterations—Answer when applicable ..... ................ ...........:..............................................................
e.
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TiTIE 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.
Sign e :__.. _
Application Approved
B ..
Date
Date
Application Disapproved for the following reasons---------------••------------•-------------------------------------------------------.•--------•------•--••••---
................••-------.......--------------------------•---.....--•-••••-•••-••----•-•------•--••----•---•-••--•••-•••. -----------------•......---•------......---
Date
i, Permit No......................................................... Issued.........
Date
-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
t OF.... .:.. ..
.......... ...............................
TrrfifiraU of Tompliattre
T S 0 CERTI , , That the Individual Sewage Disposal System constructed (41� or Repaired ( )
by....... "' ............................
f T5 of The State Sanitary .Code as described in the
application for DisposalVVorks Construction Permit No. _..____�:_—r..... da.ted_-..__; _'` . '..% ". .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE r
SYSTEM WILL FUNCTION SATISFACTORY. 4
/\
DATE. :............2�......'_. ....:...��...:........................ Inspector �----...-.................................... _
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD QF HEALTH
� � ✓� . .�.........OF..... , ✓a� ............................
I
No..............: ::..... FEE....... ........... ,.
Permission is hereby granted ' ..... ,may ...---•------ --•-----------•------------- =
to Construc ( �or Repair ( ) :a Individual S rage Disposal tern
at No .. ..........?X•�-- �`� �--•--- d
t .....
4e Street
„ as shown on the application for Disposal Works Construction Per ___ Dated.._3 __ . ____/__ ........
PP P �. .
.........-- .-- ...............................
�� Board of Health
DATE..... .....................•-•---•.-......... •••.........
- 1
's FORM 1255. HOBBS & WARREN. INC., PUBLISHERS !�*
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CERTIFIED PLOT PLAN
Ez.co.4 WCATION L�.9 T,9 'L . , , . ,. . • . . . .. , . . .
�zc SCALE . /yr 4o ' DATE
� mac.s.�:¢ , r3E/n�•. Lo r 3S'9
Et.S7 l eLl?.4. PLAN REFERENCE . ... . .. G. . . . . . . . . .. . . . . . .
LoT .3'.S'a .Sf/0wA/ oiv A PLAN.
/. . . . . . . . . . . .
I I I CERTIFY THAT THE .VLZ497oV
SHOWN ON THIS P I ED ON THE GROUND
AS SHOWN HERE T IT CONFORMS TO THE
SETBACK REQ OF THE TOWN OF
Qts WHEN CONSTRUCTED.
DATE
PETITIONER: 39
CeW rt--A—,'V t L4-4C• 114 5 S• REGISTERED LAND SURVOR
SNCC7 2 of 2 Sf/EZT5
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
e 4"CAST IRON 12"MAX. r 12"MAX.
• PIPE (OR 4"ORANGEBURG(OR EQUIV) '
EQUIV..)— MIN. PIPE- MIN. LEACH
' PITCH 1/4"PER. PITCH 1/4"PER•FT PIT PRECAST
° LEACHING
o' NVERT a
SEPTIC TANK T OR
INVERT DIST. INVERT ?� w PIEQUIV.
EL.. GS BOX EL.-�$,3,3 ; >= o:
a INVERT F' . .. GAL. INVERT
EL.-�cBZ.. 4' • •
F-
ELs so INVERT ;:' ww o: ::a 3/4°TO II/2
w
WASHED
•' STONE
0 0 ..
• , /� — —6'DIA. —�
DIA:---+�
PROR LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALEPR EL'
MINA"
SOIL- LOG WITNESSED _ BY :
/�f1 r.L H�.�e e A
PATE H'`►:/.!s!y7B_ TIME. ���oo A.h. _ ,~/. BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 E-: A:",-e4e". /?E ENGINEER
ELEV. . GI'Go . . . ELEV. GZ.Go _ • .
eDws�2D •�".• .�czGe� K..L�S,
DESIGN DATA
so"
NUMBER OF BEDROOMS
TOTAL ESTIMATED FLOW . . . . . . . . . GALLONS/DAY
n.sr GenvtZ BOTTOM LEACHING AREA SO.FT. /PIT
r 7 2
SIDE LEACHING AREA SQ.FT./ PIT
nEv��ti GARBAGE DISPOSAL (50% AREA INCREASE)
rJE-�,�,•► F...C
Sew 4
Sao TOTAL LEACHING AREA z�7 a v SQ.FT
PERCOLATION RATE MIN/INCH
LEACHING AREA PER PERCOLATION RATE .'' SQ.FT.
No .WATER ENCOUNTERED
NUMBER OF LEACHING PITS . .1 !o!T w17?V
Twv Ft7 7' oF -5ro�fE� T'HOMAS E.KWLEY CO.
APPROVED . . . . . . . . . . BOARD OF HEALTH
ENGINEERS—SURVEYORS
QN AGG !a�S 346•LONG POND DRIVE
DATE . . . . . . . SOUTH YARMOUTH,MASS.
AGENT OR INSPECTOR
OFTHO
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2..64gc /5 �'�� ®Z' DwARD
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TNT✓ Div/Q �/��.G,eGt o? 'KEIE s o ' 4;
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PETITIONER SU�dp