HomeMy WebLinkAbout4317 MAIN ST./RTE 6A(BARN.) - Health F4317 Main Street Barnstable
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No. J 1 f Fee
THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: Yes
—�
PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS
ftprication for Misposar .6pstem Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Locatio Address o of No. q 7 ®fi e �� Owner's Names,A�d���d�`NNO.� Q � . 2S
� 6(� ``bb 1
Ass sSor's Mapirc l 0
IVt�Vr'sAiamAddress and T 1.No. Sp ��' Designer's i �dress,and Tel.No.
11�!3 ury��i7i�o' h S°L✓tPr+° ,�h�j'!`�1 �j
Type of Building: J
l S'ovt. konf
Dwelling No.of Bedrooms Lot Size 6 6;4 f sq.ft. Garbage Grinder( WV
Other Type of Building IZO—J` ` No.of Persons 'Showers( ) Cafeteria( )
Other Fixtures
4/0 Design Flow(min.required) gpd Design flow providedD (3�� gpd
Plan Date ,15' '',Z0 —691 Number of sheets Revision Date
Title
Size of Septic Tank /p 00 Type of S.A.S.
Description of Soil C
Nature of Repairs or Alterations(Answer when applicable) 'j � WY
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 Certificate of
Compliance has been issued by this B of Healt
gned Date
Application Approved by Date 'p 0,i y
Application Disapproved Date
for the following reasons
Permit No. ��'.j f 2_ Date Issued
No.�+ '} .� �, Fee
TT Entered COMMONWEALTH OF MASSACHUSE
Yes
PUBLIC HEALTH DIVISION TOWN-OF BARNSTABLE, MASSACHUSETTS
' t 01ppflcation fDr 14906sal *pMrm Construction Permit
a
"Application for-a Perrnit to Construct( ) Repair(V/Upgrade( ) Abandon( ) El Complete System ❑Individual Components
'` Locatio Address or of No. Owner's Name,Address and Tel No. � ,7
w{: k := ,� �} 317 .. Cs t.� ? � '
Assessor s Map/Par el
Installer's Name,Address„and Tel.No/. S0 Cr 3=, besign�ir-s N`• e Address,and Tel'_No.
(% €Ii� L36o4r� Cty t ' s' 7y
t 3 1
r1 ,
Type of Building: j
• Dwelling No.of Bedrooms /"�•• Lot Size 6 1�!-;j
sq.ft. Garbage Grinder( f) �
OtherV t- Type of�Building �-Q No.of Persons Showers( '.) Cafeteria(', )
t Other Fixtures' rf r
r
Design Flow(min.required) gpd Design flow provided gpd.,
Plan Date . `..� ,�, "" Number of sheets Revision Date
% Size�of Septic Tank f F i Type of S.A.S.
Description of Soil e,r2� AV.a «'
Nature of Repairs or Alterations(Answer when applicable) �-�� , 0 J� Aff —15 gIA4.4,
,Y Date last inspected: '
Agreement: t
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-tolace the system in operation until a Certificate of '
Compliance has been issued by this Board of Health. ,
Bred E (` Date �M t �U
} 1
Application Approved by / Date / zr
Application Disapprovedob Date ( p
4 for the following reasons '
Permit No. //7�( —' r� 7 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 '
at W 3 P7 ta Qi.4 rf„r '�,� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoZt y 3iZ dated (1
Installer r;, I h'N At aTIO S Cj31<;i- / Designer
#bedrooms � Approved design flow
�: a> gpd
The issuance✓o�f this permit/ ^s�hall not be construed as a guarantee that the system will function as designed.
jDate Yf / , 1.+C'r Inspector . ,, _Y1A_Q1. � .:� ,
v . v rU
------- -----=--------=--may- - - -
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBL`I�C HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS-
e
Mi8tlD8aY *pstettY Construction Permit
Permission is-hereby granted to Construct Repair Upgrade Abandon
System located at i< ''/Z ow ' e 66 Ci4 ya't m 4 V.t
and as described in the above.Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
.l� •j4
Provided:Constructionmust be.completed within three years of the date of this permit.
Date ( l f�i�i 1 ._/�.�Z( Approved by
i
Town of B;alrnstaWE
blip
o Inspectional Services
Public Health Divsiott
'BLASSThomasMcKean Director
200.'Main Street,_Hyannis,MA 02601
Office: 5084614644' Fax: 5084907636.4
Installer&Nsigner Certification Form
Date: S.ewage;Perm t# O�f 1 essor's MILF. 09el- t
ill► ' � oAb a,
Designer. fe�eInstaller� C
Address: 0 D 6G1 713.. Address:
On 10 G L1.3:S o S• C'di�s t was,tssued a permitao install a.
septic system at 43 V7 �-O( 1 ff, 6 based_on a design drawn.bdate* 180
�` (address):
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or.septic tank Strip out of required) was inspected and the soils
were found satisfactory.
k
I certify that the:septic system referenced above was installed with major changes (i.e.
greater than•10' lateral relocation of the SAS;or anywertical;relacatidi of any component
of the.septic system)but.in accordance with:State&Local Regulations. Plan revision or,
certified,as-built by designer to follow: Strip out(if required)was::inspected and the;soils
were found satisfactory:
y' I certify that the system referenced above was;constructed in �liance°with thete;rms of
the I1A approval letters(if applicable)
NtH OF
�7 1 C y'
�c.
itRE
(Ins let's Si `,7. LJ
79
No. cl
. sTems',
,. Me— s Signature (Affix p Here)
PLEASE<RETURN"TO BARNSTABLE.PUBLIC HEALTH DIVISION.- cERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM .AND AS
;BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.,
THANK YOU.
UtoaktepWIFAG't HEWER eonnecASgMC1Desigm Certiticelion Form Rev 84+43 bi G .
` L0 AT ION SEWAGE ERMIT NO.
T il 'w
VILLAGE
"s d22w, oni4 „2 EnJ��2n i 2� �A2l�dl �-
INSTA LLER'S NAME i ADDRESS
c J_;+
e U i L D R OR OWNER.
GATE PERMIT ISSUED
:DATE COMPLIANCE ISSUED10 f 0
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TOWN OFnB ST I s
LOCA ON 3I 9 n 4 iAR 1�67' lot- SEWAGE# 61aL
VILLA& ASS SSOR'S MAP&PARCEL O O
INSTALLER'S NAME 7HONENO. b't'� V U �S C040 ►
SEPTIC TANK CAPACITY /60 CS s®��
LEACHING FACILITY:(type) -r*0 C6 vm(�i -5 (size) (1-X q0 X � 4-4"
NO.OF BEDROOMS 5 JZwe L
OWNER iPr
PERMIT DATE: �� A09A 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
E
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No.../.... '� .lff.. � FizDOc7
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diiplalial Works Tonstrnrtion thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( Vj"'an Individual Sewage Disposal
System at:
................---. ' m . ... . r6 .._.... -� ..............................
Loc n Aid, or Lot
Owner }� -. //!J1 Address 411
......•....._enw .— ._..l. =.f.rr1.�!s[1.8.r_.!!_.Y:.......... ..• ---��w;l!! � �
Installer Address
Type of Building Size Lot----------------------- ---Sq. feet
Dwelling—No. of Bedrooms............e...............................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building . No., of persons............................ Showers — Cafeteria
Otherfixtures -------------------------------------------------------------
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.......I.........:... 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 ( )
aPercolation Test Results Performed bY------- ............................................................ Date........................................
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' -----•--------------------------------------------------•-•-•--•-------------------------------- -----------------------------------------
----------------
0 Description of Soil......................
x
x ----•------------------------------.-------•--------------------------•-......---------------•-••-------------------------•----------------------•--•----------------------------------
U Nature of Repairs o Alterations—Answer when applicable "._.4w�-- 6� y
PP
Agreement: 6
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 been iss_ued by the board of health.
Signed ------ - ----- ---------------------- ---� ��---�-
Application Approved BY f"" --- ---- ✓�-'--?r am'; ---
-------- -------- ------------'----.........---- '-------------................... Dare
Application Disapproved for the following reasons• ..................................................... -----------------------------...............................................
.......................-------------- -..........................................................------------------------------------ ------------------------------------------------
9Y �//� ' Dale
PermitNo. .. -------------------------- -------------------- Issued .------�----..`� .. ---------------
Dare
No....n.�>
tt THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Allp iratiun for Disposal Works Tonstrudion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( y/�an Individual Sewage Disposal
System at'. x w
....................... ...._..&A ='.-- .................. _!-�'�.....Ay --e-A_--------------..--------------
Location-A�dress or Lot L�o..�L_ A /J
•=^•"` '-+1 .::'�_.._ -.-Y ...... ..................... .......�71-.7..1.14. -�v' -�.C.....l0- ..�..1.��f�>/
* ner /! Address
.......... L e. ....fie ,��".� -b�,r3 2 .. •;- ........ ✓,�_... �yu/ol It
Installer ! Ad Tess
Type of Building '"' ///� Size Lot--------------•.............Sq. feet
V Dwelling—No. of Bedrooms............. ----_•--------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T of Building - R.......... No. of persons............................ Showers — Cafeteria
ther fixtures .........................
W Design/F ow...........................................gallons per—person per day. Total daily flow............................................gallons.
WSeptic—Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................
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 ( )
a Percolation Test Results Performed by.....................................
...
•.................................. Date........................................
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........................
fX •---•••--•------------------•---••--••••••••-•--•-•••••-----•••.....••••--------•--•------------------- -j' .............................
0 Description of Soil...............................................................................-............................................ .........................................
x •-----•�•---------•---. ....................... ....................-•--•...------....-•-••-•••----•••••-••------------------------------••--••••-••••-•---•-•......•-•--•......•-•...... ---•--
U Nature of Repairs or Alterations—Answer when applicable...... / n4�!. a l_.....
� �,! p_ .
ram: d� =fir':: � ; -. 'a�a; -g o: J Y 3 S
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
'y
s system in operation until a Certificate of Compliance has been issued by the board of health.
Signed G £4 �4 � ate to
D
Application Approved By ........ ✓`: ' "( f - -If=� .. �.............................. Date
Application Disapproved for the following reasons: -----------....-------------------------------------------------------------- - -------------- --
- ------------------------------------------- - -- --................... ............................---...------------------------------..... ....:.------.........---------- ----------------
Date
Permit No. ... G..�"./y.......�...�----------------- -_ Issued ------ 1� a � �---------------
♦ Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C'Ier#ifira e of C antyliattre
THIS IS TO CERTIFY, That the Individual
/Se ....wage Disposal System constructed ( ) or Repaired ( )
by ....... /,.. ....
?�... In taller �.........--.
�. . .. ................................. ................................-----....--.................-
at a - '//J - 1 }/ ///, . /,o�w...................................................----------------------
s- _✓ /- / T�"" T ... --------�. .�i. .._...........J-----�i' i.i.T..
has been installed in accordance with the provisions of TITLE 5 of The Stat Environmental Code as described in
the application for Disposal Works Construction Permit No. ....3P4.�-...`�r/..... ....... dated ......C�..,-..THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED—AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE � ...----'.�........./--1.............................................. Inspector ....-------- ...............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c � / TOWN OF BARNSTABLE
No........................ FEE...:....:..........
Disposal Works Tuns#rudiun Prrmit
Permission is hereby granted. / ..... ?:� ... - ;:.. . ;... ..:...............................................................
to Construct ( ) or Repair ( U)'�an Individual Sewage Disposal Sstem
Street '
as shown on the application for Disposal Works Construction Permit NP '. ... Dated.._ .. .' —•- Q---
.........
DATE. ... Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
R
EXECUTIVE OFFICE OF ENVIRONMENTAL
AFFA
IRS
�a
DEPARTMENT OF ENVIRONMENTAL PROTECTION
k
TITLE 5
FG ViY ASSESSMENTS
_._vim A
CEWFMCATION
Property Address: `/3 1? /'► din sf-
Owner's Address: 44,317 rfl-a 1+. Sfi ai
Date of Inspection: a (A3 p( SEP 2 8 2001
Name of Inspector: (please print) M(Gkc-e( rOwHEOlLzgARNSTggfE
Company Flame: ea
� ' arlL fv�ty/7`C �u ./ Eh � nJ HDEPr.
Mailing Address: ,O�jpK
Telephone Number: Sa8 394-- 69
CERTIFICATION STATEMENT
I certify that 1 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: t Date:
—� .
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable. and the approving
alltilOriiv-
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 I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLIMS I`ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: S/3 (7
Owner: Ttjv�eS
Date of Inspection: `t Ziao
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Soctiea 0
A. System Passes:
4l have not found any information which indicates that any of the failure criteria described in 310 CMR
03 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. Svstem 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,N-D)in the for the followin tements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or th ptic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration faihire is imminent System will pass inspection if the
existing tank is replaced with a complying septic as approved by the Board of Health.
'A metal septic tank will pass inspection if it is cturally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years d is available.
ND explain:
Observation of sewa backup or break out or high static water level in the distribution box due to broken or .
obstructed pipe(s)or due a broken,settled or uneven distribution box.System will pas inspection if(with
approval of Board of alth):
broken pipes)am zzphtmd
obstruction is removed
distribution box is leveled or replaced
ND p in:
The system required pumping more than.4 times a.year due to broken or obstructed pipe(s). The system will
pass in if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
y
Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection: Ck��\CA
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordanc ith 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect publ' ealth,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 v etated wetland or a salt marsh
2. System will fail unless the Board of Heal (and Public Water Supplier, if any) deter
mines that the
system is functioning in a manner that pro cts the public health,safety and environment:
_ The system has a septic tank and oil absorption system (SAS)and the SAS is within 100 feet of a
surface water_supply or tributary to surface water supply.
— The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septi 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 e well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile or anic compounds indicates that the well is free from pollution from that facility and
the presence of ammo 'ia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are ered. A copy of the analysis must be attached to this form.
3. Other:
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOL-MTAItY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM N FORM
PART A
CERTIFICATION(continued)
Property Address:
arv.s'kb�.Q
Owner-
Date of inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X 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 ''/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS, cesspool or privy is below high 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.
_IL 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 dKmld 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 t srrve a fac3lgy with a design flow of 10,0W gpd to 15,000
gpd-
You must indicate either"yes"or`" o"to ach of the following:
(The following criteria apply to large stems in addition to the criteria above)
Yes no
the system is within 0 feet of a surface drinking water supply
the system is wi in 200 feet of a tributary to a surface drinking water supply
_ the system i located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II o a public water supply well
If you have ans ered"yes" to any question in Section E the system is considered a significant threat,or answered
"yes" in Secti D above the large system has failed. The owner or operator of any large system considered a
significant eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
C CHECKLIST
Property Address:
Owner: JCAA&S
t
Date of Inspection: p
Check if the following have been done. You must indicate"yes"or"no" as to each of the following-
Yes No
Y _ 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)
f _ Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out?
X- _ Were all system components, excluding the SAS, located on site ?
of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
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 CMR 15.302(3)(b)]
t
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NO'ITFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYS ] INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:�Qy�
Data.of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): c3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd z#of bedrooms):S.'y
Number of current residents: oZ
Does residence have a garbage grinder(yes or no): (�
Is laundry on a separate sewage system(yes or no): I{�C [if yes separate inspection required]
Laundry system inspected es or no):—
Seasonal use:(yes or no):RQ
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):f'JU _( I
Last date of occupancy: LV freV4.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.
Grease trap present(yes or no): _
Industrial waste holding tank prese yes or no): _
Non-sanitary waste discharged the Title 5 system(yes or no):
Water meter readings,if av able:
Last date of occupancy/ e:
OTHER(describ
Pumping Records
GENERAL INFORMATION
W� R LA l V
Source of information: d 2 CGS r C'." .
Was system pumped as part of the inspection(yes or no):_Q
If yes, volume pumped: Qailons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
x 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)
_ [rrnovative/Alternative technology. Attach.a copy of the cnun=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:
Were sewage odors detected when arriving at the site(yes or no):0
I
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: i �}
Owner: e
Date of Inspection: C1b
BUILDING SEWER(locate on site plan)
Depth below grade: Sal
Materials of construction:_cast iron 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments (on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK:jL(locate on site plan)
Depth below grade: 0
Material of construction: x concrete—metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):
certificate) _(attach a copy of
- ll
Dimensions: l C) G C�
Sludge depth: (�
Distance from top of sludge to bottom of outlet tee or baffle: b tt
Scum thickness: �N 1
Distance from top of scum to top of outlet tee or baffle: yu
Distance from bottom of scum to bottom of outlet tee or baffle:_ L*tl(
How were dimensions determined: f e z b v r eWL-
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels
as related to outlet invert, evidence of leakage,etc. : �(
� u
�..
GREASE TRAP: _(locate on site plan)
Depth below grade:_
Material of construction:_concrete—metal erg lass_polyethylene other
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to top of det tee or baffle:
Distance from bottom of scum to ottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping re mmendatious, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert vidence of leakage, etc.):
I
' Page 8 of l l
OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 17 ci%i,- Sf
Owner: _ s �—
Date of Inspection: ( pr
TIGHT or HOLDING TANK: (tank must be pumped at timelocaee on site plan)
Depth below grade:
Material of construction: concrete metal erglass_polyethylene other(expfain):
Dimensions:
Capacity: gallons
Design Flow: gallo day
Alarm present(yes or no):
Alarm level: Alarm in rking order(yes or no):
Date of last pumping:
Comments(condition of al and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: (LVe,
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.):
1 `l ll 0 N,
y T C Circ, o t/1
I
PUMP CHAMBER: (locite on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no).
Comments(note condition of pump ber,tondition of pumps and appurtenances;etc.):
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: q3 1?
Owner: S�V�2S
Date of Inspection: C�
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,.excavation not required)
If SAS not located explain why:
Type
oL leaching pits,number: �.
leaching chambers,number:
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.):
� �i.s a... 6 X c`e � � ►`� W
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 groundw er inflow(yes or no):
Comments(note co ttion of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
PRIVY: (locate on site pl
Materials of construction:
Dimensions:
Depth of solids:
Comments (note con d ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
9
1
f
' Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FUR 'I-UNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'(wntinued)
Property Address: y,3 /7 /,lcq'h s,-If
Owner: 3b�/leS
Date of Inspection: ;2-{(n 1
SKETCH OF SEWAGE DISPOSAL SYSTEM
Pfovide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
46
1
Gr�ev� 36 3 � �
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 t7 Pla.(01 �S�
Owner: �76v�x,_s
Date of inspection: q 19S of
SITE EXAM ��
Slope U v v %
Surface water AZ
Check cellar G�
Shallow wells Y\)®
Estimated depth to ground water 30�ffeet
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:
l)—S y a-%_u o kj-eA 'X O
i
J +
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town.Hall) and get the Business Certificate that is
required by law.
tw DATE: y._UY,-1 1- l Fill in please:
APPLICANT'S YOUR NAME/S: S L IL-
BUSINESS CM lrrjA
YOUR HOME ADDRESS: bl IM A T Al 6 r" LfJM/YM A 611JI 4 , yyt /� d a 1=1 6
.'dh
u ` TELEPHONE #.- Home Telephone Number 56 T"IL 6, �� 3
NAME OF NEW BUSINESS 5 G/V TYPE OF BUSINESS . b r
IS THIS A HOME OGCUPATION�' °` YES NO
ADDRESS OF,BUSINESS ►°V n� ( [� % MAP/PARCEL NUMBER O .DO (Assessing)
P(
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has a infor d o the per it requirements that pertain to this type of business.
Authorized S' nature*
COMMENTS:
3. CONSUMER AFFAIRS [LICENSING AUTHORITY)
This individual has bee&or d f icensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
Certified Plot Plan
RyAr �at�.
&W' 16 0L )P9 4317 Nain St
�Q U " oL' Bam-stable, ILIA
SURVEYING • ENGINEERING ( ps>s'a7ared ��
HOME PLANNING&DESIGN \� Steplzen F. Butter
scale.- r = 4a,
3 GIDDIAH HILL ROAD P.O. BOX 439 �T Pate.' rune 30, M08
SO.ORLEANS,MASSACHUSETTS 02662
TEL:S08.2SS.8312 FAX:S08.240.2306 529' _
86'
i
i
-� .SOT 5
1Refemnce.• Plan Book 170
Assr S.map 350 Pct 004 Page 153 1
Ld Bk. 14801 Pg. f06 O.6 -4c.1-
'N
M Bk. 170 Pg. 153
NCd
ti 1
PPOPOSE11) 30.
"PITION m
14 Ft. z. 24 Ft. v 4
Cry �• '.
"'Appro=septic per 3 ¢ p
B.0.A AsBui& e'24'
l'zzstzng
.� Creenhouse/
.2nd Floor Deck
Ax siting
i Shed
-�NOF
PHI LIP OyG
I certify that the dwelling shown hereon is ' ODYSsEus
located as it exists on the g7»und and that as so a sCH°LOMITI
located it complies with the minimum property line u 436867
setback reguimments of the Town of Barnstable.
Pmfesszonal Land Surveyor
Job No. 9926
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e
,f FOUNDATION 20 FT. MINIMUM FROM CELLAR OR CRAWL SPACE
=: 10Q00 10 FT MINIMUM 10 FT MINIMUM FROM SLAB —
CLEAN SAND
(ASSUMED) 6" SLEEVE 150 PSI PIPE
CONCRETE INSPECTION PORT
COVERS (WHERE SHOWN)
4" SCHEDULE 40 PVC PiPE LOAM AND SEED
MIN. PITCH i/8" PER FT 2" LAYER OF
1/8" TO 1/2"
wASHED STONE
3.00 4" CAST IRON PIPE ---- 97,45 MAX OR FILTER FABRIC VENT
(OR EQUAL) MINIMUM �20 �• REQUIRED
PITCH 1/4" PER FT. FLOW TEE
t E VELERS
FLOW LINE _ 45
ELEV. _ �7 QQ_ 10
t -— rn
`TM N 2 0 0 D ❑ ❑ ❑ ❑ O O ❑ 0 0 ❑ -
ii LEV = 96.'_S_3 LEVEL o 0
° ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 0 ❑ 0 0
ELEV. _ _ zQ_ ADD GAS ELEV = _ _ 6' SUMP ELEV _ _44�d_ ° 0
BAFFLE 0° 0° ❑ ❑ ❑ 00 ❑ ❑ ❑ ❑ ❑ ❑ 0 2' o
DISTRIBUTION ELEV. _ 0 0 0 D ❑ O ❑ ❑ 00 ❑ D ❑ ❑ 0 o °
LIQUID OUTLET 0 _ 0 0 ° 0 ELEv
-- ---DEPTH TEE (EXISTING) BOX - - 3 5Q0 GALLON GALLEYS WITH
-
4 FEET 14 INCHES 5 FEET 19 INCHES //��//���� /� TO BE WATER TESTED
6 FEET 24 INCHES 1 VW GALLON IF MORE THAN ONE OU Tl_E T STONE IN AN
7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) 13' X 40' X 2' TRENCH FORMATION z WELL NIA _
8 FEET _- -- 34 INCHES SEPTIC TANK -- -- --- /1p -n-n��--- 20 ZONEv,_
3/4" t0 1 i/2' CLEAN SOIL ABSORPTION �, INDEX
DOUBLE WASHED STONE ADJUST
FREE OF FINES do SILT SYSTEM SAS H-20
USGS PROBABLE WATER TABLE ELEV. =
SEWAGE DISPOSAL SYSTEM PRMLE ._-__-_--
PERCHED WATER TABLE (5/19/202t) ELEV. = .-ALA--
NOT TO SCALE PERCHED WATER TABLE (8/18/2021 ELEV =
BOTTOM OF TEST HOLE ELEV. =
SOiL TEST P#21-141
DATE OF SOIL TEST MAY_ 19 2021_____
SQiL TEST DONE BY SWEETSER ENGINEERING
WITNESSED BY _�LANTQN,_________
! *'43 y
" oC ,7, , OBSERVATION HOLE 1 ELEV.=_96_5_
PERCOLATION RAZE
6, MIN./INCH IN C HORIZON
5.ala --
DEPTH HORIZ TEXTURE COLOR MOTT OTHER
0-65" FILL NO
96 _/ENT LIMIT OF 5' 65-138' C LOAMY FINE SAND 2.5Y7/4 CEMENTED
/ 13 OVERDID t 20
\ 1 � 0' \ 96 2 PERCHED WATER ENCOUNTERED AT __ _ ELEV. = 86.5
OBSERVATION HOLE 2 ELEV.=__96.5-
+/ DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
Solt. t.,... LOT 5 ►- 0-6
8' FILL 0
��.
ST 2 1' "�'' TESn ' Q 26, 163.-9 t S.
- N
6.5( 68-138_�C- LOAMY FINE SAND 2.5Y7/4 CEMENTED
Q .-___
PERCHED WATER ENCOUNTERED AT 120` ELEV. = 86_5
i Sol 'Q� OIL SOIL TEST P#21-243
9 >>. S 3 TES DATE OF SOIL TEST AUGUST 18 2021
y 1_--___
i 1 4 SOIL TEST DONE BY SWEETSER ENGINEERING
3 D +'c'` f� ' WITNESSED BY -- MARAI�-.------
�J
M 9$, 96.4 94 9
,+ To oo•
'4 OBSER VATi ON HOLE 3 ELEV.=--- -4--.
t50TLpND �` PERCOLATION RATE < 8 _ MIN./INCH IN C HORIZON
y!E O 96.5
/ 98.8�' i DEPTH HORIZ TEXTURE COLOR MOTT OTHER
( ►tE 0-72" -- — --
�r 98 1 1 (�6J FILL _ NO
% 96 4 72-144' C LOAMY FINE SAND 2,5Y7/4 CEMENTED r
' '�- - - i
/ 9 PERCHED WATER ENCOUNTERED AT9,0 __126- ELEV. _ _ 859_
OBSERVATION HOLE 4 ELEV =--96.4
1 / 99_6 9 2 1 96.6 g DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
-.. _
�, 96.9 + / j ►-C 0-68" FILL NO
68-144'ic LOAMY FINE SANG 2.SY7/4 CEMENTED
,98.8 EkIS nNG i PERCHED WATER ENCOUNTERED AT _ t26- ELEV
4 gf pR0 MS,NG /
NOTES:
j Q 1 ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D E P
h
TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR
THE SUBSURFACE DISPOSAL OF SEWAGE.
REfNHou �� 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
j _ 2 DECK WITHIN 6" OF FINISHED GRADE.
3 ALL. COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
10 FT, OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
USED UNDER OR WITHIN 10 FT OF DRIVES OR PARKING AREAS.
4 ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL
BE MORTARED IN PLACE.
1000 GALLON 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
SEPTIC TANK DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATiCNN CONTRACTOR
IS TO CALL "DIG-SAFE" AT i-889-344-7233 AT LEAST 72 HOURS
PRIOR TO COMMENCING WORK ON SITE
7 CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL. AS
SiTE CONDITIONS PRIOR TO COMMENCING WORK ON SITE ANY VARIATION
O iS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER
IMMEDIATELY
8. PARCEL IS IN FLOOD ZONE _ X_
9. LOT IS SHOWN ON ASSESSORS MAP -__ X A`; PARCEL X
10. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER AND
FOR A MINIMUM OF 5' AROUND SOIL ABSORPTION SYSTEM AND BE
REPLACED WITH MATERIAL AS SPECIFIED IN 310 (,"MR 15.255:(3).
11. THE INSTALLER IS TO GIVE THE ENGINEER A MINIMUM OF 48 HOURS
(2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION (NUMBER BELOW).
12. EXISTING LEACH PiT IS TO BE PUMPED AND BACKF'I11 ED WITH SAND.
I r.S Op, i. 1 �cp 6f
o /STEM
Ilk AS\)
VAL Lr�0
yY.
llos9. APPROVED: BOARD OF HEALTH
C_,A TE AGEN T
CMMAQUID, MASS. I PROPOSED SEPTIC DESIGN
Oi:AVA
C, 1
vTER �� ----- S 1 E •L' BUTLER
_a
// ROUTE 6�-----__1 LOG -- -- 4317 ROUTE 6A
DESIGN
SA,V11k �' CALCULATIONS
UM, MASS.F 4 #
I
NUMBER OF BEDROOMS 4 (DOSTM)
_
GARBAGE DISPOSA;. UNIT /�JLi u
- _ � _
-- z -
TOTAL. ESTiMATED F„Cry
( 110 GAL./W/DAY X 4 fit.) _440- GAL /DAY 203 SETUCKET ROAD
REQUIRED SEPTIC TANK rAPACITY _AML GAL i 508— P. 0. BOX 713 '
ACTUAL SIZE OF SEPTIC TANK (E)1STNdG) tQQO_ GAL. I L385-6900 SOUTH DENNIS, MASS 02660
LEGEND SOIL CLASSIFICATION - �__-- -- T _�_�
- 1--
DESIGN PERCOLATION RATE S_4..__ MIN,/IN. _
EXISTING SPOT ELEVATION OOxO EFFLUENT LOADING RATE GAL./OAY/S.F.
EXISTING CONTOUR - -00---- LEACHING AREA SO. FT # DATE 20, 2021 ,� 20' i
FINAL SPOT ELEVATION O.
-- FSCALE�_
FINAL CONTOUR---{0 -- LEACHING CAPACITY (AREA X RATE) 4M112 GAL./DAY -- ----.--_-
SOIL TEST LOCATION 73200 X Q� ` I REV. AUG. 1 �02 JOB N0 pC�am�►.p 000/� -
i;TILITY POLE -p- ! oJVv�W RESERVE LEACHING CAPACITY !18.'i,12 GAL./OAY --- ---__-____.._ � � ---� #
TOWN WATER —W—W—
CATCH BASIN ®', REV.
GAS LINE LOCATION MAP
CLEAN OUT J a I cH E OF
T
CESSPOOL C.P.
1 CR 1 PgI7/i Re.4R-00%,4.,i RrOgR. se c nW .e"1')n?, C1NFF-TCFG FN(:INVFRiN('