HomeMy WebLinkAbout0109 COVE LANE - Health 109 Gore lane
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Barnstable w FIR
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COMMONWEALTH'O'F MASSACHUSETTS n:
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 M= .
OFFICIAL INSPECTION FORM-NOT FOR VOr
LUNTARY ASSESSMENTS • -
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 10q 41foddKX
'
� ��"
I
Owner's Name `
1
;ems . r
Owner's Add ress• 11 o ue ` q ;
• ,r
Date of Inspection: O
Name of InspectorZ;7,k&eV-
Mailing prin ) / V1
Company Name:Address: /
Telephone Number: S pIQ —:r9 - 7 OR
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 Imy.'
training and experience in the proper function and maintenance of on site sewage disposal systems. lam a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systems
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority:' .
Fails
Inspector's Signature: ate: `
The system inspector shall submit-a copy of this inspection report to the.Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments i
****This report only describes conditions at the time of inspection and under the conditions of use at that.,.
time.This inspection does notaddress how,the system will perform'in the'future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000liv a page
Page 2 of I 1
OFFICIAL INSPECTION FORM 'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM '
PART A
CERTIFICATION (continued)
Property Address: t05 Cave
u v7 <.
Owner: a�'
Date of Inspection: 7110 '
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CNM
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or'
repaired.The system,upon completion of the replacement or repair,as approved by Board of He ,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statem If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank i ure is imminent.System will pass inspection if the'
existing tank is replaced with a complying septic tank as oved by the Board of Health.
*A metal septic tank will pass inspection if it is structur y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is av able.
ND explain:
Observation of sewage backup o teak out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due.to a broken, ttled or uneven distribution box.'System will pass inspection if(with.
approval of Board of Health):
broken pipe(s)are replaced �1
obstruction is:removed
distribution box is leveled or replaced.
ND explain:
The syste equired pumping more.than 4 times a year due to broken or obstructed pipe(s) The system will,
pass inspection i with approval of the Board of Health)-,
broken pipe(s)are replaced.
obstruction is removed z
ND explain: A e
r y r .r ,,,
.awe 3 of 11
OFFICIAL INSPECTION FORM-`SNOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART A
CERTIFICATION(continued)
Property Address: O od e LO! J
Owner ,
Date of Inspection: Q
C. Further Evaluation is Required by the Board of Health: ;
H
Conditions exist which require further evaluation by the Board of Health in order to ` ermine if the system
is failing to protect public health, safety or the environment. -
1. System will pass unless Board of Health determines in accordance ' h 310 CMR 15.303(1)(b)that the "
system is not functioning in a manner.which will protect public alth,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water t
_ Cesspool or privy is within 50 feet of a bordering veg ted wetland or a salt marsh
2. System will fail unless the Board of Healt and Public Water Supplier, if any)determines that the
system is functioning in a manner that prote the public health,safety and environment:
_ The system has a septic tank ands tl absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a face water supply.
_ The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply.`
The system has a septic t and SAS and the SAS is within 50 feet of a private water supply.well .
_ The system has a sept' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a`
private water supply well . Method used to determine distance
*This system passes • the well water analysis,performed at a DEP certified laboratory, for colifortn s
bacteria and volatile rganic compounds,indicates that the well is free from pollution from that facility and
the presence of am onia nitrogen and nitrate nitrogen is equal to or less thane,5 ppm, provided that no other .
failure criteria ar triggered.A copy of the analysis must be attached to this form.'' ,, 1
41
3. Other: {
fir]v "
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAUSYSTEM INSPECTION FORM
PART::A.
CERTIFICATION(continued)
Property Address: l0 60!/{ n;
w
cop
or
Owner: i
Date of Inspection: !0 06
D. System Failure Criteria applicable to all systems: ,
You must indicate"yes"or"no"to each of the-following for all inspections:
Yes No
Backup of sewage into facility or system component due to'overloaded or clogged SASor cesspool
_ Discharge or ondin of effluent to,the surface of the ground or surface waters due to an overloaded or}
� g P g - ,
clogged SAS or cesspool
-41 Static liquid level in the distribution box above outlet inverrdue to an overloaded or clogged SAS or
cesspool
t
— 'l' Liquid depth in cesspool.is less than 6)9 below invert or available volume is less than /Z day flow ,
_ ( Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high groundwater elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone,l of a public well.. r
Any portion of a cesspool or privy is within 50 feet of a private water supply well. -
K 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.componuds
indicates that the well is free from pollution from that facility and the presence of ammonia-
nitrogen and nitrate nitrogen is equal,twor less than 5.,ppm,provided that no other:-.failure.criteria
/ are triggered.A copy of the analysis must he attached to.this form.]
V 0 (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 systerri owner should contact the Board of
Health to determine what will be necessary to correct the failure:
E. Large Systems:
To be considered a large system the system must serves facility—with a design flow of 10,000 gpd to 15,000
gpd,
You must indicate either"yes"or"no"to each o ollowing.
(The following criteria apply to large syste addition to the criteria above)
yes no
the system is wit 0 feet of a surface drinking water supply
the system is ithin 200 feet of a tributary to a surface drinking water supply
_ the sys is located in a nitrogen sensitive area{Interim Wellhead Protection Area-IWPA)or a mapped
Zon of a public water supply well
If you hav answered"yes"to any question in Section E the system is considered a significant threat,'or answered
'yes"in ection D above the large system has.failed.The owner or operator of any.large system considered a.
signif t 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.,
4 f
Page 5of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART B
CHECKLIST
Property Address: ry 60Ve
u t�—
Owner: Q tt t {
rt r
Date of Inspection:
Check if the following have been done.You must indicate`des"or"no"'as to each of the'following:
Yes No
K _ Pumping inform
ation,.was provided by the owner,occupant,or Board of Health'
� Were an of the _
_. Y
system,components.pumped out in the •previous two weeks
Y P. P P P ,
— Has the system received normal flows in the previous two week period?
of Have large volumes of water been introduced to the system'recently or as part of this inspection?
Were as built plans of the system obtained and examined?f(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up.?
Was the site inspected for signs of break out? ,
Were all system components,excluding the SAS,located on'site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,"depth of liquid, depth of sludge and depth of scum
'�E _ Was the facility owner(and occupants if different from owner)provided with information on the proper
mtenance of subsurface sewage disposal systems? " • t
The size and location off the Soil Absorption System(SAS)ion the site has been determined based on:
Yes no
Existing information.For example,.a plan at the Board of Health. `
im
— 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)]
Page 6 of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION T'
Property Address: /D49 Cove (nA.wt t
Owner:
C. `
Date of Inspection:
FLOW CONDITIONS"
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual)
DESIGN flow based on 310 CMR 15.203 (for.example: 110 gpd x#of bedrooms):
Number of current residents: S
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):�A",[if yes separate inspection required]
Laundry system inspected(yes or no): NQ'
Seasonal use: (yes or no): YQS
Water meter readings,if available(last 2 years usage(gpd)): -
Sump pump(yes or no): ? ;
Last date of occupancy: C vrr
COMMERCIAL/INDUSTRIAL
Type of establishment: `
Design flow(based on 310 CMR 15.203): gpd.
Basis of design flow(seats/persons/sgft,etc. „
Grease trap present(yes or no):_
t
Industrial waste holding tank pr t(yes or no):_
Non-sanitary waste discharg to the Title 5 system(yes or,no): „.
Water meter readings,if ailable: fr .
Last date of occ, an use:
OTHER(des e):
,A.
GENERAL INFORMATION
Pumping Records
Source of information: `
Was system pumped as part of the inspection(yes or no);
If yes, volume pumped: gallons—How was quantity pumped determined'
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool "
Privy =
_Shared system(yes or no)(if yes,attach previous inspection records, if any) w
_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 approval
Other(describe):
Approximate age of all com vents;date installed(if known)and source of information
�eloa o b
M
1 �►
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C r
SYSTEM INFORMATION(continued) ,
Property Address: 0 CaVQ LA4
a„
Owner:_T
Date of Inspection: 71/01016
r
BUILDING SEWER(locate on site plan) .. '
M .
Depth below grade
Materials of construction:_cast iron 0( 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 on,.site plan) ,
;
Depth below grade:
Material of construction: K 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:
Sludge depth: - -p7.
Distance from top of sludge to bottom of outlet tee or baffle:
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 by�ffle:
How were dimensions determined: LO.'s',,C? e
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,liquid levels. .
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction: concrete_metal "fiberglass polyethylene:_other
(explain): x:
Dimensions: _
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: p
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'cond it.ion, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.): .. • _.
- _ ..
Page 8ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued):
Property Address: /( -7ye
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: (tan;stlbe pumpe time-of inspection)(locate on site plan) .
Depth below grade:
Material of construction: concrete fiberglass Uolyethylene other(explain):
Dimensions: v
Capacity: .g ons
? ..
Design Flow: allons/day r .
Alarm present(yes or no):
Alarm level: Al in working order(yes or no): M
Date of last pumping:
Comments(conditi of alarm'and float switches,etc.): `
'f
DISTRIBUTION BOX:. Ix (if present must beMopened)(locate on site`plan)
Depth of liquid level above outlet invert:file-H _•
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage in��tpp or out of box,etc.): p
Tie b o x Gc y` c �I- t s +2 va G t A vt o i s(ri c1 CGc y�-VI O vfif
PUMP CHAMBER: "
(locate on site plan)
Pumps in working order(yes or no):. :
Alarms in working order(yes or no `
Comments(note condition o p chamber,condition of pumps and appurtenances,etc.):
- i 8 - - a
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM _
PART C
SYSTEM INFORMATION (continued):
S 7
Property Address: lot 6y y
v o1
Owner:
Date of Inspection: 7 0C1106
SOIL ABSORPTION SYSTEM (SAS): (locale on site plan;excavation not required)
If SAS not located explain why:
k
. • - . - .i 4
Type f t
leaching pits,number:
leaching chambers number:
leaching galleries,number: .
leaching trenches,number, length.
a ,leaching fields,number,dimensions: / /<✓ �C,3o? ,
+ _ r
overflow cesspool,n ., umber: ,
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.): e''
iS TLw L rk!; k4L Lowt GK- `S�OWcs
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) A" " • ,
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 groundwa r inflow(yes or no):
Comments(note co ition of soil,signs of hydraulic failure; level of ponding, condition of vegetation,etc.):
PRIVY: (locate on site plan)
y ,
Materials of construction:
Dimensions:
Depth of solids:
Comments(note co ition of soil,signs of hydraulic failure,level of ponding,`condition of vegetation;etc.),
+. . • -t. -
Page 10 of 11
t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'(continued) ,
Property Address: o t- 2 t, e f
v Nh wvc c"v— -
Owner: C�l f
Date of Inspection:
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.
6 5
•
Page 11 of l l
OFFICIAL INSPECTION•FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION (continued)
Property Address: /of ec"VC
Owner
Date of Inspection: 0.6 i ^
SITE EX
AM
Sloe NO
Surf
ace water IUD r *z
Check cellar t*.S -
Shallow wells V-70 -
Estimated depth to ground water 5 yfeet t
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:
Observed site(abutting property/observation hole within 150 feet of SAS) ,
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation) f g
Accessed USGS database-explain:
You must describe how vau established the high ground w ter elevati
u ` r
' ^ • ...
permit
s
Comp, `
Site Location: � W V ej [�+cLot No.
v�
Contractor: Address:,
Hates: N
1p 3 Measure _h to � gable �
to nearest vib,ft. _
•
n ,
Cy
STEP EP 2 Using Water-L-eve: '�a�'•#t��mP'2�_ - + 1
Se$e anu det.,rm9nee: i P
•J t(A) (/yam
STEP 4 Umsinr TWIe of water AdNsstments F
for index Well (STE P 2AJ>cumentdePtft
La er-
mad ur�_T se,4t zone €CTEP,28:- g.
_.
iei'LZS£?2 b 322F-iL'uEi ett�t3 Ones--- i._ - }-s
_ l
5 $LPrY3?2e LGe 7 ?'£C3'fS{' h
the Water
retie:adiustsism!STEP 4)
f_�p .a a ` - .
'.eve`t aa1L`-�9 f�� 'a} .:....:........ ... ..... ....... .. ._-___--__- --. ___ � � 67,
''••(`j, +
.. x - _ t
- � - ��`... e . rt.. }. � ° •fix '.
. •dye ' ;Aqy f. h,'�+�, fir'' �..� ,.A t ref 5 r' a �
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'Town of Barnstabie P#
Department of Regulatory Services s
Public Health
Division Date
yortHe, $ 200 Main Street,Hyannis MA 02601
9 : NA CrA
M �g U Time U' O Fee'Pd. / U� `
Date Scheduled D
Suitability Assessment for Sewage Disposal
Soil ty B
Witnessed By:
Performed By:
d'I , Ili. I"'il" 'nnn I..5�...:il:4i.i i...�:c crl' ir•I.;il.il`:y,i:9',IP I p�� �N.N ,'�'.jl �' i r, 'b .y}:..��•,
sj� h' lrc�15 ,. 6 _ ..
l�r};� airG�
' Owner's Name
Location Address !0q" Cove blMt
Address
l Engineer's Name 0 '(Q'I y ,
Assessor's Map/Parcel: 3PA
REPAIR Telephone#
NEW CONSTRUCTION .
Land Use
Slopes(%) Surface Stones
Distances from: Open Water Body
ft Possible Wet Area__---ft Drinking Water Well ft
• �Drainage Way ft Property Line �--ft Other ft
.
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands is proximity to holes)
Z6Z- >
v
Al, /
l ''/
/ �
_ _-- -- eoto is -. Depth to Bedrock
Parent material(g g `_ lJ
5tandingWaterinHole: /yp�6 Weeping from Pit Face
Depth to Groundwater:
Estimated Seasonal High Groundwater
. ,I,,.,.rre,� I 'I - 'fir='
E� � I �., j. I I r 7 { I, i h ii j.II I I I ry��6�1
rr, -
ri..9 I
Method Used: in. Depth to soil mottles: — in,
Depth Observed standing in obs.hole: in Groundwater Adjustment ft.
Depth to weeping from side of obs.hole: Ad factor. Adj-Groundwater Level
Index Well H Reading Date: Index Well level
\ '" IF R• 1 �� ,I rh�it'.' C '
' ^'ih!.� fly! Im II .'1 � 5s1.31i 96i :5n.. 16.1.5.' Ii•F�•I'I I!. ..
I I 1 ��1 h t I I ' ' ' I. i
��jj,I,iAl 11J II�������II ,u, r,.�1.r, '14 II �„�...m.
I�h4.11''Ilpl J' 1I IHL,]1iNf j i IlBiit��nF9'I �Mllii C� ,1, m
Observation Time at 9"
Hole 1!
Time at 6"
Depth of Pere
1
Time(9"-6")
Start Pre-soak Time @
End Pre-soak f O:iG AM
Rate Min./inch
/ Additional Testing Needed(Y"
"ap.snitability Assessment: Site Passed rd Site Failed:
; y.}:::>:::;>.;;�:::}>:<•:;:::s3i:r•' � Other
.,...: :a�<?::}.,�:t,.:<:::.{.;•}:«{•,�:•;<:::}:;{.,?.::::::::.,.:::::.�::.:,..�,:. Soil
Depth Gom Soil Horizon. Soil Texture • $oil Color Mottling (Strocture,Stones,Boulderes.
Surface(in.)
(USDA) (Munscll)
F u
..,k.:..;; ,.•,�;yyk:2ixc�?g;�,{y>�ol$' ::?: {:::?y:'a. �•�$:rr Y::<6ir'•:.:,wti:
D ..(� �.:.:....:..... :
...:.......
Other
Depth from Soil Horizon Soil Texture, Soli or Mottling (Structure,$tones,Boulderes.
• Surface(in.)
(USDA) (Munscll)
f .
Other
Depth from Soil Horizon Soil Texture Soil Color Mottling (Slructure,Stones,Boulderes.
Surface(in.) (USDA) (Mansell)
. 01
c
--------------
�y �'(�'1 •:;F.�?.}r^.SC. "'''`r`.'•t:::sk:`�3tifh:#}�?n::2`>,:`•,`.:d�>.
>'•��<� <z:i{: ,•:}{.... :�:::;;<;�}:; ... Sotl Other
'Depth from Soil Horizon Soil Pexturc Soil nsell) Mottling (Structure,Stones.Boulderes.
Surface(in.) (USDA) (Mansell)
Flood Insurance Rate Man:
Above 500 year flood boundary No— Yes
Within500yearboundary No Yes
Within 100 year flood boundary No_ Yet
npnth o[)ti'aturaliv Occurrine Pervious Material
Y
of natural) occurring pervious material exist in all areas observed throughout the
Does at I ur feet
east fo
area proposed for the soil absorption system?
If not,what'is the depth of naturally occurring pervious material7___----
t:;ertification •
•a.r nn
(date)I have passed the soil evaluator examination approved by the
__ ..�. ____c....e.r ti,..mw cnncietent with J
TOWN OF BARNSTABLE
LOCATION C o v-- L t -• SEWAGE #
VE-LLAGE ASSESSOR'S MAP & LOT 3SI' Oi6
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /vo y
LEACHING FACIL=: (type) /°� a' t'''` (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
V 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 brZ,w:
f
3s
s1
.R
A
i-TOWN OF BARNSTABLE
LOCATION q CO t1� r��rJ 49 SEWAGE #
4�
VILLAGE jf^ 1!11 M /.l l;.0 1 [X ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. "T t�J /M6 2 / dV
SEPTIC TANK CAPACITY Eio
LEACHING FACILITY: (type) Gt0d (size) .X 3 �_
NO.OF BEDROOMS
BUILDER OR OWNER &AIAJ
PERMIT DATE: o �� COMPLIANCE DATE: -
NSeparation Distance Between the: —/0'—O�
_ Maximum AdjustedGroundwater 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 Y)facilit Feet
Furnished by
"" ' 13 '>g
" a
< "o
Lco
k
C
out IN,42
No.
t �� �+ r Fee_THE COMMONWEALTH OF MASS'ACHUSETTS Entered in computer:. Yes
PUBLIC PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(pphratton for Mgooal bpgtem Con5truction Vertu
Application for a Permit to Construct( . )Repair W Upgrade( )Abandon( ) ❑Complete System individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's c/PiK e-11 L-4'6 a �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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 3 3 c. s �-- gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /b eD Type of S.A.S. ��oZ
Description of Soil 4�02
Nature of Repairs or Alt ations(Answer when applica le) /1J�t c� r� _ I�f X 3 Z
"n n • l o✓ /
CArz
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 ' 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y tht B and Mlth.
Signed Date 49
Application Approved by Date 7—2-01
Application Disapproved for the f wing reasons
Permit No. Date Issued
x _ q
a V_y No. .,(.f�0 2 '2g� 174
t Y Fee
THE COMMONWEALTH Ol MAASSACHUSETTS,.-' Entered in computer: Yes
l
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
r :
Rpplicatton for Migool *p!tem Congtruction Permit
Application for a Permit to Construct( . )Repair�4)Upgrade( )Abandon( ) El Complete System individual Components
Location Address or Lot No. � Owner's Name,Address and Tel.No.
l �
Ass�ess� cel
U° 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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 3 S �— gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets / Revision Date
Title
Size of Septic Tank Z:> Type of S.A.S.
Description of Soil -Sf D Ira,c
Nature of Repairs or Alterations(Answer when applicable) /l,' ecr"'
J s
A r/ `.G i `CG u.n ire Hn
Date last inspected:
t
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-td•place the system in operation until a Certifi-
Cate of Compliance has been issued by th\B and of -_alth.
f � +Signed Date 7� 9 - ey
Application Approved by Date
Application Disapproved for the f wing reasons
Permit No. uoI t 29 Date Issued
i; THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of QCompliance
THIS.IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded( )
Abandoned( )by
at f G g of 4.0*4,,s� �__/a yib.�t a_ P. c%' has been constructed i accordance
with the provisions of Title 5 and the for Disposal System Construction PermitAo. 2W "99-5-dated d�
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syst mill fun�tion as de�jigned.
Date ' o 1 it -Inspector�l J ti,">!/ ow �) �i�
I' --r
---------------------------------------
s
p r
No. U0 , `.�(S Fee ,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
li5po!5al *patent (Construction erntit
Permission is hereby granted to Construct( / Repair( )Upgrade( )Abandon( )
System located at to /' Z) tj eg L4/U P 0 eM IU 4 /_ U f J
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:Constru do must be completed within three years of the date of this p
Date: / U Approved by �.
TOWN OF BARNSTABLE
LOCATION Q 1--A,,o 0 SEWAGE # D Z--2-8��
VILLAGE r'_t2 Jn9 o t ASSESSOR'S MAP& LOT 3 E/04 6
INSTALLER'S NAME&PHONE NO. 0- P /MeT l2 f �V
SEPTIC TANK CAPACITY ( Go
LEACHING FACILITY: (type) (size) 3 2—
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: —
0'
Separation Distance Between the:
-02
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facili
ty (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
t 14 3z.
A--6—
q
" ezr
le — s a
�COUe.(t-4—
N Y
6 w `
fir.. -.. '1..� .....•
No....... s Fics....�...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALT .
'✓..� /1- OF.....kwe.h..6...` W ./.. -----------------------_
Appliration for Diipoml Works C on,5trurtion Pprutit
Application is hereby made for a Permit to Construct (A/5 or Repair ( ) an Individual Sewage Disposal
System at: % n
Locati n Ad ss or Lot DjV
e�tl- ------�- ----�---------�------------------- .....- / A/...... r�YYI r�sr
O ner Address
-------•---------------------- .. ------------........ -----•------•-•--------•--------------- --•---•---•--•-••-•--•----•.---.•---•------
nstaller Address
U Type of Buildi> Size Lot...�Y_0®6__Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p� Other—Type of Building ............................ No. of persons_-_____.-_-___-__.-.---_.-_ Showers ( ) — Cafeteria ( )
G4 Other fixtures ---------------- -----------------------
W Design Flow________________----�.. `� . gallons per person per day. Total daily flow--------- _.._____.__-_._._____gallons.
- -------
USeptic Tank—Liquid capacitvfOD.Qgallons Length---------------- Width.........__..... Diameter---------------- Depth____..__.._.....
xDisposal Trench—No--------------------- Width-___------___------ Total Length------_----._..-_.._ Total leaching area--------------.-----sq. ft.
Seepage Pit No...../------------- Diameter./MAW-Depth below inlet____________________ Total leaching area------------------sq. ft. "
z Other Distribution box ( ) Dosing t n ) 1D
Percolation Test Results 1—Performed by.__ ,_____, _ Q_r_..__.._.. Date._ `2 7- '
a -
Test Pit No. 1----------------minutes per inch Depth of "lest Pit---------- ____.. Depth to ground water......140_
(z, Test Pit No. 2....._----------minutes per inch Depth of Test Pit-------------------- Depth to ground water----------------------
�... -----•---------•----------
O
Description of Soil_----.----._L1_:'./__..- -__--l®-__-- -- 2.._----
c� --•---••--------------------------��) j.`7_.:_ ._:..__ )k.J---- :�� � ¢. �'�,�-
x ----------------------_---------------------- ------
U Nature of Repairs or Alterations—Answer when applicable.-.----------------- ------
h ------------------------------------- -------------------------------------------------------------------- --------------
Agreement: (
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 VDate
lth.
a
Signed.._... C� "1 f Z-
I
I Application Approved By--- Cf� ---••- = = �f �. .7
,e�,(�l�c( ate
Application Disapproved for the following reasons---------------------------------------
----------------------------------------------------------------------
.........................................................................................................------------------------•-------•-•----T^---------•-•-----------------•---------------------
��"� Date
Permit No............................................
............. Issued.. _ .e
No......................... 4 . , Fas.... ....................
• f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALT
-oF..... Y..h.. _-----
..... r
AliptirFa#iuu -for i-4pusttl lVarka Cnutulrurtioaa Vaunt
TM ._Application is hereby made for a Permit to Construct ( or Repair ( ) an ,Individual Sewage Disposal
System at: -
L.c4' n Ad ss or Lotbio
4 l Owner •Z Address
q \ Installer Address
d Type of Buildiw Size Lot...?_:TA_-00d__Sq. feet
Dwellingw=t No. of B` rooms-------------------------------------- -----Expansion Attic ( ) Garbage Grinder ( )
pi Other—Type-of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P4 Other fixtures
Design Flow--------------------.___ _ S _:________gallons per person per day. Total daily flow.......... gallons.
WSeptic Tank—Liquid capacity/1 gallons L.ength---------------- Width----------- ---- Diameter-----.........__ Depth-__"________---
x Disposal Trench— o ....................,Width__ ______ Total Length Total leaching area--------------------sq. ft.
Seepage Pit No------ _________ Diameter_� S�tDepth below inlet______ Total.leaching area____,_;.__.___.sq. ft.
z Other Distribution box ( ) Dosing t n )
a Percolation Test Results P--Performed by.___ ( - --y�_,*- _-____ D�!"' Date_ •�►"�_!__..__.
# : - .
Test Pit No. L_______________minutes per inch Depth of Test Pit---------- _----- Depth. to ground water-__-- tY
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.____"_____________
Q+' -------f
Description of Soil.__,_t Q f �.___(." �" T _______."_...
x -------------------- '014__1_ .._. _. - - F` -
w i -
x ----------- - --- --------- -----V t.�. .1G- ----- ---- ,.mac 3� �''�'K' -----
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued by he.board of h lth.
i ned
g ., ' _ c
Application Approved By-f / j{/r,. /�
,. - .�rq`�� I '4• /� / � ate
�'Rv s Date
Application Disapproved for the following re¢sons_____________ Y�Gi�t
........................................................... --••---•----------•--•••-•...•-•---------•• -•--•-----•--•-----•--•----••-•---------•-------•-_----- -------_.__.._...•----
_ Date
PermitNo......................................................... Issued..........................
Date
$ ti
THE COMMONWEALTH OF MASSACHUSETTS
b BOARD OF HEALTH'
... .. . ......OF..........: '.-a�+4-' ...:... ...... .....
rdif ira#r of womplianrr
THIS IS O CERT Y, t e Individual Sewage Disposal System constructed or Repaired ( )
y 1
b --•-• --------- °-� I�..'�alb--- --- ---•-------•-•-------------•---•--------_._---------•--•-----•--•----------
------------------- ------- -
Installer
- ---.ff-''------ -cam---- ----- --;---- .��.=-� --------
has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described m the
application for Disposal Works Construction Permit No......._Zh✓r __________________ dated_-_,. + -�? __________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE`THAT THE
SYSTEM WIL FUNC ION SAT,IAICTORY.
DATE:.......... • ��--�-•----2.................................-- Inspector_-=-• • l --
Y--•--
l ...4A..4o . ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
. OF-....-..- ��I
ys' !' . ... .....-...
I''EE!__ r(! ...............
air Cn titrurfivar Prrmi
Permissi hereb ranted �'J-l ' ---"--- ----- i Yg -------------
to Constr ) r Repa ) .an Individ Sewage Dispos ystem
at
street
as shown on the application for Disposal Works Constructio er it No. : __.___ ..
Dated---�,,/14�_---a�---------•--
L� r--------------------
'of ealt
DATE...............................................--...............................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
n
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JUN 11 1974 1`
Td P' cop ei T 1 0 C) BOARD HEALTH,
7N LET 56K t01,36
1 i. [_ET 5�t?�tG -TA t- K�
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A��A1L 6-P'Si. ;�Z i~r. sa-r ypt-� ✓ T E5 �nr' «7
WILFRED
f� F. v y '✓,,�'i%�-! -T.hv't� 'T�F�it« ,_.3 s� ��k `t`�a,
TAYLOR � ;s i CPU,c'�.�✓J�r-1T"�
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t�JV�.2T �;P� �w� c��= �c.�uf..ad.es.�'��ra lA�•.�! �_.C.� C.4T1 Dt�..!' [,ut•:�.�.,a,.����, f�.,�A:��..t. �;'�� �.
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TAYLOR
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TOP OF FOUND.ATION
CONCRETE COVERS
•'; 4"CAST' IRON 9 "MAX.
,`; OR SCHEDULE 40
P.V.C. PIPE MIN. PIPE MIN.4"SCHEDULE 40 F'V.C. (ONLY} 12"MIN,
I
�f PITCH - LEACHING FIELD (. ...REQUIRED)
' PITCH 1/4 PER.FT. >
1/8"- 112.16 WASHED STONE
INVERT GAS BAFFLE
♦' �`� :,a EL.. INVERT ., NVERT WASHED ��STONE
ar , SEPTIC TANK g 3/4 - 11/2
v ,.A INVERT /voo 99,`G
EL.......... .... . . . . .... . .. ... GAL. INVERT OIST. INVERT INVERT
EL
3.
8ourt Gq .�' " 60X ELM,7?.. EL.:........... uv& z.
6 RUSHED STONE
LOCCJ.S M/-'1�? Sc'R« t ''-t000' �,, /�� .��i
�SS� � ZS M�l� ��/ �R/STi
01 _
S "C. PROF1 LE OFTABLE
l'" /ozsi SELVAGE DISPOSAL SYSTEM TYP CALNDCROSSESECT ON
SOIL LOG NO SCALE LEACHING Fl ELD
DATE :` 3�.ZX1 Z- TI M E ./O bo A.7 . . NO SCALE
TEST HOLE I TEST HOLE Z
. . . . .. . .
DESIGN DATA
ELEV. I/a'-1/`L"
n 3 12"MIN. WASHED / ¢ ,
TrI -1
NUMBER OF BEDROOMS . . . . . . . . . . . . . . . . . . STONE
�z. y'q,BS TOTAL: ESTIMATED .FLOW . . . .jp. . , .. GALLONS/DAYBOTTQM LEACHING AREA . .. ea. SQ.FT./TRENCH 4SCHEDILE 40 P.V.C. rZPERF�OR ATED P i PSIDE LEACHING AREA . Alo"4-1 SOFT./TRENCHZ3/4"-1 I/2"
,4,dwD"oyg /�!o/�l�.;(�50% AREA INCREASE:) WASHED
�G GARBAGE DISPOSAL . .
TOTAL' LEACHING AREA . .:¢4$.'c� ..: SQ.Fl". 3,�.� 3Z� 3�`STDN `�� dVE72
_ ' PERCOLATION RATE l.C- 571!✓ ! TIA/o!�l.,vPER. INCN
( J LEACHING AREA PER PERCOLATION RATE :�:3�'.-'.Z. SO.'FT
Ss�tD y ��' GROUND WATER TABLE
APPROVED . . . . . . , . . . .. BOARD OF HEALTH
1 --
1 .No...WATER ENCOUNTERED
' r DATE . . . . . . . . . . . . . . . . . .. .. .-. . . ��S S�H Of Mq
9S AGENT OR*
INSPECTORo�'� .T
WITNESSED BY
R.
JT/-�w TU>tt' 8 0 A R D OF H EA LTN /d _ CoVI
'cc� � �r I ' S77`TSON •� �/�LL /Z.S.
1 . . . . . . . . . . . . . . . .�. ENGINEER
00 .LOT .� �� EVALUP�O
PETITIONER . ./,? A-1 .���G. . . . .
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