HomeMy WebLinkAbout4022 MAIN ST./RTE 6A(BARN.) - Health 4022 Main Street 6A
047-092 Barnstable
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COMMONWEALTH OF MASSACAUSETTS
01 EXECUTIVE OFFICE OF EwiRONML•'NTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
'ITI'ME 3
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSUP.FACE SEWAGE DISPOSAL SYSTEM FORM
FART A
CERTMICATION
Property Address: 4022 Route 6 A
ummaqui
Owner's Name: Pau Richard
owuer'sAdldress_ PO Box 196 La • �L�
CummaquidQ 3
Date of Inspection- S'� "
Name of Insptctor:(please print) mean Jones --
CompanyName: William E. Robinson Septic Service
Mailing Address: P O Box 1089 1 Centerville. --MA `'
Telephone Plumber: (508) 775-877-6. '
CERTIFICATION STATEMENT
I ccttify that I have personally inspected site sewage disposal system at this address and that the inform tation rem rted
below is true.accurate and complete as of the time of the inspection.Th=inspection was performed b on tfiy I�
training and experience in the proper functi maintenance of on site sewage disposal systems_I m a Dd
approved system inspector pursuant to loll IS-3d0 of Title S(310 CMR IS.M). The systettt.
Passes
Conditio
Needs ! ion by the Local Approving Authority r'
Inspector's Signature: Date: ✓ td ( /�
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heattttvt
DEP)within 30 days ofcompletittg this i wnt,if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shalt submit the report to the appropriate regional office of the
DEP.The original should be settm,to the system owner and copies seat to the buyer,if applicable,and the approv.ing
authority_
k
Notes and Comments
`**'This report only describes conditions at the time of inspection and under the conditions of use at that
tune.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 6/152000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC`f ION FORM
PART A
CERTIFICATION(continued)-
Property Address: 4022 Route 6 A
Cummaquid
Owner. Paul Richard
Date of Inspection: 1l�
Inspection Summary: Check A,B,C,D or E I ALWAYS complete all ofSsction D
A. Syst Passes:
1 have not found any information winch inmates that any 15. o€the€�nre aria dcscrr�Cd in 310 CMR
303 or in 310 CMR 15304 exist Any failure criteria not evaluated are Wicated below_
Comments:
i
B. System Conditionally Passes: LA
One or more system componentsasin 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,M)in the for the fottovving Statements.If'�30t determmed-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 cx oration or tank failure is imnd ncnL System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Reatilr.
•A metal septic tank will pass inspection if it is structurally sound,not hu& tg and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
NO explaim
Observation of sewage back-up or break out or high static water kvd in the distribution box due totroken or
obstructed pipes)os dui to a broken,settled or uneven disc f n box.Sysum vvill pass inspection if(w48t
approval of Board of Health)_
broken pipe(s)are replaced
ttbsMKUM is rived
ditstrtbution box is ICvekd or aphr-ed
NO explain:
The system required pumping more than 4 tunes a year dt:e is broken or obsmtcW pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)am replaced '
absbucfim iS tt�trod
ND explain:
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS = ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION(continued)
Property Address: 4022 Route 6A
Cutnmaqui
Owner, Paul Richard
Date*[Inspection:
C. Further Evaluation is Required by the Board of Hwtlr.:
Conditions-ckist which require further evaluation by the Board of Health in order to'detertnine if the system
is failing to protect public health.safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(t)(b)that the
system is not functioning in a mannex which will protect public health,saafety and the environment.-
Cesspool or privy is within So feet of a surface hater
_ 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 wlc 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 vxll.
_ 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" 1Vledwd used to determine distance
•'This system passes if the well water analysis,perioruted 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 S ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be anached to this form_
3. Other:
3
Page 4 of l I
d
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address* 4022 Route 6A
Cummaquid
Owner: Paul Richard
Date of Inspection: J 7
D. System Failure Criteria applicable to all systems:
You must indicate gees"or"007 to each of the following for all inspections:
Yes No%
_ V /backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
i/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
dogged SAS or cesspool
Static liquid level in the distribution box above.Qiaalet invert die 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
— _,. kequired pumping more than 4 tirnes 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 100Seet of a surface water supply or tributary to a surface
water supply.
i/Any portion of a cesspoea or privy is within a Zee I 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 crater
supply well with no acceptable water quality analysis_[This system passes if flee wee water analysis,
performed at a DEP certified laboratory,for colirorttr bacteria and volatile organic compounds
indicates that the well is free.from pollution from that facility and the presence or ammonia
nitrogen and nitrate nitrogen,is equal to or less than S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.1
(YestNo)The system fails.i have determined that one or more o(the above failure criteria exist as
described in 310 CM1R 15-303,theFefine 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 sy esrr the system insist serve a ficHity with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either"yes"or"nca`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 Prolcction Area—IWPA)or a trapped
Zone II of a public water supply well
1f you have answered"yes"to any guestima in Sergi E that:syu=i4 i&r d a significant itueat,or ahswcred
..yes"in Section D above the large system leas f'at _The a-Am-=or operator of arty largi system considered a
significant threat under Section E or failed tinder Section D shall upgrade The system in accordance with 310 CMR
15-304.The system owner should contact the appropriate regional office of the l3cpartrnent.
4
Page 5 of!!
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address* 4022..Route 6A
ummaqui
Owner: Paul Richard
Date of Inspection:
Check ifthe following have been done.You must indicate"yes"or`W as to each ofthe following:
Yes —o F
Pumping information was provided by the ovrtter,occupant,or Ord of Heap
Were any of the system components pumped out in the previous two weeks?
/ Has the system received normal!lows in the previous two ureek period?
— Nave large volumes of water been introduced to the system rex=dy or as part of this inspection?.
1-7—
Were as built plans of the system obtained'and examined?(If they were not available note as NA)
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 an 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,dimensioass,depth of liquid.depth of sludge and depth of scan?
Was the facility owner(and occupants if diff'eaeat from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Stall Absorption System(SAS)on the site has been determined based on:
Yes o
F,' Lino in-f sntatism.For example,a plan at the lard of HealdL
_ � 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))
5
Page 6 of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM-INFORMATION
Property Address: 4022 Route 6A
-Cummaquicl
Owner. Paul Richard
Date of Inspection:
FUIWCONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(acts}:
DESIGN flow based on 310 CUR 15-203(for exatttple: 110 gpd x 9 of aortas): 61
Number of current residents: 6- -
Does residence have a garbage grinder(yes or ttoY_ A/D .
Is laundry on a separate sewage system(yes or no):.9 [if yes separate inspection]respired)
Laundry system inspected(yes or no):="�A
Seasonal use:(yes or uo):
Water meter readings,if available(last 2 years usage(gpd)): 1st 1 /2 2007 — 20,000
Sump pump(yes or nor A0 - 2006 — 78,000
Last date of occupancy: DV410C
COMMERCIAIJ MUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seatslpersonsfsq 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 occupancyluse:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: n 6-Ae-r FLe
Was system pumped as part of the inspection(yes or 110.- AV
if yes,volume pumped:`=Aall�ans How was qaaatiy pumped determined?
Reason for pumping:
TYP OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overliow cesspool
—Privy
Saia?cd systems(yes oT no)(if yes,attach previ+GILS inspection records,if arty)
InnovativelAhcrnative technology.Attach a copy of ft ztaa-cttt ap=zfwn and maintenance contract(to be
obtained from system owner)
Tight tank •�Attach a copy of the DEP approval
_Otlter(describe):
Approximate awe of all components,date is 5wi'd kit` i"�UwSl%aia�'a��iia£-4 Lt��a�as.ai,uia^vH3:
Wcre scwagc odors detested when an iving at the site(yes or no):IVO
V
I - -
Page 7 of t i
OFFICIAL INSPECTION FORA4—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEIYAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOHAIATION(continued)
Property Address: 4422 Route 6A
Cummaquid
Owner: Paul richard
Date of luspeetlon: Z -3
BUILDING SEWER(locate on site plan)
Depth below grade: 3 e-f Y
Materials of construction: mast iron w"'140 PVC odic— — r(explain).
Distance Gom private water supply wc11 or suction "
P 1 P y lute:
Comments(on condition of joints,venting,evidence of kakagc,etc.):
ter.. .0&—' - ^+ca 1 ec Ac
SEPTIC TANK:uoca►c on site plait)
y
Depth below grade: Isle
Material of construction-✓ncrete—metal fiberglass—polycdiy lcnc
_odicr(ex lain —
P )
If tank is metal list age:— Js age confirmed-by a Ccnifrsatc of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 61,
Sludge depth:_ C6-e e f
Distance Gom top of sludge to bottonn of outlet ice-or baffle:
Scum tltickncss-._ _�
Distance from top of stunt to top of outlet ice or baffle: 6v
Distance Gom bottom of scull,to bottom of outletpice or bafllc: I
f low were dimensions deicnitined. bpe'te Cr ,f "'n
Comments(on pumping recommendations,inlet avid outlet ice or baffle cortditicll,structural inttcgrity,liquid Icvc Is
as related to outici invert,cYidcncc of leakage,ctc_):
GREASE TRAt': (locate oil site plant)
Depth below grade:—
Material of eons"ction:`conctctc_ritctal—fibctgWs_polycdlylctic _otltcr
(explain):
Dimensions:
Scum thickness:
Disiaricc (soul top of scum to top of outlet ice or baffle:
Distance from bottom of scum to bottom of outlet ice or baffle:
Date of lass pumping:
Conuncnis(on pumping icconuncisdatimis,inlet avid ouilct tie or bafl3c conditimni,structural iniv:Vity,liquid Icvcls
as iclatcd to outlet invert,evidence of leakage,etc.):
7
c8of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INI<ORiti'IATION(continued)
)perty Address: 4022 Route 6A
ummaqu1
rner: Paul Richard
it of Ioipectton: 7 v�
GILT or HOLDING TANK:VAtatdc must be pumped at time of inspection)(locate on site plan)
:pill below grade:
atcrial of construction: concrete meta! fiberglass_____polyelbylene otlter(explain):
itncnsions:
spat ity: Qallons
csign Flow: gationslday
larm prescnt(yes or no):
larm level: Alarm in working order(ycs or no).
ate of last pumping:
orrunents(condition of alarm and float switches,ctc_):
)ISTIUBUTION BOX: (if present roust be opencd)(locate on site plan)
)epth of liquid level above outlet invert:
:orruncttts(note if box is level and distribution to outlets equal,any evidence of solids carry over,any evidence of
cakagc int or out of box,ctc.):
PUMP CHAMBER: IV (locate oil site plan)
Pumps in working order(yes or no):
Alamis in working order(yes or no):—
Coninicnts(note condition of pump chamber,cretrddivtr of leurnps and aPPurtenances,ete.):
Page 9 of l i
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address; 4022 Route 6A
Curnmaquict
Owner.• Paul Richarci
Dale of Inspection: 6"
SOIL ABSORPTION SYSTEM(SAS): (locate an site plan,excavation not required)
If SAS not located explain why.
I, n
Type _.
leaching pits,number:_
leaching chambers,number
ching galleries,number.
teaching trenches,number,kngth:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativelaltemative system Typefname of technala 6r:
Comments(note condition of soil,signs of hydraulic failure,level of panding,damp soil,condition of vegetation,
etc.):
CESSf OOLS; � -iceispoul must b_�aukape a as pails oe€eu�"t_E:€�%3ce eesuaec ets��'s[e'View)
Number and configuration:
Lepih—top of liquid to inlet invert:
Depth of sobds lay=
Depth of scum layer.
Dimensions of cess mt: -
t`JL�'[_Ci'EGeS tblr�Ctis4tSeE'E=sF`E4�9�'
Indi cat:AGn of gs oundh ate.an floor (Yes€.n-01:
Comments(mote condition of soil,signs of hydraulic faslure,level of po€tdi€ig,condition of ve-etatior,etc.►_
Dimensions: __
Venth og solids: ——j
r. *+fc f—f. ifin ..;9 ..F i. 3-- 3 S of,p d n rondition of £--e0:t San eic 1.
_ r • M =1 of so.,%signs __.33yd—32jl?..� f�.,__�T�j s� �:.__,a��_ ,a.s .. -.� -
G
Page 10 of 1 I
(OFFICIAL INSPECTION FORM—NOT FOR YOB-NARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM'NSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4022 Route 6A
Cummacmid
• Paul Richard
owner:
Own .�,
Date of Inspecti0w 7
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system induding ties to at least two peantaneni reference landmarks or
benchrharks.Locate all wells within I4B feet.Locate where public water supply enters the building.
P-I} GA
i
'TA n/w �?
q35 c
t t�
SA-s
5_3
Page 1 I of 11
OFFICIAL INSPECTION FORA—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address;
4022 Route 6A
ummaqui
Owner. Paur Richard
Date of Inspection: 7
SITE EXAM
Slope
Surtace water
Check cellar
Shallow wells -
Estimated depth to ground water ` feet
Please indicate(check)all methods used to determine the high ground water cleevatiort:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting propertylobservation hole within ISO feet of SAS)
Checked with local Board of Heahb-expt 1
Checked with locat excavators,installers-(attach a o armetttation)
Accessed USGS database-explain:
You must describe how you established the high ground water-elevation:
11
Town of Barnstable
�F THE t
Regulatory Services
sniuvsrnate Thomas F. Geiler, Director
9�A b 9. r Public Health Division
lFD MA'S A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 5087862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
C
TOWN OF BARNSTABLE
LOCATiOr!!;�/f).42, SEWAGE # ��
VILLAGF(o)oln ASSESSOR'S MAP & LOT ®�
INSTALLER'S NAME & PHONE NO. � � o'!j e (C 2
SEPTIC TANK CAPACITY j 0
s A LEACHING FACIIM
Y• / 1
r
'`.140. OF BEDR PRIVATE WELL OR PUBLIC WATER
BUILDER OR O
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED Z-z oz,
VARIANCE GRANTED: Yes
\, �
� ,
\_ �,
vea '�
�g
� _
.�
�. `�,
��� '�`
,�� .
-.�
TOWN OF BARNSTABLE P
LOCATION 4/0, ;? SEWAGE #
M VILLAGE ASSESSOR'S .MAP & LOT3 �
L, INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY a�'6 za
LEACHING FACILITY:(type) ( y � (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER.
BUILDER OR OWNER JS`i�. ,[��¢ �,�UL � yC'cl .• ._
DATE PERMIT ISSUED: 4
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No v/
- 1
�=
-� ��
��
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r '��
FRz,2......... ...........
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOAR® OF HEALTH Vj
Barnstable Conservation Department TOWN OF BARNSTABLE
i9„ed 1ir i �,�`f' r Diripwml Works Tontitrnrtinn "ermit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
.... ...��.�...... ........•--•..... ,� � �.�1. ��- .
r� oc 4011- \d rrss or Lot No.
wncr,_ Addr s
M Installer Address
Type of Building Size Lot-.............. Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
p`4 Other—Type of Building ............................ No. of persons.--..----.---:------.------. Showers ( ) — Cafeteria ( )
0.t Other fixtures .............................. .
d -------------------- ---------------------------------------------------•---------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width...--.-----.-.-. Diameter--........--.--. Depth................
x Disposal Trench-- No. .................... Width........---.---.--.. Total Length.----............... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.--.-.--.-.-.--.-.-. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit------.--........... Depth to ground water.---....I.................
fx, Test Pit No. 2................minutes per inch Depth of Test Pit.-.---_--------... Depth to ground water..--....................
P4 •---••-•-•----------------------•-•-•••-••••--•--•-•--•---•----•--•-----•-•-••..._..........._:. ----------•------- ............
.......
..
0 Description of Soil........................................................................................................................................................................
x
U --•--•----••-•----•••--•--•--•--•---••..............•-----••---••--•--•-•.......•-••------------------•-•--•-•. --------•-••---••----------••----•--••-• ..--••- ...
-------------------------- --------- -----------
Nature of Repairs or Alterations—Answer when a ltcable- � � ..-•--•-. --- --_. C
U P PP f.. ...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant e,board of health. q
Signed ...v .. ... - .- .. .. .. ............................................ �f.. ....... ... ......
Application Approved By ... .....�,s v�.�•- -----.--------------------------------------------------------.-------.----- .....L/
Application Disapproved for the following reafonr: ...................................... .. .............................................................. ........................
.......................------..--.....----......'-'---................................------. ...---......-----...---------_-........................................--............--.. ................. ....--............Date
PermitNo. ... . .... ...................... . .... . Issued ....................--...... ................----..........
Dace
.. - r� _-..--^�. -..� _.. .. .. .- .. .. .._ vim. •-4,.✓.. ,-.._•,i^i..._..�- —' .� �.�� .� ��.J -a -
Fics ......................
THE COMMONWEALTH OF MASSACHUSETTS /
is
BOARD OF HEALTH j
y TOWN OFBARNSTABLE
Appliration for Di-tipwial Work.6 Towitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Loc,tion-Ad ress —or Lot No.
----------------------------
Owncr�_ [Yddr s
�-- -- --------------
� Installer Address
UType of Building Size Lot............................Sq. feet
�. Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )�
aOther—Type of Building --___-_-------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------_----- .------------------------------------•----•--•-------------'----------•-••-•--------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........ ---------------------•---•--------------•-------------•-•------.. Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................
w ._...------•----------------•••---•••.....••---•-••-----•--------•••••----•------•-•..........---•--.........................................................
C) Description of Soil.................................................................................................------...-----------------•--•---...--•--.........----••..............
x
W .................•••-•--••-•-----••••--.....---••-------------...-------------------•••••.......•--• � ......... •--------. _.---------------- ... . _...
U' Nature of,Repairs or Alterations—Answer when applicable.--._.-�-_�.._f___ ._�....... .....................va.=....._...j�u..__.
f
•----•.........................•----•---------------•-----"•---•"--------------------.......-•---------------------------------------------------------•---------------------------1��..............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant as-bee=issue• by the board of health.
- - - -= --- _.-- Signed f.. ...................................
ApplicationApproved BY ........... ...... ........ ..........._.........................- . ............................
_- Dare
Application Disapproved for the following reasons: ...................................... ......... ......... ...........................................................
- .................-------............................--`--................................................................................................................................................... ................ —..............
Dace
PermitNo. ..... ....................................... .............. Issued -------- ......-............ ................................
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CIler#ifirate of Clomplittnce
THIS IS j
'TIFY, Thai the Individual Sewage Disposal System constructed ( ) or Repaired ( �
Y ....
Insr;her
at . � �`a .... .......... - -. .... . .. � . .. P'...............................
has been installed In accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No- -----yam..-3.-._/ ... dated .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORk
- .... Inspector ✓�,�..DATE..................... .......... _... .... .. �" lrf�. ./i ._._,..<.-_....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No..9q TOWN OF BARNSTABLE
3-I�/ FEES:.....................
Bigiviial Nab T jrtion ranfit
Permission is hereby granted_ //��...------------ ---------/
to Construct ( ) or Repair (� an Individual Sewage D:' posal System
Street qq
as shown on the application for Disposal Works Construction Permit No.L,�'�9!�- Dated...........................................
= - - -.......
V Board of Hcalth
G
DATE-----------------y--`�'-G---`�-��-
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
Z
123.65 0
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g
- 1.7'.
EXISTING LOT AREA LOCUS MAP
BARN
31,891 SFt SCALE 1"=2000't
���... ASSESSORS MAP 336 PARCEL 44
LOCUS IS WI A I L THIN FEM FLOOD ZONE C
4 . ZONING SUMMARY
ZONING DISTRICT: RF-2
MIN. FRONT SETBACK,, 30'
EXISTING MIN..SIDE SETBACK 15'
GARAGE/WORKSHOP MIN. REAR SETBACK 15
.9
OWNER OF RECORD
vi PAUL G. AND NANCY RICHARD
N 4022 MAIN STREET.
O CUMMAOUID
to
,o
N REFERENCES
&0!
DEED BOOK 8161 PAGE 177
PLAN BOOK 17
PROPOSED
c ADDITION
Q
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LLJ :>� DOST.1800 Da
.. Z SEPTIC TANK - - -
BEDROOM SAS 'EXIST.
N
(PER ASBULT'
DWELL.
FunitOEPr.'
IT-, PEAYIT - OE PL.AN
F.
4022 :MAIN STREET
(CUMMAQUID) BARNSTABLE
m PREPARED FOR.
1.45
119.74 PAUL RICHARD
RpUTE 6A)
moo? ARNE JUNE 15, 2007
STREET H.
MAIN OJALA
No.26348
I l,NF Scale:1"—20
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