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HomeMy WebLinkAbout0195 DROMOLAND LANE - Health 195 ®romoland Lane A = 335-084 Barnstable 33s- o g� _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Dromoland Ln. t Property Address - CA Richard Bernard' CA Owner Owner's Name information is 4= required for every Cummaquid MA 02637' 8/18/2017 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:Whenfilling out forms A. General Information on the computer, J use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return key. Name of Inspector Cape Cod Septic Services " I Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 SI5016 p ' Tele hone Number License Number B. Certification 1 certify that I have personally'inspected the sewage disposal system at this address and that the information reported below-is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes 0 Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a . �8/18/2017 Inspector's Signature ' Date The system inspector shall submit a copy of this inspection report to the ApprovinjAuthority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,•the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority, ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 o- V v Commonwealth of Massachusetts u r Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information isequired or every Cumma uid MA. 02637 8/18/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A;B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: System in working condition., B) System Conditionally Passes: 0 One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y,N,`ND)for the following statements. If"not determined," please explain. ` The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating.that the tank is less than 20 years old is available. El Y ❑ N ❑;ND (Explain below): t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts v. Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is required for every Cummaquid MA - 02637 8/18/2017 page. Cityrrown State ' Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level.in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El broken pipes)are+replaced ❑ Y f ❑ N _ ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): r ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 1 ❑ The system required pumping more than 4 times a yeardue to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑.N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation9 by the Board of Health in order to determine if the system is failing to protect-public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh tSlns•3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . . Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name , information is required for every Cummaguid MA 02637 8/18/2017 page. Cityrrown State Zip Code ,Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank'and'soil absorption system (SAS) and the SAS'is within 100 feet of a surface water supply or tributary to a surface water supply. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS and.the SAS,is Tess than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed:at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitro en is equal 9 q to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u r Title 5 Official onsfpedi®n .Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Dromoland Ln. Property Address F- Richard Bernard Owner Owner's Name information is required for every Cummaquid MA 02637' 8/18/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 ® 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 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ®' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A'copy of the analysis `and chain of custody must be attached to this forma ❑ ® The system is a cesspool serving a facility.with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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: To be considered a large system the system'must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either."yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system js within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200feet of a tributary to a surface drinking water supply ❑ 13 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 has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section.D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. , 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection 'Form ' 's Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is required for every Cummaquid MA 02637 8/18/2017 page. City/Town ' State Zip Code Date of Inspection C. Checklist ` Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No Purrs in -information was provided o ded® b the owner, o❑ ccu ant or Board of Health p 9. p Y occupant, El ® Were.any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of Water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility-owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems?' The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® . ❑ Existing information, For example,-a plan of the Board of Health. ❑ Determined in the field (if any of the failure criteria related to'Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System`riformation Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 110x5 550gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is required for every Cummaguid MA 02637 8/18/2017 page. Cityrrown 7§tate Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder?- ❑ Yes ® No Is laundry on a separate sewage system?(Include.laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2015=800gpd ( Y 9 (gpd)) 2016=663gpd Detail: Note irrigation system t Sump pump? ❑ Yes ® No . .Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: . Type of Establishment: Design flow(based on 310 CMR 15.203):x Gallons per day d P y(god) Basis of design1low(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes Ell No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 ®fficil Inspection Form s Subsurface Sewage Disposal System Form Not for Volunta Assessments ry rr 195 Dromoland Ln: Property Address Richard Bernard Owner Owner's Name ' information is required for every Cummaquid MA 02637 8/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 1 Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped,determined? . Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system. ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or,no) (if yes, attach previous inspectionrecords, if any) 4 ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract .Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 } Commonwealth of Massachusetts a Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is required for every Cummaguid MA ' 02637 8/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) , Approximate age of all components, date installed(if known) and source of information:. 1997 Per BOH records - Were sewage odors detected when arriving at the site? ❑ Yes ® No Building•Sewer(locate on site'plan): 3411 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): u Distance from private'water supply well or suction line +10feet Comments(on condition of joints, venting, evidence of_leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitchedwith no sign`of root intrusion. Septic Tank(locate on site plan): " Depth below.grade: 26" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Gal Sludge depth: 3.411 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is required for every Cummaquid - W 02637 8/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to;bottom of outlet tee or baffle11 - Scum thickness 1-2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated. Comments(on pumping recommendations, inlet and outlet.tee or baffle condition, structural integrity, liquid levels as,related to outlet invert;evidence of leakage, etc.)" 1500Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Inlet, 10" below.grade with outlet 26" below grade. Grease Trap(locate on site plan.): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: date t5ins•3113 Title 6 Official Inspection Form;Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments, 195,Dromoland Ln: Property Address Richard Bernard Owner Owner's Name information is required for every Cummaquid MA 02637 -8/18/2017 page. Cityrrown State Zip Code Date of'lnspection. D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass . ❑ polyethylene ❑other(explain): 6 Dimensions: Capacity: gallons Design Flow: gallons per day j Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping-. Date, Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts, _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 195 Dromoland Ln, Property Address Richard Bernard Owner Owner's Name information is every aq for eve required Cumm uid MA 02637 8/18/2017 4 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on,site plan): Depth of liquid level above outlet invert Oil 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.): H-10 DB-3 with 1 line in and 2 lines out in good condition:Box is clean and'level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover at grade. : Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑. Yes ❑ No* Comments (note condition of,pump chamber, condition of pumps and appurtenances, etc.): *,.If pumps or alarms,are not in working order, system is a,conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 l . Commonwealth of Massachusetts 4 v Title 5 Official Inspection Form 's Subsurface Sewage Dliposal System Form-Not for Voluntary Assessments ••` 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is required for every Cummaquid LMA 02637 8/18/2017 page. City/Town State Zip,Code , Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers numr:be _ 4-500Ga1 ❑ . leaching galleries number: ❑ leaching trenches number, length: ; ❑ ..leaching fields number, dimensions: El overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4-500Gal chambers with stone. 6"of effluent in chambers at time of inspection with no staining. No sign of overloading or hydraulic failure. Chambers 4' below gra& Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspectiono;rm s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is Cummaguid MA 02637 8/18/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information.(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition"of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil,signs of-hydraulic failure, level of ponding, condition of vegetation, { etc.): t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 14 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments " 195 Dromoland Ln. Property Address Richard Bernard Owner Owner's Name information is Cumma uid required for every q MA 02637 8/18/2017 page. Cityrrown State Zip Code Data of Inspection D. System Information (cont.) Sketch Of Sewage Disposal.System: Provide a view of the sewage disposal system, including ties to at lea st two permanent reference t landmarks or benchmarks. Locate all wells Pe Is within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately' t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official' Inspection Form ^ Subsurface Sewage Disposal System Form = Not for Voluntary Assessments 195 Dromoland Ln. Property Address Richard Bernard " Owner Owner's Name information is required for every Cummaguid MA 02637 '8/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information'(cont.) Site Exam: ® Check Slope . r.. Surface water ® Check cellar ® Shallow wells' Estimated depth to high ground water:' feet - Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record . 1997 If checked, date of design plan reviewed: I 'Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ` Checked with,local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: . You must,describe how you established the high ground water elevation: Test hole data per-plan-on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "e 195 Dromoland Ln., Property Address Richard Bernard - Owner Owner's Name information is required for ever y Cummaguid MA 02637 8/18/2017 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist • Inspection Summary::A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of.Sewage Disposal System either drawn on.page 15 or attached in separate file , r t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.17 of 17 i-,uiiL%,aiva -. Page 1 of 2 5 r y5 . .�K�MO`f1�ND L 1 TOWN OF BARNSTABLE LOCATION Ccl 1+ SEWAGE If...' VILLAG ASSESSOR'S MAP&LOT . INSTALLER'S NAME&P ONE NO. lr.f �L�(✓tst�n \2� SEPTIC TANK CAPACITY LEACFENG FACILITY:(type) (size) No.OF BEDROOMS-- BUILDER OR OWNER PERMPTDATE:- - COMPLIANCE DATEJ;�I�`S l 1 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet: Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leeching facility) Feet Furnished by �a + i✓ �,. Nam n r http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=33 5084&seq=1 8/17/2017. L 1 TOWN OF BARNSTABLE LOCATION C l'/ �a���l� SEWAGE VILLAGE ASSESSOR'S MAP & LOT `/ INSTALLER'S NAME&P ONE NO. 6 ti ►l"oy) SEPTIC TANK CAPACITY LEACHING FACILr Y: (type) (size) NO.OF BEDROOMS •� '��� BUILDER OR OWNER PERMIT DATE: 176"- e � COMPLIANCE-DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by X ,1q r-,,� T No. 97 ' Fee 06 It____r_`T,HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., aA sACHUSETTS 0(pplication for �Ngpogar *pgtem Construction Permit ` Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 78 to rv,,o �d y��n w o erName Add;ess Tel ` r IL51(I Assessor's Ma /PazceI Yn Ctq-� /g ,S ®/��� Cv r P- ,3 s �1 . c Installers Name,Addres Tel.No. De§ygner's e,Address and Tel.No. 1j;11��.m �non 1 c �e r vac k c ,I Type of Building: Dwelling No.of Bedrooms Lot Size �artcsq. ft. Garbage Gn der(/)o Other Type of Building No. of Persons S Showers(7 ) Cafeteria( ) Other Fixtures Design Flow (a� y ''~ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 0 o CLl, Type of S.A.S. Description of Soil 50� f.a .. Nature of Repairs or Alterations(AP-�.: er when applicablc y. ( 5 _ In '014-4 as 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 Environments ode and not to place the system in operation until a Certifi- cate of Compliance has been issued by this d of h. Signed Date "3+� Application Approved by Date Application Disapproved for 4-following reasons -. Permit No. 9 7_ o Date Issued 4 g / wNo. / —7 d ! ,j Fee _ +19-COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes _ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEi ISCHUSETTS 01ppYication for ;Disspaaf *p!Otem Cottgtr-uction Permit 6 ` Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. /` ro rn(7 Ian y1n p �3 U n ,o� er' Name,Address Ajd Tel.No. Assessor'sMap/Parcel, C11�dY1Y1�1.O1�(.�' /r�rT • 5 - ` � d( S aa ,, � yQ5( aAhn Installer Name,Address and Tel No. Des�ner"s: e,Address and Tel.No. 1�vbinSc�n Sc�F.� 'Sc c��c e k ►�f I I canric Vh(� D} n CA , ���2 Type of Building -- Dwelling No:>of Bedrooms`" ��" 11Lot Size `J� q.ft Garbage Grinder c0. Other ' �, Type of Building s;,` ¢ No:"of Persons Showers(y) Cafeteria( ) Other Fixtures 44 Design Flow gallons per day. Calculated daily flow gallons. Plan Date I ff'Number of sheets Revision Date Title Size of Septic Tank f /_SD,CS �a I . Type of S.A.S. Description of Soil rG n Nature of Repairs or Alterations(Answer when applicable) Us !` w I . Date last inspected: R Agreement: Th`e 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 andnot to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o�Hth. Signed Date 3 Application Approved by Date 2— 9� ' Application Disapproved for th ollowing reasons Permit No.—Tr — 9� Date Issued ] �. —, r -———————.——————————------————— —————————— - -1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(✓) Repaired ( )Upgraded( ) Abandoned( )by e' at has been constructed in accordance ( with the provisions of Title 5 and the for Disposal System Construction ermit No. — , dated ? - — •4 Z. t Installer `V(A m = 'L)i 0 An Designer The issuance of this permit shall not be construed as a guarantee that the system-will funct on as designed. Date ': u Inspector ------------------- THE COMMONWEALTH OF MASSACHUSETTS � . r. . PUBLIC-HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogar *pgtem Congtruction Permit Permission is hereby granted to Construct �Repair( )Upgrade( )Abandon( ) System located at ( 1 �,r' (/1�JQ 1 •���y I y 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 provisioo�nss or special conditions. PrhvV,tded�:�Construction� mt b o b lete�wtthiSth�ee yea"s of the date of this permit. Date: -3 � �— 9 Approved by A_,A,4 .,. 1/7✓i ��,'Z � i TOWN OF BARNSTABLE r� LOCATION �� >7�1 SEWAGE #._'%��� l�.� � � VILLAGE, ���i ?�' aJ l�� ASSESSOR'S MAP &LOT 3.3 INSTALLER'S NAME&PHONE NO. o SEPTIC TANK CAPACITY (size) LEACHING FACILITY: (type) NO.OF BEDROOMS %! r 4, BUILDER OR OWNER PERMIT DATE: ��� COMPLIANCE DATE: — Separation Distance Between the: I Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet j within 300 feet of leaching facility) Furnished by 0 Zh 0 3 4 J1/pl"E - w vN.�'u T.E3BGt�' MA7z-5eYFI e- `lam y r • p�I 27 � '6 4V "ef7T P✓cam : �A ,�J✓�C3 ..�'�T day / a. A N T 01 T OF FOU D I V OP ^� f 4+i-►-rt�i~H C.OhICR.,.Tt COVERS , C.J , 9 . 4"CAST IRO �r OR SCHEDULE 40 � r ow 1` 4 SCHEDULE 40 P.V.C. ONLY } ., ,. P,V.C.PIPE MIN t 9. MIN . LEACHING TRENCH t Z)RE©: . _ PI PE-M IN. „ 36 MAX. ....�.: ...:_.. ...._._. PITCH C, I c � ,. 1/B - I/2 WASHED STONE �i /4 P�R.FT PITCH c n e# , Ij4 P�.r 1. ._ .-... .,•.< aa.....x.a< -..r. �..•�� rrr.. ..::-.:....a..- Q,...C1 t� . „ ,o - �: iNVc7 INWcRT �. - r 24 rt tL«.. :. ... �IST ChJG7• C4dL-� .O�'C1' C%,t� 1`.7 ., SEPT)C TANK �:� Locus t Box. ,.. INv��T e� . f,5"aa . ... GAL.. iNvEr T a INvERT Precast 500GaI.Leach 3/4„-IV2,r (om) REQ. Chamber WASHED STONE e a ., 6'CRUSHED STONE y pry , i f H- / ��r ,�,,► �"?°1 � is 40 � 7 -------.--� GROUND WATER TABLE SENVAG DISPOSAL SYSTEM • E TYPICAL cRas.,� src�ION SOIL LOG _ : 'too SCALE LEACHING TRENCH D ATE'ZA"C.q c TIME,/O.00 ,tl/Y a ► �A! - TEST UO'_E I Z. TcST HOLE ;� t �i � . 6zJzv DESIGN DATA : , ,S'4 ca ELEV. , , .. . . ELEV. .. . . .. . ... „t,rl 1/8'-- /2 } - s n 9. iN. W"5 'CD 36"MAX, ER O SED-01-1 11, 2 Ile �t.dZ.ya, TOTAL cS,I,,.N,_? FLOW .. . .. I: . . .,. GALLONS/DAY J B« .�$ BOTTOML=.4G;iia"�G .AREA ' 24 SIDE LEACHING AREA . . . .%..5./. . 3.... . � . NcI ,IF-. T�E _ ,�. 50 jo o CoR/zSE GARBAGE DISPOSAL .IYPe . ..( AREA INCREASE)ry^.C/jy�./may," _ A7vL%� o.4f�rS T�7„aL LEACHING AREA .. So.r CeDor , *ac I ; yWL f c to D PERCOLATION RATE*. . . . .�F�r. . . .. .. P_R.INCa Zt� ` �l { C — .: , F.( L_AC 11NG An_A P R P_r?COLAi ION RAC ! .SQ: Y [ t GR ,�..53• ..,U AAA R ,..�L l0 c ..Lt « � , N _ .3o r �1 5"�n 2r� APPROVED A.. ,' S3 .. : . . . . . . . . . . .. BOARD Or Fi�AL�H _,:_ — ^ a�_� NCO N, _ c c - - DA i t • _ OF t N D t INS PE 4 ' r AGENT OR IN,.P_.,tOR a ` WITNESSED BY G d e D r r a r��,�_ �! EDWAR t. � �s > _ L , ENGINEER C.F_a r nl ,00 O E. F rY LJ/' , G R - C S a ,' 1 TE 1 AL LAM TlbN c EV A ALU « a i � I - 13 ' t Z p � ► I ILA GS r 4 \Ns % , ..tom• o d l / 1 6 ---"" , r 1 -LL , Y r T 1:91a- e. a/ 3 l000l RZ zo 01 s � E s �•+ «,. +ems.,. :- ,:.. _.,-. • n G rz - . r _ G C� f . .. _ . : c _ ram- ---