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HomeMy WebLinkAbout4170 MAIN ST./RTE 6A(BARN.) - Health 4170 MAIN ST. RTE 6A BARNSTABLE A = 351 002 002/001 r. f 5 ' TOWN OF BARNSTABLE L OCATION Ze SEWAGE # jai VILLAGE ASSESSOR'S MAP & LOT / INSTALLER'S NAME P NE NO. I . SEPTIC TANK CAPACITY ! � LEACHING FACILITY: (ty ) (size) i✓y J NO. OF BEDROOMS BUILDER OR OWNED PERMTTDATE: COMPLIANCE DATE:. ' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet . Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet:of leaching facility) Feet Furnished by -- k. oil �.1SLa v�lb/ { ; oftn,�J We ,l { r fi TOWN OF BARNSTABLE LOCATION `7® 4944�1 SEWAGE #,::�&W— f VILLAGE ASSESSOR'S MAP& LOT l� '- INSTALLER'S NAME&P NE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) toe (size) aul:W ` NO.OF BEDROOMS BUILDER OR OWNE PERMIT DATE: noCOMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands'exist within 300 feet of leaching facility) Feet Furnished by bU�► � c , a� a No. Fee /_� � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for M!5po5a pgtem Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ( 6 1�1 dam\W S r Owner's Name,Address and Tel.No. Assessor's Map/Parcel Q Z oo Q P7e L'�e.L Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. c4,e . 60 K Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) rJ'to s� cfj Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed ell- Date Application Approved by Date Application Disapproved for the following reasons Permit No. 6 Date IssuediiL- 2- _�_ o Mo. �/°C �V/O — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migo!m *pgtem Congtruction Permit Application for a Permit to Construct..( .)Repair( Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. I �b. \A_\W S Owner's Name,Address and Tel.No. Assessor's MapTarcel z 00/ Installer's Name,Address,and Tel.No. f1 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms�� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) t�C_ Mh J� \_ c _„A'�----�=��'J-�-v c v�"'�l tiv� \JiOY 76 e� Ohe 1,070 puw,p �.. T--- a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed ev_Q.A_ Date lgl& Application Approved by /[� Date Application Disapproved for the following reasons Permit No. 242/v 'G 6 P Date Issued --------------------------------------- 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 1 ,--s v— at t-.k k7a 2 r s AC has been constructed in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No.—Z-VVG--Gti P dated Installer Designer 4_11N The issuance of this permit shall rn�ot ,e construed as a guarantee that the systemas d / will-function esign ! ed Date _ &.40 Inspector II�/� �`�/� %f4 ——————————————————————————————————————— No. 2U11V - 30— Fee 3 �—f— 00 2_G o r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogar *pgtemzde ngtruction Permit Permission is hereby granted to Construct( )Repair( ( )Abandon( ) System located at �(� �O V`'�. s� � �� �sXCk;Aq_ 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:Constructio mus be completed within three years of the date of thi jet. Date: �� Approved by , 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION RUCTION P.+:RMIT (WITHOUT DESIGNED PLANS) I,�o,,� ��- •� , hereby certify that the application for disposal works construction permit signed by me dated kkI �I zo 0 , concerning the property located at . LA t?ID ( 'vre— C ir. C�ww.�c�o,A meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system / • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the'proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 50 B) G.W.Elevation +the MAX. High G.W.Adjustment. _ 1,57� DIFFERENCE BETWEEN A and B \136 SIGNED : .. "`` DATE: l l lul C�b [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert "� I !I --'--- � © U � a -� 0 __ �� �� 061 TROY WILLIAMS SEPTIC INSPECTIONS Af `1 p -^4 Certified by MA Department of Environmental Protection tO OF 999 t� (508) 385-1300 19 Hummel Drive h OQ,O South Dennis, MA 02660 A ti S y , _ = COMMONWEALTH OF MASSACHUSETTS - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address /170 /c 7. (.4 Name of Owner L r Lr 7 cj Address of Owner r?C . r3osr y78 Date of Inspection: 5/-71// qq u Name of Inspector:(Please Pri Troy w dlliame / � 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) O G 3 7 CORpany Nano: Troy Williams Septic Inspections Maaing Address: 19 Hummel`Drive, So. Dennis MA 02660 Telephone Number: (508) 385-1300 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails 1 Inspector's Signature: e.�,� Date: / The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to Vm system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised � ; 9/2 / �,, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 4170 Route 6A, Cummaquid,MA - - Date of k spection: Barbara Brent Lewis March 2, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: VI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: /t//9 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. Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 ruge2ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4170 Route 6A, Cummaquid, MA . Owner: Barbara Brent Lewis Date of Inspection: March 2, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /V14 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water suppl tributary to a surface water supply. y or The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER P Rc 3 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4170 Route 6A, Cummaquid, MA Property Address: Barbara Brent Lewis Owner: March 2, 1999 Date of Inspection: D. SYSTEM FAILS: lV/A You must indicate either 'Yes" or 'No' to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 1 5.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 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 water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public . water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Puri or II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property address: 4170 Route 6A, CummaquicL MA owner: Barbara Brent Lewis Date of Inspection: March 2, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of-Health. _ None of the system components have been pumped-forest least two weeks and-the system has been receiving rrormal flow rates during that period. Large volumes•of water have not been introduced into the system recently or as part of this // inspection. Y _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. �[ — All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Y/ _ Existing information. For example, Plan at$.O.H. _C _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation pproximation of distance is unacceptable) The facility owner(and occupants,if different from owner) were.provided with information on the Subsurface.Disposal Systems. propermaintenance�f revised 9/2 "9,1y Page 5'of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 4170 Route 6A, Cummaquid,MA Date of Inspection: Barbara Brent Lewis March 2, 1999 FLOW CONDITIONSRESIDENTIAL: Design flow: //!) g.p.d./bedroom. Number of bedrooms(design):____ Number of bedrooms(actual):3 4- Total DESIGN flow 330 Number of current residents: Garbage grinder(yes or no):-iv-0 Laundry(separate system) (yes or no)WO; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):N0. cy Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no):-VL5 4e, Last date of occupancy: 1)C-c COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ and ( Based on 15.203) Basis of design flow Grease trap present: (yes or nol 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: b 4 F b l T f System pumped rs part of inspection: (yes or no) JJV If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6 of l I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 4170 Route 6A, Cummaquid,MA Dace of Inspection: Barbara Brent Lewis March 2, 1999 BUILDING SEINER: (Locate on site plan) I Depth below grade: �'q Material of construction:_cast iron_V/40 PVC_other(explain) Distance from private water supply well or suction line Ar/,g Diameter Y , Comments: (condition of joints, ve�r�tl�ng, evidence of leakage,etc.) LL d/ .i A- G.'dc/� '7D Q.�-✓ C"+ SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:-V-/COncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: s �/ iX 6 /60 Q Sludge depth: /• Distance from top of sludge to bottom of outlet tee or baffle: - Scum thickness: /x O�_F' Distance from top of scum to top of outlet tee or baffle: t/d ,S L Distance from bottom of scum to bottom of outlet tee or baffle: Ald s C.✓�'+ How dimensions were determined: Comments: (recommendation for Pump in , condition of inlet and outlet tee or.baffles,depth of liquid level in relation to outlet invert,5J cturet4ntegrity, evidence of leak e,etc.) C-� .f-P �Y ✓ d u { /�� c�h �( �✓!l L �"- �! G✓'-� cr ut � - � 'L't r � h �t O 0 � L+ S d ca - [�✓ � �^a. l r,� Lt h.ct 6 -� i.�J�✓t_ , t_c-- w7 GREASE P:�� (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethyiene_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: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner: 4170 Route 6A, Cummaquid, MA Date of inspection: Barbara Brent Lewis March 2, 1999 TIGHT OR HOLDING TANK- /a (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) + ' f I Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal,//evidence of solids carryover, evidence of leakage into or out of box; etc.) —13d.Y_ S_ �✓, ( � I� � •�-h LR-- TD r.r� � �7 t G L G 0.�� tl /.� I A trt/ ol`•�. 6 O 0. c.✓+� C cam.. ,�..L C� V ^0 h c—rt ) .L.c_ . ?:4-I wwy tLW/oo jade �,� W—4-cam L^) j rG.h b � 6�SYr� rtts a✓ .l �c'.-r•� 7b��. dL , 0_PUMP CHAMBER: I�io✓� , �,�rpf S /3v?� 61C S cJ (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.) revised 9/2./98 P.R'Nor 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 4170 Route 6A, Curnmaquid,MA Date of Inspection: Barbara Brent Lewis March 2, 1999 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: / leaching pits, number:Qln< leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of egetation, etc.) o u CESSPOOLS: /V/ '9 (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: IVIj (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) _ n . revised 9/2/98 1'.ge9of11 I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 4170 Route 6A, Cummaquid, MA Date of kispaction: Barbara Brent Lewis March 2, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) \16'6 t �.t., j214 ScrS revised 9/2/98 ' Page 10 of 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirxied) Proporty Address: Owner: 4170 Route 6A, Cummaquid, MA Date of Inspection: Barbara Brent Lewis March 2, 1999 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited 2 y� -q y Observation Wells checked Z��� rt 3 Groundwater depth: Shallow Moderate J Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater'20'f Feet Please indicate all the methods used to determine High Groundwater Elevation: V/Obtained from Design Plans on record Observed Site 1Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records /Checked local excavators,installers V Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) C�r-� • �.�.I -�'c—s�. 1, / 11 / it (��'�G✓ Jhok o n ��.s� ) C CI r CL•- O A-- y w o.. S h o 4-- 0 pp �d Syy(sf-�.� ; �. J3 �t L)4, revised 9/2/98 - i'uy;c 11 of 11 - - TOWN O- BARNSTABLE LOCATION /&/---6--j4�,;l "t SEWAGE # `5It2 -e;P'n VILLAGE G0,44m.96o 0 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �� (size) `? NO. OF BEDROOMS, PRIVATE WELL PUBLIC WATER - ,; ; . UILD OR OWNER DATE PERMITISSUED: DATE COMPLIANCE ISSUED:. VARIANCE GRANTED: Yes t Fl- Q� Q r 6� No.... ---216 V/ FEB THE COMMONWEALTH OF MASSACHUSETTS ` BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Dispuutt1 Works Tonstrurtiun rrmd Application is hereby made for a Permit to Construct (tom'or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. .-- l�a-r„ /r .......................................................... --...........---•--------------------........ --------....----••------------..............-- Owner Address a _ --�'`-«__._... Cow c.u"/4 Y._...2�....-----•..!!iZ Installer Address Type of Building Size Lot.. `',..7��...:Sq. feet � Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—T e of Building ............................ No. of persons--_-•_______________________ Showers Cafeteria Pa Other fixtur s d W Design Flow............... ............................. WSeptic Tank—Liquid capacity.r 'agallons Length__ �� -_- Width. ��`r.._ Diameter................ Depth___.'�_H x Disposal Trench—No.........1......... Width.................... Total Length.............__..__._ Total leaching area....................sq. ft. Seepage Pit No_...../......... Diameter...._ ...... Depth below inlet....3......... Total leaching area._Z -sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Date --------------------- aTest Pit No. I...e_.L._.minutes per inch Depth of Test Pit.....&ro---- Depth to ground water........................ 0i4 Test Pit No. 2...G.Z.._minutes per inch Depth of Test Pit------... Depth to ground water........................ �+ ----------------------------------------------------------------------------------------------------......................................................... 0 Description of'Soil..----0--R,.;- �u�`-p-, -,a- so�c. ^CL°� ` � ------------------------------------------------------------- x �`11 /3L'-'/6 �!G �S/ U ---••-••--••----•••-••----•------•-•-•••• . ----------•---------------------------------------------------------------•.............-----•-••----•--...---------------- W UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ----------------------------------•-------------------------------------------------....--••--•----------------------------------------------------------------------------------------------------•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h bee4iss d b the b d of health. Signed ----------- ----- - - - ........ ------ ------.. ' ��--- Date Application Approved By ---- - -----_-_---- -------� -�f t....� Application Disapproved for the following reasons: ------------------------------------ ------------------------------------------------------------------------- .------------ --------------------------------------- -------------------------------------------- ---------------------------------------_------------................................................. ........................................ Date Permit No. --------� .. Y--6------------- Issued ---------------------. ... ................. ------ Date F MASSA HUSE E:�.. f 7 3 q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH' TOWN OF BARNSTABLE 7 - ; App iiatiun for Disposal lurks Tonstrur#iun rdmi# Application is hereby made for a Permit to Construct (v)'or Repair ( ) an Individual Sewage Disposal System at: ---- ----------------------- -------•e_10 T .......• - .......................... Location-Address or Lot No. ........ -- l�/a-i r .......................................................... ..........--------------------------------- ..----------------•-•-----------••---...--.... - capio ---7 n .•.._... WCJr t'{ LQ i_ C�t4ti1 e /�o�- C� `/tL�t�S y 1' ✓�/t Address C) Installer Address 6¢ �Q� Type of Building Size Lot_____..r..................Sq. feet •- Dwelling—No. of Bedrooms............................................Expansion-Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 1 1 'Other fixtures ----------r•-----------------------------------•-----.-----. ........................................................ W Design Flow............... ...........................gallons per person per day. Total daily flow____.___.___ 3`34________.....____gallons. GG Septic Tank—Liquid ca.pacity_l_Pe!qgallons Length__i K ___ Width_'!?�.K'_�___ Diameter________________ Depth____-67_ Disposal Trench'No--------Z_........ Width____________________ Total Length.................... Total leaching area....................sq. ft.- Seepage Pit No.____.__l......... Diameter...../?.______ Depth below inlet..... Total leaching area...Z sq. ft. .. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed by........................................................................... Date........................................ aTest Pit No. I___L_L...minutes per inch Depth of Test Pit_____�G�'+'�_. Depth to ground water......................... 44 Test Pit No. 2...G__Z___minutes per incli\Depth of Test Pit______ ... Depth to ground water_____ '____._____- 1:4 --- -•----•------ ----•----•----•--.......... .• -.....-••--•-•-•-• -.....----•-_---- --------- ~O Description of Soil.....4 B4 . r-f 5 --so«--•---�'� ........ `-S4-•••_/�Z"...�N�� W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable............................................................................................... .............................................................................................................. ....................................-----•-----=_................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with i 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 Compliance has been issued b the boaxd of health. = °.71 \ Signed --------- Date Application Approved By ........ ... � n M ar«-.,, ,e J ---v ---------------------------------------------------- ------ Application Disapproved for the following reasons- -------------------------......................................---------------------..................................-------- ---------------------------------------------------------------------------------------------- -----..........---.......... ............................................................... -------------.......---- -- -------- Da Permit No. ------ G Issued ......................................................... --ce -- -- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (1ler#ifirate of (�umplizutce THIS IS TO CERTIFY, That,thelndividua,Sewage Disposal System constructed.( ✓ ) or Repaired ( ) by --------------------------------------------------------------------/SJ ^......-:..... Gr17.v--..s --------..--....-..-.................................................................. - Installer /Jn at .. .Q. ..-/...-.. -....74.-........ _G_�'✓/ ---------------------------------------------- -------------------------------------------------- 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. ....19---3.----�--�P,6......... dated ................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. l Gj .................. .. Inspector ... .. THE COMMONWEALTH OF MASSACHUSETTS / ¢ - BOARD OF HEALTH TOWN OF BARNSTABLE Disposal nrr Tunstrudiun "pimmit Permission�• hereby granted.............................. _....--�'� ' ?.................................................. to Construct (' ) or Repair ( ) an Individual Sewa a Disposal System t atNo.......4•_*_. .....&A.......... ��*�! --•--•...........................................•r--............... Street (� as shown on the application for Disposal Works Construction Permit No.-b::; 4... Dated....... � ..`9„ ...... ................ ............................_ r •••._ f Board of Health DATE..............!�j.._ ................................... , FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS { a 1.. 1 ; Y 1 ZL Zs- 1 -77 OEM _ aI h 1 - 1 J ' i t �I n AZI 1 --- 7-17 f L 1 /n/S7HLL AlE A4 AL,9,v&'7 +�1'v .'V L•Q A �LG7/V +gyp�/��[ ,. / ,•it ..r � , ) JO,tJ IV "'• rY7 r S=LE Qo O!+ PVC p,o- ° -4' Asr Leo•✓ /2" YAx cE 4° r.v�Ex� �' ° ¢9.?8 /,vvE7Zs SGrle'F"' rz . 9 s5 Disc. 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EDWIA'D /KELLEY No. 26100 FCISTSAN � � r t