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HomeMy WebLinkAbout3610 MAIN ST./RTE 6A(BARN.) - Health 3— ( 610 Main StreetAte- 6A, (Barn) Barnstable P A = 317 018 r' z s .'t a r ^ f • • .. - � �:�:. •. � .: a "�� _ � ... a f. l No. Fee — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Oigoml *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade NI/ Zbandon( ) O Complete System XIndividual Components Location Address or Lot No. (��(� (�C 6Pr C�� Owner's Name,Address and Tel.No. Assessor's Map/Parcel31� ` O(0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i s vv c s s ( -c ti -I,VQ, 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 5-6 '1�0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank arc.,'+ •L i��1U S��: Type of S.A.S.��� V� Cep nC-C_I++�.T�' U IV Description of Soil 20-Pc C"&! &Iat,n Nature of Repairs or Alterations(Answe when applicable) mac_ 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 ha issue y of ' / Signed Date "T Application Approved by Date — Application Disapproved for the llowin reasons Permit No. Date Issued Fee c THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(pprication for Miopaal bpgtem Con!6truction Permit Application for a Permit to Construct( . )Repair( )Upgrade(Abandon El Complete System ,Individual Components *, Location Address or Lot No. 3(o,l b V71ap, Owner's Name,Address and Tel.No. Assessor's Mai arcel �Z ©(0 Installer's Name,Address,and Tel.No.�/ Designer's Name,Address and Tel.No. ``* 4\iO-GF�Is �l�I l 1 Uv1s t i { r't.V"S ` Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) r Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures _ Design Flow 5�5a gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank _Ya= 1�C Type of S.A.S. 'S\A Cc-,4'C't Description of Soil Co 1A2.�c.. S V-t Ao Nature of Repairs or Alterations(Ans a when applicable y-vt-.Sl 7) 1�C`1 Q ��S- '` �� '�S �.�� W 1l � . J 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 hwbeen'`issued by tiis' of t Signed Date Application Approved by Date 62 Application Disapproved for the Yoliowing reasons Permit No. d-V (3�40 Date Issued r_ ——————————————————————————————————— -- THE COMMONWEALTH OF MASSACHUSETTS A BARNSTABLE, MASSACHUSETTS t Certificate of Compliance THIS IS TO CERT]FY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(L�< Abandoned( )by t a r p-c vA p r- S�p-,k t.c_ at 3 ` �` Cvv�n vtii CL,.c 11HWS, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.9"- o�DU dated Installer Designer The issuance of this permit shall not be construed a's a guarantee that the system will function as designed. Date ti � Inspector s / ��y—�O---------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS . PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS s igooY Opgtetn Con5tr uc ion Permit Permission is hereby granted to Construct( )Repair( )Upgrade )Abandon( ) I System located at 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 provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by �, TOWN OF 3ARNSTABI,i✓ I,:�C eTION3416 0— ZA SEWAGE # Wig_ a ,ilAGE ASSESSOR'S MAP& LOT 2,6 24.kLLER'S NAME&PHONE NO. SEPUC TANK CAPACITY x, ^o LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATF: �?i - 1000 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 i P r. 13 Y�C) ra . 1/6/99 IFNOTICE: �'IN Forlm Is To Be �sect For the Repair Of Failed Se!) ie Systems Only. _ CERTIFICATION OF SKETCI€AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify e�rt i� that the application for disp osal works construction permit signed by nee dated �i , concerning the property located at! �(Q�(7 �ivVthyi,�t��,� _ meets all of the following criteria: (/• This failed system is connected to a residential dwellingonly. There are no commercial or y business �Ses associated with tine dwelling. • e soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • ':'here are no wetlands within 100 feet of the proposed septic system (,-- There are no private wells within 150 feet of the proposed septic system 6 There is no increase in flew and/or change in use.proposed t/ There are no variances requested or needed. v The bottom of the proposed leaching fac;lity will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frin}.ptor method when Z1f !cable] e S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be ':oc-�tcd less titan !burtcen (14) feet above the rlaximum adjusted groundwater table elevation. Please complete the fo!':o%ving: A) Top ofGro,vid Eievaticn(using GIS inforn}ation) W. C.W. elevation �� '`": IAX. ':igh G.W. Adjustment`Vv _ DIFFERENCE qn rwF--F-'r� A 4:}d B SIGNED : — _--_- — _-- _ -- DATE: [Please Siu.rc.•.t p3 posed plan . sN s:e!n on 1.ackl. NOTICE, Baseti.upon flit:abov8 };f rl;tdt�0il., a T;3J23''Penn:,:, sYi'! for --- bedrooms maximum. No additional be6�4;oms z.,c, it vll;: s -ptic system plans. L_..._ _ q:health folder:Celt �ij Lc..✓E1'� Lss COMMONWEALTH OF MASSACHUSETTS. M EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS FILE COPY DEPARTMENT OF ENVIRONMENTAL PROTECTION h4AP 3` PARCEL, EAT 1 -- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:,-?L f ( 1 N 6AaN-Ifa-Gt_E "rV�� Owner's Name: i,JAyw . jon t)2_1,N ECE���® Owner's Address: P.a 6rn� . Li C4 R Date of Inspection: i- 1,-,--nq o 6 �Q04 Name of Inspector: (please print) Brad J White FEBG gARNSYHB�� Company Name:Windriver Enviromental T�WHFJ�TN QEPT. Mailing Address: 107 N.Main Street Carver,MA 02330 Telephone Number: (508)-866-2503 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: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails ) Inspector's Signature: 1 '! W "_ Date: i 13-09 The system inspector shall submit a copy o his 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 I 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 ****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 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3�,J Q MAIN ' - - �ti��'ay'�TA Ohl.E b�✓�A — Owner _ 11�1A 21 I IJ Date of Inspection:! Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ff�� B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 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. 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 INrD 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: SW O VvW t Nj R th^nJ STA C�( (- • INIA Owner: rW�2T 1 N Date of Inspection: 1-1t� �`� C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiirther evaluation by the Board of Health in order to determine if the system is failing to protect public health,safe*:y or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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: • ifl. T--.,f;—n',.r.,,411 rlilnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) -Property Address: 3to I y jVA%N 7rn.Cc7 MA Owner:_hnA(7Tr N.e_,, . Date of Inspection: - I -o`I D. Svstem 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 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. 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. 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 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.] (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: To be considered a large system the system'must serve 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 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. . t z. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:,?,u f Q ttiW 1 N 5T Z Aa 2 ti A eat.C T MA Owner: V vyk¢-►1 N Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period'? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up'? Was the site inspected for signs of break out Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum V/ _ 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: r Yes no Existing information.For example,a plan at the Board of Health. _ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 C M 15.302(3)(b)] r;,iP Tnc..Art;nn F r,,,`�n�i�nnn 5 ,; I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 h I l] P�AQ4-NSi lachUs. VIA Owner: r0A2 I►N Date of Inspection: -3 -0`-i 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): ,�- o&pcc Number of current residents: 6 Does residence have a garbage grinder(yes or no)'LS Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): N" Water meter readings,if available(last 2 years usage(gpd)): zpo Sump pump(yes or no): Last date of occupancy: C OMMERCIAL/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): 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:(} t.3 eo e.-L Py M o g-o 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 1 Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known) and source of information: 5`ISs�rv� arpvc2 24.7r) 0 Pt_z CIFCTIVICAMr br= cor.1P4lONcr Were sewage odors detected when arriving at the site(yes or no);N bb Page 7 of 11 • i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:, o l 0 MAW awl Owner: "(z i%t4 Date of Inspection: ;_ -n-1 BUILDING SEWER(locate on site plan) Depth below grade: 2-0 / Materials of construction:_cast iron ✓ 40 PVC_other(explain): Distance from private water supply well or suction line: -A Comments(on condition of joints,venting, evidence of leakage, tc.): -; �ilor�0 " IWG SEPTIC TANK: ✓ (locate on site plan) Depth below grade: i 2.0 Material of construction: v,"concree_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:,,o' Sludge depth: 1 Distance from top of sludge to bottom of outlet.tee or baffle: 3 Z" , Scum thickness: 2A Distance from top of scum to top of outlet tee or baffle: 10 Distance from bottom of scum to bottom of outlet tee or baffle: _ How were dimensions determined: r,)C_gry,,C o, Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): C-> 1 i 1 cN I C\ i'7 l I V e `L e. •°'r`A&A L 1 V Q GREASE TRAP:_(locate on site plan) 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 conditi_on,'structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tifl. Tncnnrt;nn Fn ..,�i�v�nnn Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,;ln 10 iMAI M 5r2T- Owner: W( �2 T)N Date of Inspection: i_Q • 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): 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -19- 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.): LC&9c,-t ;Jh ��>>��=vt� r, c 5nU� 5 CL1n�zyn Ev�f7kxC iF Lt=N-K4(ri PUMP CHAMBER: (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.): T:r1A G TilC,1P +��n Fnr..,sir�i�nnn 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: '-3(o1(- t1nA1m Z-Pt7xrr vtnA Owner:J AO-TIN Date of Inspection: ; -1 7, -0 Li SOIL ABSORPTION SYSTEM(SAS):_✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: v/ 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.): _ LiC- i15 NIC) SIC;A)S C2 CA0LIG pAlLt12C 1 c [rt / TT" IS i�CZ �ja,l 1��7 PC`".1c)ir�(7 iOl 6L221::�0C_'r 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 or no): 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.): r;*iP T„cnvrr;nn Fnr,,,�n ti�nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: '3(I IQ M ra t y 5aa v r-f n W-,r Asir I'M Owner: Date of Inspection: 1 t 3-u-i SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Loca all wells within 100 feet. Locate where public water supply enters the building. t =N3� 1G v w G :a 4 A 2 314 -2 b2 C0 S G9 T;r�o G T---,;--n',,—4n rionnn 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:-;(o)n yy\Ak N s'TQxC1i Owner: MA2T1 N Date of Inspection: SITE EXAM Slope p Surface water Check cellar Shallow wells i Estimated depth to ground water 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: ✓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: Av�t-a2Nn i j izx+be �71 wo _&rzovnj 2 Foa,-�v j Clan C_.) A is / t r. 411 r1i1)nnn 11 TOWN OF B.ARNSTABLE 3 C 7 — C 1 8 7NSTALLER'S ON SEWAGE # � �7 E Q, qe„(, ASSESSOR'S MAP & LOT NAME & PHONE NO. TANK CAPACITY 1 G 0-0 �ii(✓�d ki LEACHING FACILITY:(type) aT— (size) NO. OF BEDROOMS PRIVATE WELL O UBLIC WA BUILDER OR OWNER .s` �c,,�l� a✓ , DATE PERMIT ISSUED: � � DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No re' paw �4 boo w3` S4Tdwe - Je3! P 2c .C.r 0/9 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .._................... ......OF.7,.....�-�.te!.11.:� ...'�'.�...�'i�........................... Appl ration for Disposal Works Cfunstrurtiun 1rrrAft Application is hereby made for a Permit to Construct ( ) or Repair �—. 'Individual Sewage Disposal System at: - ._......._....� C .�. ...........!�..�. .(eta................:. ................ ...._.........---.....:..__..:. Locat', n-Address or Lot No. - -......._... ✓'_.. ...L2 ------------------ ....... ........-•--•--•----•?.�!Q-' `'.` ...--------------------------_..._._....-... ----- ----- ^� 0 a ........_..1.G.. .A" �.:�Gl.`................. --- - ---------5..... ..-----.......: .tv w . ------------ Installer Address Type of Building •� Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms.......,.7:..............................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building .............. No. of ersons.............:_ . Showers — Cafeteria Other—Type g P- ------ --------- --•----------- -•--------------- --•-----•-•---------- d Other fixtu ._. . WW Design Flow......t�.............................gallons per person p r day: Total daily flow..._.......-,w..3..(--_.--......gallons. WSeptic Tank—Liquid'ca.pacity/150gallons Length•-•j�I-- Width......V.. Diameter................ Depth................ x Disposal Trenchj—No............:........ Width 3 .._`............. Total Length.................... Total leaching area...................sq. ft. Se Pit No._._....�.....__..._ Diameter.....Seepage Depth below inlet....�.�...... Total leaching area..................sq. ft. ... ...... Z Other Distribution box ( ) Dosing tank ( ) _ .-4 . Percolation Test Results Performed by-••-••--•-----------------------•--.,..................................... Date........................................ � . Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... P4 ••. • ---•••--••-••-•---.....---•--------------- .........---.......................................................... 0 Description of Soil............................................................................--•---------.._.--•-------•-----------------------------•---.......-•-.........-•-•-•-•-_... V .............---------------------------------------------- --- ..... x Nature of Repairs or erations-Answer when a licable. ... _.:.- _. U eP PP ..... S- `� _S ,t?t!. ................. .... -------V�1Kp m......_.1 �0 •� ....�L)Z t f. ..ti✓.��1�� , Agreement: The tndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha sued by the-bWd of ea Signed...... .................... ................... ..:.... . Date Application Approved By-••--•.. ....." - ---�t -•---------------------......... ........ ............Date.............. Application Disapproved for the following reasons:........................................................................................................---- ...................••---•-•-........-----------......------.....---•........._..----------.. .._...._..•--•-••----•--•-••-•--••---••-•--•--••..._............--•--•-••-••. •D�----•--•----. Permit No....... --1• —� 1 ..............»_.... Issued....................................................._ .�. . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... No.12::2-7 ........... FEE.. Disposa-1-16orks Tonstrurtion f ernfit Permission is hereby granted I................. ................................ ................................. '7' to Construct or Repair an Individual Sewage Disposal-SyVn • .44— at No.............. ...... ......................... ............zz.................................. - Street— as V. as shown on the application for Disposal Works Construction Perm*t No.U-.''�-22,Dated.......................................... ............. ----------------------------------- -----C� --- ----�30a•r oi�eaiiii DATE---------------- --------------------------------------- No. � '7 a—- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...OF. ------- ......................... Appliration for Disposal Works Tonotrur#ion rrrmi# Application is hereby made for a Permit to Construct ( ) or Repair 6() -an Individual Sewage Disposal System at: •.................- �.A.10............ '.��................... ------•--. i"1r t.��:.:5-?��::�� ....................._....._.._.._... �- .............1 V!✓'� Location-Address ._........-•...... ....... ................... a� ...or Lot No��-.-----........................ ......_. 1r1.t�\yam � ...............w��._.. _ Address Wa � r .... ............................................... •--•......... ----------- �� ........•. Installer Address Type of Building 2 Size Lot............................Sq. feet aDwelling—No. of Bedrooms.........-.?...............................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) PaOther fixtures --------------------------•••......-••--•-•----•-- •-' ..- WW Design Flow......:-.. �.....................•..gallons per person per day. Total daily flow............. .. ............gallons. WSeptic Tank—Liquid capacity,46;/ Ions Length... :... Width..... ...._ Diameter................ Depth................ x Disposal Trench—No---------------- -•-- Width..-................ Total Length-------------------- Total leaching area...................sq. ft. 3 Seepage Pit No....... ............ Diameter._._�� _(..... Depth below inlet..../.1...... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ `-1 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------•---..... ....... ---_... ................_............---•----.......................--------------------........_.--.... 0 Description of Soil........................................................................................................................................................................ V .............•-----••.......... .--.-------... W .••• ---------------••--:`.-----.......---...---------------------------•---•-•-•---...........--•---......-�A�•..-------_.............. .._.......--------•-- UNature of Repairs or Alterations—Answer when applicable.......... ...��__<9_�-!.................... S_rY_ n..s =-._....... .... S :'._...... r Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boaard of h-e-al th--� , Sided••----•-• - `-- -----•--•-•--- . .....E`-� Date — Application Approved By.... —� '� �.__ ._ram-ram•:..:. - ........... •--------------•-- Date.............. Application Disapproved for the following reasons:---•-•-•------•----------------- .: .................................................--- ..................•-•--.....-•---------............---._._...__.....-•-•--•-------------........---..._..----------------.._..--•------............ `............................ Date..._....._.._ PermitNo.. .7.:.-a-� ...............----- Issued............................................_........- Date --------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH( i Z�1/Sc b�,......................... Trr#if uttte of (Dompliana THIS IS T-O-CERTIFY, That the Indivi•ual S .wag-,Disposal System constructed ( ) or Repaired ( C� by...............:...................�; �-• �=-=� .1.. ...... ''=----------- ------W................ -•---.---..-.--•-•-------. .......... •- ----- Installer <•--� at..........•..._...-----•--•••-••..`�h1._��--------------�---_&...:r�-.._---....... ..4.� .'�G L,� •..-.------............................ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. :.:.. ` - '� - ........_.. Inspector ..._ x^ ... �..a_r!l! Fri^- .......................... l� j