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HomeMy WebLinkAbout0179 COUNTRY CLUB DRIVE - Health 179 Country Club Drive Barnstable A = 350 034 y . e COlM1ti1 T —� 0����. .ar.TH OF i= EXECLTIV OFFICE OF E ? O'� i - =_-- ��' DEPAR�Yr �a� o-F���- o T E�TAI -FROTECTION OEM cam•�y` a 3s0 TITLE OFFICI_AL, INSPECTION FOR-NJ—NOT FOR VOLL-NTARy ASSESSNt _TS SUBSLRFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Propertv address: / / 46O C114 6 A,k'r-- Owner's Name: e�7--p/c ti Owner's Address: /oo /�o�C %S6 Date of Inspection: 6 iL a 6 s ame of Inspector. Tease print)Company Narne- 11, / }r Mailing Address: - f- Telephone-Tumber(� -:r CERTIFICATION STATEMENT i 1 cer!iry that 1 have personally inspected`'ue sewage disposal system at his address and Gn vas ;�. lea below is rue, accurate and complete as of thee of the cootie-o�—�on `0}` wining and experience in he proper functio>i and maintenance of on site sewae e �o�d based on m�: approved system inspector pursLant to Section 15344 of Title 5 I as a CEP (310 C--MR 15.000). ses Conditionally Passes Leeds Fz beer E aluation b` e ails v e Local ocal-kpprov�ig A'•;hoT?^ - , HlSpector's Signature: Date: The system inspector Shall subrnit a co of this.rr. _ copy inspection report to uie A-r-11MV!_ a uih;t,r'es-Oa_�zd _ _': Ds r/Within SU days of completing this inspection If:, system is a spared sy,te rr or has- d _ewe =r. opd or greater; the inspector and the system ovmer shaltsubmit the report to theappropriate:�` 00 DER The original should be sent to the system Owner and copies --or.rd o-`'o, -he author.ty: sent to the buyer. if _ Votes and Con-u-nents "This report only describes conditions at the time of inspection and under: F 1,use at that time. This inspection does not address how the system will perform in the future u der the conditions of use. �' , =n e insLecr:nn �,,_ r Page 2 of I i OFFICIAL INSPEC TIO'V FO _ Ri SLBs� AOE SEtivACE DISPOfl�� TEM LVSPELTION E'-(}IZN PART A CERTIFICATION(continued) Property Address: 9 CO LI � 7'i C/cat Owner: Cam,-• so v, Da te of Inspection: Inspection Summary: Check A B,C,D or E/AL_ Whys complete all of section a A= system Passes: Vi have , not found any information which h dicates that any of e fa-dur.e=dtenm desc=Led in ? c a. I�_�03 or in 3 14 C7R 15.304 exist Any failure ci ter i a not evaluated are?�cated befog%. Comments: . B. Svstem Conditionally pass' sc /'t/ One or more system COnTonents as described in the"Conditional repaired. The system.upon completion of the replacement or re, as Pass"sermon need to be-ep'•ac,or r approved by the Doe, 3f uea: v �oss Anse er yes, no or not determined(Y,N. \'D)in the for the,_ r« explain statelne .IZ I_o€det` �finedr r please -'-he septic tank is meal and over 20 yeah old*or the septic. unsound exhibits substantial en (:�hethertai or-no i�zzfiItration or exfiltration or tank failure is i. =ct Willy existing tank is replaced with a comply- ' �"T""""' Systemtsars .. ^. := mp, g septie tank as approved by the g =pec._,.,r--to *A metal septic tank will pass inspection if it is,truc`arally SO'1MCL^ot lei" : d°`health. i�dicar�ng that the tank is less than 20 years old is available. `�' atul if a Czr-ficaEe of Cn, ;=a T7� -arc, N D expi.^.T,n• Observation of sewage bac�,n nr hro t, high obstructedpipe(s) oI -r "a'"mot or rzgli static%,•ate-Ievei in the '. due to a broken,settled or uneven distrioution bex Sven, ., aiszotsan Sox due`o approval of Board of Health) F.I�asSSpOr: _•f=_; blOken Dipe(s)am r,pIaced obstruction is removed distrbution box is leveled or refaced explaiII: The system ree*,fired pumpuIIg mo e thann 4 tines a year due to broken or obs;>Lct :-,�,,; pass insr ection if.(wi h approval or the Board of Healtiq : ). ti_� _ broken pipe(s)are replaced ' Obst1 action is re'noved ti�c X D a : Page.. of i 1 OFFICIAL INSPECTION FoR-M-NOT FOR VOi;ZN-TARS_3 55€5S?IE c st sr ACE SEWAGE DiSPOS_AL SYSTEM SPECTION FORM PART A CERTIFICATION(con�xued) Property Address: 1219 CEO�-t n�✓ C(� // Owner: (f C-- Date of Inspection: C. 0 Further Evaluation is Required by the Board of Health: ! Conditions exist which require further evaluation by the Board o_`Iiealth in order ode r z;=- -_ is failing to protect Public health,safety or the environrsent _ _e'-s e 1. System will pass unless Board of Health determines in accordance with 3I0 CNIR 25303(i)(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 wertland or a salt marsh 2. System wiII fail unless the Board of Health(and Public Water Supplier.if an )determines that the system is functioning in a manner,that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the S A-S 100 Jr a surface water supply or M--burary to a surface rater supply- = The systern has a septic tank and SAS and the SAS is within a Zone 1 of a pubbl=. -:aim — The system has a septic tank and S,e S and the SAS is w-aim 50 feet of a private=war-:gin;,• ;ell. The system has a septic tank and SAS and the SAS is less` lull feet but 5 feet or mere cm a private water supply Well".Method used to determine dis'wice '" i Pis syste11 passes if the well w ' ater anal;sis,performed at a OEP cer =ied?aborts co;=�--astern IIu VOid:itc Ur aLLC Compounds indicates that tlue well is iree a0m,DOUIi"'.OR from the presence of ammonia nitrogen and nitrate nitrogen is equal to or less t �5 o_the anal ; . " failure--:tem are triggered.A copy, -=_' the must be a-_ched tc this th er: 5 paae 4 o`i l OFFTCI_ - - AZ, I`SPECTIONi FOR I--NOTFOR V-OI.LNI'_-RV -SS_ESSA ,-.r.$ SUBSL`RFACE SEWAGE DISPOSAI, SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / / / Cp Uh Owner: GGB vISO 63� Dare of Inspection: G 6 O D. System Failure Criteria applicable to all systems:' ' You must indicate `yes"or"no"to each of the following for all inspections: Yes No .ackupo f se wage into facility or system,component due to overloaded or c3ogged:SAS or ces,-�,oi v Dischar-ge or pondin`of eii,uent to the surface of the r- ,cIogged SAS or cesspool Found o. stz a waters s cue to z cver?oaded or _/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged o= ,zesspool t/,iquid depth in cesspool is less than 6'below invert or available volume is less t /day:�o ./ Required pumping more than 4 times in the last year YOT due to clogs •_ tines purriped e�or o ^� ac'p ''port'iOn Of the SAS,cesspool or privy is below hie �/ � p �h groundwater elevatom _ Any Portion of cesspool or privy is withztt It}0 feet of a surface water�13'or_ibu..��,to a Surface water supply. � _ _ ny portion of a cesspool or prig;is within a Zone 1 of a.public well v 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 Beater than�0 i�from a�t�V i SUP well with no acceptable water quality = a=e _ _ p { Sys s (This System passes if the well water analysis; performed at a DEP certified laboratory,for coliform bacteria and volatile organic comDounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.provided that n0 other failure criteria are triggered.A copy of the analysis must be attached to this f©r m. / 0 (Yes/---\-;oj The system fails.1 Dave determined that one or more of above ze described in 310 CVIR 15' '` —, R '' Y lia __�e_��east �0.3 therefore the system.fails. the sys�--0—mer should cc� Lt the 3oard c_ Health to determine what will be necessary to correct the lure E. -Large Systems: To be considered a large system the system must serve a facility with a design flow of I ,ft€?fl to l�, gpQ' J00 You_rust indicate either"ves"or"Lo"to each of the following: ("The follow•in2 criteria at; ly to large systems in addition to the criteria above) p. Yes -o the systern is within 400 feet of a surface drinking water supplly �e sys err , it wit 200 :_'eel o_a u outa�.to a su-.ce�' �7 g d ll,iLtr v if,%a:YS SUDDi,j — _ 'e ,ste;r:is 'located in a nirrog ` ` j ea sersitiye area(lrltet:nl;Yej;b`i j Z^r.-e 1 of a pubs: :01erti0�_ a- _ _ c water supply=%veil - _ a e a-s �erec "ves` to any e��°, Y q,I s^on L1 Section E e ^t or.D y _ i7 sUstem is corsiee � := -L _ _ above L :2IQP j 'Stamm i;G$-?l .` - -- ,�--+=•Cam= :, `i?riI Ca_._ i re2r u^Cer r i 0�=�7ei Or�t}eT7?Or 7^ --- _ - ,� Jecron E or,sled rid r Se - Z Ci ST-er i CI ' e Ction D s�_a;l upgrar. SP_Oul�C,,nt2C.the 2�i3ZQDP_2're?iorai ofl�qce ofLtlie D ep ar--rlGi.�7 Z?�� _ti � •`-'`] ' en r. - Page 5 of l 1 OFFICIAL INSPECTIOti FORM—NOT FOR VOLUNTARY_ SSr_SS_NfENTS SUDSIiRFACE SEWAGE DISPOS__AL SY5rEvtE"4-SPECTIOti FORM PART B CHECKLIST , Property Address: / / �p c t P1 7`,� Cl u 4_7,4 v-/Sor.� p1l Owner Date of Inspection: /6 U 6 Check if the following have been done.You must indicate`Ives" .� o. _e"as to each o`t_e Yes �Purnping information was provided by The owner;occupant or Roar'of Flea- 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? rav large volu mes�i water n .. _ ,to been— introduced auced t � . _o the�z o-, _ _ ._=2C�.c_�y C�.iS��r O_,�.c= S�2C3C1 � Were as built plans of the system obta red and examined?(7N Bey were not a allat e no e as N r_6 j Was ,.he i facility or dwell ng inspected for sips of sewage ? gns g Dees up . Was the site inspected for signs of break out? — Were all system components,excludingt, he SAS;Iocated on c_i# / e . v _ Were the septic tank manholes uncovered;opened,and the erior of tie k m,_ zo ,;- oTe baffles or tees, material of consuucaon dizrensions d n "?i ,_ `'` or — "one_on ep' o__e�s:d,depth of sludge and`e; of scum LIZ Was the facility ova er(a,a occupants if different from' Oro eI)Provided waFh t I -,atFJM on the�'O�;er maintenance of subsurface sewage disposal systems? - .e Size and location of the Soil Absorption System -rp stem(SAS)on he site has been de=„=I=�' d based orr �no Fxistinv in�r"Orn4L, �� ­Oic i OT.e aul}�le, d p1aIl at he Board of---eaFtll Determined in the rieId(if any of the fa'lure cti -related to Part a acceutabej10 CM_R is a issue ayLr) 5.30%(;)�b) i Page 5 of l i r OFFICIAL INSPECTION FORtYI NOT FOR'VOLT--,N-T--,iR h SUBS1UP-RACE SEVS AGE DISPQSAL sYsZE vI iNmpECTIO- roR- P_RT C SYSTEM ni TORMaTI4 Property ' Address: / co 7�i (��c r Owner: Ga ? 7 ° o y �h Date of Inspection: /6 Q -f- , FLOW CONDITIONS �,,•�� ' RESIDEN TIai Nurnber of bedrooms (design): � Nurnbcr of bedrooms(actual): ,3 DESIGN flow based on 310 C-1va 15-203(for exa=le: 110 Ppd x-of b6,roomsl: N-i-mber of current residents: 02 Does residence have a garbage pander no): S Pe C O n7 Is laundry on a separate sewage system(yes or no):;CV.if yes sepaate insoec-Tion reed? Laundry, system inspected(yes or no):�/� - - - - - Seasonal use: (yes or no) F' Water meter readings_ if available(last 2 years usage(o-pd)):. Sump pump(yes or no): 2� Last date of occupancy:CL'rley, - C O tiLViERCIALJLN-D L'S TRZ--1�L Type of establishment: Design:low(based on 310 C-,Va 15_203) a. Basis of design flow(:eats/persons'sgfl;etc.) Grease trap present(yes or no): Industrial waste holding lank preset(yes or no).,_ '' x N on-sanitary waste discharged to the Title system(yes or no): Water meter readings, if available: 3 . Last date of occupancviuse: OTHER(describe) GEI. RAL L FOR-NMTO Pumping Records Source of nformationc /�U ; ��n'.N►n¢'� Cr t PWt © L•• - :vas system pumped as part of to ffis-pection(yes or no). If yes, volume pumped: aaildns.-=hogs was q;tantity p 7—ed??erR_.;i?exd? Reason:i5of pil ing: s TYP OF SYSTE'_V1 Se7r'C T,nk 11Ct* tinn}env cni7 iron S v 66 teau _Single cesspool Overflow cesspool _rnvy Shared system(yes O rO I (_f VgS, ai3Ch Previous z "any) � p -nsvecti,on records "any) > to.O✓2t ve,•'a ite'I12iIVe ?c-j•).nology.Attach a copy of the cL�S*ept CDCra C.n an ` l bra ned orn s`lslem cwre,I -ir r rank __ r ach, a copy-of Lhe DEP approval+ Other Gescrbe): -` iy i7 OX'_ fi:c' age. Cr all:C1--Mroore7'ts,Latee Lnstalled{Ii GrIC-) *tom` brio a 41 :_1 ti ar.1 e t-, ✓.,�C e ✓r no) x e Page 7 of 11 OFFICTAT, I\SECTION FORT—tiOT FOR y0LL,�-�--i_n—v sL�sL.t2F'ACE s�WaG�DISP©SAL SYST�I$L�SPEC 'ON FORM PART C SYSTEM I'VFORiVfATIO-N(coast ra ) Property address: C-`u� O c.,v+ ,r4 �r Owner: CG.-�fo `` c�/J�'L eao 6,3 Date of inspection: G �6lea BUILDING LILDI�+- _ G SEWER(locate on site plan) Depth below Z�-ade: Materials of consttu-7 t ion � Distance from Pwater _ — P� .,--other(exp }: private w . P aver,ur lv rP. x ell or suction"Me: Comments(on condition of joins, venting,evidence of Ieakage,etc.): SEPTIC TAINK:—(locate on site plan) Depth below grade: Material of constntction: c�e mRtai fi o.,i other(explain) sus �o�vc y.e e c iI ank is metal Iist aQe: Is ale _��mm - certificate) con ed by a Certi$cate of Coirimlianc-,(Yes er no`: , _:a-ac a coY Dimen sions: X 8 Sludge depth. , Distance from top of sludge to bottom of outlet tee or baffle: o2 Scum thickness: Lesf_/ A/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of oudet tee or b�/� :How were dimensions determined: /91 /e Comments (on a . ( pumping -ecommenda`ions. rlet and outlet tee or,baM as rziated ro outlet e cono � f invert; evidence of le Q - _ _C.c:w= akao'e,etc.): - ?'c;1,1 4 yb L e a.l�s ee Od Co.z ion GREASE T AP:&_/(locate on site plan) Depth below grade:_ �iateriai of construc concrete metal `bet(zxplain): .— — _ glass polyethylene over Dimensions: Scum thickness: ' Dista ice Lo n top of s— c :op of ouilzt`ee or ban:z_ fr + Distance om bottom of scum to bottom of oli }e — ' Date of last um gee er baf�le: pumping: _ .�_ Comrrenr_z on o urtmptn� .econrendzµons i�'ei and ouuet tee 0r bai�?e cony for .�: i; as related ro cartel inve� ev oenCe of lzakage.etc.):• �-��' Page 8 of 1 I OFFI0AL INSPECTION FORM—NOT FOR VOLL��A- ZY SUBSLRF'ACE SEWAGE DISPOS--.L SYSTEM rgSPPCTIO FORM PART C SYSTEM LNFORA4XION,co ued} Property Address: / �p vt r7 A- Owner: CG✓'�Sor� Date of Inspection: TIGHT or HOLDING TANK: �(tank must be punped at ime oI i I S w-L0n Depth �lrJC2` te on ci n e� ) below grade: Nfate,ial of constmctiori: conc-ete metal _fiberglassDimensions: Capacity:Capacity: gallons Design Flow: gallons/dav y Alarm present(yes or no): J Alarm level: Alarm,in working order(yes or no) Date of last pumping: Comments(condition of alarm and float switches,etc.). DLSTRIBL ITON BOX:: (if present mist be opened)(locate on site pIarf) Depth of liquid level above outlet invert: 140/v'7 G L Comments (note if box is level and distribution to outlets equal any ej�dence orsoLids ca-vC�L-��" leakage iytp out of bob etc.): an:;e-dice of , 2 /1 N PUMP CHAtiIBER:44/ (locate on site plan} Pumps in working order(yes or no): :^%larms in working order(yes or not- Comments(note condition of pump cyan bet;Condit on of pumps and apotri�,e, =ees, etc"): F Page 9 of I i OFFICIAL INSPECTION FORNI-vOT FOR VOLUNT- 3,ScESS-Aa TS SUBSURFACE SEWAGE DISPOSA. SY'STE� L�SP�CZIp� FC3F��i PART C SYSTEM I-'FORINIATIOr(coutinned) Property Address: 129 . (�Oti H 7�i - vr w1 N'�c► 61 v„� �:� Owner ��✓�So Date of Inspection: SOIL ABSORPTIO\SY"STE Vi(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type V� x ;b leaching pirs,number: v leaching chambers, number. (�/i leaching galleries, number: leaching trenches, number,length: leaching fields,number, dimensicns- Ovetilow cesspool, number ianovativeialternative system Type/name of technology: + Comments (note condition of soil,signs ofhydraulic failure,Ievel ofpondin&da=coH coldidon e_' ep— cn� / L.1 v7-e CESSPOOLS: /y (cesspool test be pumped as as of insnecdona locate - r P r ,( on site p_an) `umber and configuration: Depth—top of liquid to,inlet ir_vert: Depth of solids layer: ;Depth of scum layer: Dimensions of cesspool: _Materials of construction: lydicaucn of groundwater inflow(yes or no):_ Comments(note condition of soil,signs ofhydraulic,failure,level o"pond g,,ondit=oT o_.'egeta=on. PRIVY: {locate on site plan) Material's of cons`7-,Cticn: Dimensions: Death of solids: On Oi_T.eP_i$ Ote OP.Qit:OP_OI J011. ' ?igI1S0• ;{�2!!�C.'all� eVelOar a Qln:,00 Paae 10 of I 1 OFFICIAL INSPECTION'FORM NOT FOR-VOLL.NTAgy ASSESS-*--IEN-T- SUBSL-RFACE SEWAGE DISPOSAL SYSTEM IINSFECa-10 FOR-Nf PART C SYSTEM INF'OR'NLATIOti(continued) Property Address: D � GH wtrh A 62u, Owner: or�So 7 Date of Inspection: G /6 p (� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at!east two per-{�ent ra-��nce dot or benchmarks. Locate all wells within ?00 feet_Locate where public water s-4-p€y enters he bla7 — 9_ S Q.0 C . L !/ _ z �J / i J �y.= 9s, r� page l i of 1 i OFFICIAL INSPECTION FORM ' NOT FOR V-OLUNUAR A,SSESSN1ENTS SL �SL:RFICE CF.WA(TE. DTSPOSAT SYSTEM r SPECTION FORM ' PART C SYSTEM //E\TFORVIATION(coat n ed2Y property Address: Owner: Date of Inspection: STTE EXA�1 slope Surface water C Check cellar J Sha?low wells I !9 f 51 +ate ,rh 3s l nor N 3 Estimated dew to ground water �..... Please indicate(check)all methods used to deterr_niue the high ground water elev-a?on: • Obtained from system design plans on record-If checked,date of design plan viewed: Obb '-ved site(abutting property/observation hole within 150 feet of SAS) To F C_-- pecked with local Board of Health-explain: checked t:*?'local excavators,installers-'attach documental-on) Accessed i SGS database-explain: You must describe low you established the high ground water elevation: , A- -AA1r Ice.,4,00 s 35.E /0.9 �,,' /� S 0�E• A,5 h -------- 9 � � - I ' a 0 O a to rt� /0;� ------------- �. 0Ll /7, til - 3.S',� . c lb r.. r ✓ "�, 'f-- .:S E AMU Y :- . .>,... .. .. _ .... _ 41 r f {Q Nil. }` •� �.i ,. �'� , s ��'" <.•'_ mot-'�y�..`� f �( "=3 / �+-,.w: -� �. '4 .tea �.�.�13h ..� �a. •5+�' !! ik a &I v • A s �- sue-'' �� 3��`- --�.,r•�� � .� Y .Y� �` t § - ' _- vT-�9«\� 1. "_" ..� .' a�: �' _."' >,R�T _ -.F9!t. Ts_ -�`•_ '�..- ..�' Y: �_ aid � � ...s.-� "'..•.a'.` � � F�..,� --' ct ��A _ ..y_ i � •� :. �6•����_ - �` Y Sri �r �� `'• y z9AM- - VVVV �... r TR fVIA- smwvvQk 3.� :. ' t AGe . �i 7 ' - ION . SEPTIC TANK QX— TOP OF FLt1. ` ' t31Ti3aa So> fl t=�tR €2 STD i A IN- OUT- IN- OUT- R4+ =TtKCr `t'(mRZ./ . -. (. ei1 ELEV. ELEV. ELEV. q i 3 V' .. Cn.a Qts.g - -3 ELE of k� LOG Ar Tr�s� MST DATE � DES IGN 440 M. ELEV. 7 [ _ PERC RATE FLOC#A £ 330 to i' TIC TANK 3 €� _ lb TOTAL - i � �: L� - t NWATE-R EOCWNT.ERED .No Ek. EU�tLESS OTHERWISE NO €r�) _ 4,ep,"u S QUADRANGLE KAP 1.fTAT61AV13sASL3+.TAXEN FROM -- Z:iVFtMJCJPAL WATER 3 ____-_-__AVAtE Bt E '3_ PiTGH_Vasa MR 44 4.'1�G1+1 LOoE FOR ALL-PRE-CAST LlNiTS:AAStiO- � � fi.TAtf�1.Gf20tFfi1€)COVER CVV AER ALL SEWAGE FACILITIES:I FT. . ` 6,..PIP€J@INTS SHALL'BE MA€3E WATE9t TFGWf .. . 7.-COr4STRUCTfjaN dETAILS To�ACCC-0RDjkNCE W1TH COMM.OF kAA55. STATEENVii2t3�i7s E tTA COt?E TITLES + ". Z old C.t cs� !r�•''Z�g ..��-s vs>�E,.i��. �N��- t��,a ., '+ — . ----- nrtwt.3 1 ice. (£XfSTMO)-_ - ;` `= -. all TOWN OF BARNSTABLE ii L OG,ATION 1 � Cv u it;R"Y CAJ6 )R EWAGE # o I� VE-LAGE C-/yl M/I 4") ASSESSOR'S MAP & LOT 3 INSTALLER'S NAME&PHONE NO. A L SEPTIC TANK CAPACITY /E' F .0 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNERi7ti PERMITDATE: 3 COMPLIANCE DATE: �0 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 b :1 '70 y6f t �7S D l No. d/" I Fee�5 THE,COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ `� Yes pUSLrC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0ppYicatfon for lafopogar *pmettt Conttructiott Application for a Permit to Construct( )Repair( grade( )Abandon( ) El Complete System �'Irtdividual Components ' Location Address or Lot No. 19 C 0411 /�Y C4 UB -P2 Owner's Name,Address and Tel.No. C &,Alm 4 Q-/h lee,&XIF7` M.A, 'TI/t' Assessor's Map/Parcel v7—�a C4116 ")If Installer's ame,Address,and Tel.No. �Q 7,j-�7� Designer's Name,Address and Tel.No. '246 ("AX-11Co 3Sv arl S T Type of Building: Dwelling No.of Bedrooms -3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures��.. Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) C C 1604, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been islttcq by this Board of Health. Signed - Date Application Approved by L Date U Application Disapproved for the following reasons Permit No. - Date Issued a Z. i _ --__--- ---- - - - - - - - - - - ISO — No. Fee i ✓ — - THE-COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes . .. -_ P-UBLIC_HEALTH DIVISION -TOWN OF._BARNSTABLES°MASSACHUSETTS 01ppfication for.Migpogal *pttem Congtr_uct on,Verntit Application for a Permit to Construct( )Repair( Xupgrade Abandonp ( ) ( ) ❑Complete System L�idual Components Location Address or Lot No.�l7/ C o yy7e)/ (►4 4 j1�►. Owner's Name,Address and Tel.No. 9�L -y'S 91 C jft A a1w/-0 /?oQX,1P7' Assessor's Map/Parcel !(� Installer's Name Address,and Tel.No. . .O r. �s'-a j+"Q m Designer's Name,Address and Tel.No. op 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) £ C y Q Date last inspected: Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-cate of Compliance has been is by this Board of Health. Signed Date 7- ' ,r-O,? Application Approved by Date U� Application Disapproved for the following reasons Permit No. - Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (A-)"[Jpgraded( ) ° Abandoned( )by e0441 C' O 110 ALAI , [I— /.v' �✓j/'c at / 7 l C'6 u tiT f✓ e Lu® �X C L,y,�,Q&y yi) has been constructed in acc rdance with the p n isions of Title 5 and the r Disposal System Construction Permit No. /3 dated 2 C�2 . Installer Designer The iss ice of this permit shall not be construed as a guarantee that the syst will function as desig e . Date Inspector r e No. Fee THE COMMONWEALTH OF'MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ,; - -- Mi5po5ar *pgtem Construction hermit :a ----Permission;is hereby granted to Construct( )Repair( grade( )Abandon( ) * ":System located at_ !' aiT 6✓ 1 !,�i ?1,(� C' c.or m 14 0 t+t fand as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to 4 ° comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of type s Date: 2—r _`1 C\�1 Approved by 0 TOWN OF BARNSTABLE LOCATION ' �� CCi 0 4; Iy�U �' WAGE # VILLAGE C ,1nM 1;ti v') ASSESSOR'S MAP & LOT S✓ ` S� INSTALLER'S NAME&PHONE NO.A 1 (/1,(/C�' S tj r SEPTIC TANK CAPACITY C' t 0A LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER 017471D- e0At"If f PERMITDATE: �'� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by , I Y 4 3,7 �s D e P�^ COMMONWEALTH=OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION y _ - y\ y♦ —"' 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM RECEIVED PART A CERTIFICATION MAP 350 PAR 34 APR 17 2002 Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 TOWN OF BARNSTABLE Owner's Name: ROBERT MARTIN HEALTH DEPT. ' Owner's Address: PO BOX 63 CUMMAQUID,MA 02637 383 Date of Inspection MARCH 25,2002 Name of Inspector: (please print) JAMES D.SEARS Company Name: A&B CancoMV • Mailing Address: 350 Main Street A� West Yarmouth,MA 02673 PARCEL L �34. Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience 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:. X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ��/, Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or,greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP: The original should be sent to the system owner and copies sent tot he buyer, if applicable,and the approving authority. - Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 ` Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X _ I have not found any information 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: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.-If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health: *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ' Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 179 COUNTRY,CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is 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 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 x*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4 Title 5 Inspection Form 6/15/2000 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 D. System Failure Criteria applicable to all systems: N/A " You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged'SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact , the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply ` the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up?, X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner(and occupants if 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] _ Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 136,000/2001 152,000 Sump pump(yes or no) NO - Last date of occupancy: PRESENT COMM ERCIAL/INDUS TRIAL Type of establishment: Design flow(based.on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): - Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION, Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool - Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) - Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be . obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1985 PERMIT#84-816 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 15,2002 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 28" Material of construction: X concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,500 GALLON Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scum thickness: V, Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL. ONE INLET TEE,OUTLET BAFFLE.TANK AND OUTLET COVER 28"BELOW GRADE.INLET COVER 10"BELOW GRADE.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000, 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS NEW APRIL 2002.DISTRIBUTION BOX IS 16"X16",40"BELOW GRADE WITH COVER 20"BELOW GRADE.ONE LINE IN,ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):. 1 Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding;damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT 57"BELOW GRADE WITH COVER 12"BELOW GRADE.WATER AT 4' NO HIGH STAIN LINE.NO SIGN OF OVERLOADING SEEN IN PIT. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) s Title 5 Inspection Form 6/15/2000 9 f Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 COUNTRY CLUB DRIVE CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ITs` a Title 5 InspectionForm'6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 COUNTRY CLUB DRIVE ' CUMMAQUID,MA 02637 Owner: MARTIN,ROBERT Date of Inspection: MARCH 25,2002 SITE EXAM Slope Surface water Check cellar ; Shallow wells r, Estimated depth to groundwater 27.3 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation X Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS WELL DATA WELL AIW 247 27.3 ZONE B 6.6 ADJUSTED 20.7 -0" 9' s Title 5 Inspection Form 6/15/2000 11 LOLATION ° SEWAGE PERMIT 930. VI'LLAG E ALL pEJ-R'Sn N�A��ME ��&1•g� ADDRESS /1 A71����`J 7�./ . y 04 ( �F J - ) 0 U I L D E R OR OWNER 0 (FDA T E P ERM.IIT ISSUED cl �d �, DAT E COMPLI. ANCE ISSUED 4 s- A� s ' 3 5 70 Y V N i ......_... z .1 THE COMMONWEALTH,OF MASSACHUSETT3 BOARD 'OF HEALTH 10W'n . .......OF.....IJGC'....% Appliratilan for Disposal Works -Tonstrur#iun Frrmi# Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal ' ystem at Cov► -� ..Ct�b pr.•v o-�s. ��.� • Lac ion -Address f / �1 � - . �.1N.. ^� .... ..................... QJ.1�!`►......FsCI!Jor.,Lot l c4. S fJ9B iL.... o Aadress w ............................................ .C ...� ^� - ?..1 s E --- ..,...--Alt` `^''}�•�I....... Installer Address d� d Type of Building }•cs�al Size Lot_..TT �Cz q. feel Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a YP g --------•................•-- No. of persons............................ Showers ( ) Cafeteria ( ) dOther fixtures -----•---------------------•-......•-•.......... _....-•--••-•--•-•..........•--••••-•----••.................••.............•--•.....----._.......... Design Flow.---••-.--�J__5........................gallons per person pet d�Y. Total da f�ow--- :33 .•--- -.:- S lon WSeptic Tank—Liquid capacity.k000gallons Length........z-_. Width:. fir. Diameter................ Depth.._......" . x Disposal Trench—No..................... Widthr._. . Total Length.......... Total leaching area............. ft. �. 8 e - - ire g q• . 3 Seepage Pit No.......A............ Diameter........._._: Depth below inlet..--._.._' -Total leaching area-�2_1:2Ss�--ft- G�D. Z Other Distribution box Dosin to� '•'' Percolation Test Results Performed b .. }c-110.!r� �c1.lt'b � P•C,• 6�2-1 �84 Y Date....-- ---•---•= __...•_ _.......... a u t..._..... Test Pit No. l._: ?......minutes per inch Depth of Test Pit....V ..... Depth to ground water...1DRnt-..... L� Test Pit No. 2...... minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Descr>ptto of Soil_...•— \2Tr `oaw, 12r�— �2`.`.... ? . .. v�o 2 �.-...... `1..Y - -..�5t�...... •---......---•---•-----..... ----•------- --=----------------- .----------.._._......__............. -........ .. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..--•----------------•-•--•-•--•----......----•----•----••-•---•-••---•-----............•--------...........-•------------.........................._.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.LITLZ 5 of the State Sanitar Code id The under gned further agrees not to place the system in operation until a Certificate of Compliance has is by the f health. igned. .. ....... ..... ... l_ I$ te Application Approved By.......... ...... --•..... ••= f Yl ............... ••......_............ Date Applica approved f o he f o ing r asons:...............••......--•---•..................•---.......---•--........-----........••......••-•••.......... ................................................................................................ ....__D ......._..... Permit No.........a Y--�. --•--- b•--------------_._.. Issued......... -•--�. �---�- -�..�...._...... D J THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH t �c�wr�.................OF.....` Ckrr�Si \ ..................................... Appliratiou for -4puBal Workii Toustrudhitt Frrutit Application is hereby made for a Permit to Construct ( . or Repair ( ) an Individual Sewage Disposal System at: r z2 -Loca ion-Address or Lot No .. .�?._/�.��n W: ..1! f� ^� ..:.::.................... .1� (L4'?...... 1L.....__. ,.a --•..... ..... ..........................................c`. .......................... ES(LYE!,Address a , �:��g�2w l c.►-� - ... Installer ,' / Address e 4- Type of Building -�oa ck�Size Lot..4':` o 2G--` �:--=Sq. feet V a Dwelling—No, of Bedrooms . ...........................Ex Expansion Attic Garbage Grinder...... .*...... ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . W Design Flow..__._._...1?` .........................gallons per person per day. Total daily flow............._.: � ._.....__..._..gallons. WSeptic Tank—Liquid capacity��� _gallons Length.`5...f2-•.. Width:A-T?'. Diameter:............... Depth..!4i'.�- x Disposal Trench—No..................... Width ............... Total Length....................,Total leaching area....................sq. ft. 3 Seepage Pit No.......A............ Diameter.. . �'__ Depth below inlet.._V.!' Total leaching area.,A.Z..2: sq-ft: G/D z Other Distribution box QQ Dosing tank ( ) '`' Percolation Test Results Performed by..�-i e��r�.. �G`c� r\?-`�v- K- -�,P•'Date � � ,Z ..._... ..... .�..._ ..... I ........,. Test Pit No. I................minutes per inch Depth of Test Pit...�_� __... Depth to ground water...Kl�? .._... i (T4 Test Pit No. 2.................minutes per inch . Depth of Test Pit.................... Depth to ground water........................r>' e-red 04 1 ... •--------------• -------•----------- ._........ 0 Description of Soil....fl;. .\2 �c�c w, 12 -' 2 vb �o t�2" - �I'jG - a, ....... )........................................... W ............................ y................................. _. ---•-•----.._..._.....................--•........_.f.. ..................................... x ................................................•.................------•....----•---.....--------•----••--•---•-•-•-•------•-................................._......_.....•-----...................... U Nature of Repairs or Alterations—Answer when applicable..........................: ....-•-----•....................................•-----•--•---••••-•••-_.-•-•-•-•-•............................•••-•••---..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:I':L, 5 of the State Sam tar Code—The under igned further agrees not to place the system in operation-until a Certificate of Compliance has b e is d by the r of health. 1. igned.. te Application Approved B ---' -• ............ .........................................._ _ te PP PP Y --....-_.... .. .................. Date APPliea ' Ysapproved f o the f o win, g masons: ......................... ..._ �../......................•---........---:........------•-----....... . -----....... Date Permit No........ g '. ..................... Issued.............. : THE COMMONWEALTH OF MASSACHUSETTS BOARD of HEALTH :S ys �• .E 4't�l D V £�I Z S*1 ' OF......................................:.....:........................ s�+> ! Tntifirate jaf Tout hattre r by T CERTIFY, That the Individual Sewn a isposal System construct ) or Repaired ( ) l by..•. ...................... ...........................................................0................................... at... f// � h ......... ....-----Y_•. .._ ....................eP_.............._................................•.......... ' has been installed in accordance with t visions of TI 5 of Pe State Sanitary Code as described in the application for Disposal Works Co ction Permit No... "_.��..................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM VAILL FUNC��TIONQ TISFACTORY. z DATE. ....:2......... _!l.........Q ---------------------•------. . Inspector....._. f :1-In:.. :.. �..._11_ .... ..... f 1 � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ..........................................OF....................... ._....................................... N FlX....V.............. Map Vorks Tonstrudiatt Prruti# Permissionis hereb anted.. •... ......... .......... -• •......................................................................... . .. to Construct o ai� n . " rage po System at No.... •----- .. .....--.-•-•- -------••.....................•----..---- -------•-.................. .. •---- St et 7 as shown on the application for Disposal W onstruct'�_ er ' No y-r-':91(0�} t _ � — ............... .:.G-!`L_ e. C-.^^ ................................... _ DATE-• .. . ...-- .._ Board of Y{ealth • II� q_. r SECTION - SEWAGE —SEPTIC TANK — "D"BOX — LEACH TOP OF cjly O a "2"OF,IaTO sk" (MSL) WASHED STONE IN- OUT IN OUT / . r •` / ', Fr 1 i, >.11 •.r 14 �9Z (© TIC GLGZh 45.Sc> �' TANK ELCV. ELEV. ELEV. - ELEV. r ELEV. ELEV. // �� �� A�, OF Ni"•1va" • - WASHED STONE 4��tif,' f. . LOG �^„\'`,��" � ,t3'"'•,'"t. tLl•. �` i" 1 E a ��lr 'I'i". TEST HOLE _ _ � . . "• �as�'� *����, �. ,�»'1 + � � ���{+►� � it � t .+. e -Fp,►Zfr.:sfss••15L•,?.E. r „J, "'. \ z< .• . '`•., f•a �i '•�"'a.'. ,,'"` r` '' r +�� TEST BY TEST DATE Cof'L-{ T 4 WITNESS SIGN 3 BEDROOM HOUSE DE - a T::H.. 1 49.5 T.H. # 2• �� �4 . ` w � l.' ,� ' h ELEV. ELEV. NO A Y i T �' v! `-w'� ' aa'�'� *'''•'Ci it '�1"`..� MIN AN. DISPOSER DISPOSER �L X* •�A , ✓ 4f+ ,.r " v;; = s� j /`•, . u>rn PERC RATE / .a 5�a ¢SQ r� FLOW RATE 33a (GAL./DAY) 3,'sc� `�� ` � tt. y, j �? �� - '` _.pia✓+. "�r„� '1 -") "'' f¢t�i' S+V S,l�i� le_ SEPTIC TANK �+�p ().�c I dt3C✓ � EO'D'SEPTIC TANK SIZE LEACH FACILITY IDE WALL C$� �t ��3r5t�19 G/D. C'1' r►-IIN '"SA 1.2L'� BOTTQM. �Q„ o. y ��Q. ..1 (.f'3 G/D, ' :., ,f . ' ✓ .`"- �,- Ya ., �" - ,d - i � IPP-4.`} k y > T�4� *'�{ �_ .rf,' t."t ,•' r ^41;'. TOTAL USE: ©�`` LEACHING ISCa 3itv 5:5 c6 �tGt X FL1 '�� 'G I l .__r N ""K• No WATER ENCOUNTERED Y - -NOTES: (UNLESS OTHERWISE NOTED) OF , 1.,DATUM(MSL)t TAKEN FROM � .. ......... MAP V t : ---- " 2.MUNICIPAL WATER .,—_-9 ,_.__ ___.-------AVAILABLE 3.PIPE PITCH, 44"PER FOOT F-!-(5'.,5� Ai�NE H:. � 4.DESIGN LOADING FOR-AIL.PRE-CAST UNITS: AASHO- -44 t?,jJ�U r.+.+i ---CI--DISTANCE AS CERTIFIED 5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) F7. �y CIVIL •y � , 8,PIPE JOINTS SHALL-BE MADE WATER TIGHT tJ e� __• T A 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. NO. 3079 "� w STATE ENViRONMENTAL•CODE TITLE 5 Locus.: ^ MW1�lQ�{Mt c Lc Z �!•Zp L "s16 a vu r tE ++ w NE> L ��a�a�5 "Y � yy ��,.i.>I.N(t/{�A!'a�I.xl�3� I( OFESSI( NAL11 NGINEERj R.Ef � • '' PREPAREO;FOR een down: rn a �n'p�n � . .f \0 r f CIVIL. _ENGINEERS L'AND,SURVEYORSLAND BOARD OF,HEALTH s �e31 REG SCALE. 4 t«I C+7.. (EXISTING) -------- _ . �i A J'L: MA i ' r +....` ,.v � +. e CONTOURS. APPROVED_ DATE y _- _ (PROPOSED) APPROVED.-O—O— y r A._