HomeMy WebLinkAbout1307 MARY DUNN ROAD - Health 1307 Mary Dunn Road
Barnstable P
A = 334 002007
e
0
I r 9
OMMONwEALTH OF MAS1AC1U3s
.EXECUTIVE OFFICE OF ENVIRO1VUENTAL AFF rt€, ,,
kv E .DEPARTMENT OP j; gIR9'
NVIRONMENTAL pROTE� . .
.,C�TI011i� PH 2: 33
FECIFE
05®�'I'I' CIAL TITLF S HEALTH DEPT.
N OF ABLE
INSPECTION FORM_NOT FOR YO SUBSURFACE SEWAGE DISPOSAL SY ARY ASSESSMENTSPART A STEM FORM
CERTIFICATION
s N ."hS t
dwner' ame: � C9d 6 3o �
OwnWsAddress: p L-KZ",hC `ARCEl. � 2 1
Dats of Ins a N� RCI LOT � qq ��
Pertioe: Od 6,3 -l�
Pi— p S
Name of Inspecto
Company Name: EHaul .fi�/,
A8 Addresa:
Telephone Number p y Od 6 4d
cer*SIC have
PC STATEMENT
below is have �U`' ed the
a and complete as of the time am di
s'�at this address and that g experience in the proper fimction of ance oion.'the inspection ade tlt'o he info nation arced
approved nspector pursuant to lion 13.340 maintenance of on site sewage chi mined based on my
Of Title 3(310 Sewage
15.000I, The ins I am a DEP
paw system
Conditionally Passes "
-- New Further Evaluation '
—, Fails � t Local Approving Authority
Inspector's Signature: Gv�2
The system inspector shall s Date: _ -
DE> within 30 °fit a3'of this in _
days of completing this siwtion report to the A
.theinspection. If the system is a Shared Approving Authority(Board of Health or
DEp,lie gtnal Shouldbe send the y m owner shall submit system or has a Iles'
the rt MrTriate regional
now of lkom
aiitlwrity, system owner and copies sent
the Dyer,if appticable�,oaituadl�ce of the
Notes and Comments a approving
***''This`re ,
port only describes conditions at the time time,This inspection d9e9 not the how the s s me of ins
conditions of use, i) and under the conditions of u
y ten will 1►erfgrm in the future use
at that .
hire Under the ya.me or different
' j
.. OFFICIAL IlITSFECTION FORM_NO
�SMWACE SEWAGE DISPOSALT FOR YOL�INTgRY ASSESS
SYSTEM INSPECTION FORM
MNTS
PARTA
CERTIFICATION
PrqPerty Address: 1.3 i)7 /Y!�r eontmve�
Owner. 2— R�
Glen KN
r�r2vi c, 4aZL�p
Date of bspectloa%
—off
Inspection Summary; Check A,B,C,D(WE I A
A� ppusft. comply ad of Sfttio,D
1 have not found any informgtion whic in
15.303 Or is 310 Ct� dca
h 15.304 exist Any 4111M !eSthat`nY �gi� bed in 310 Clot
Comments: Indicated below.
B� Syvz&m Coaditionai{y passes:
Qn+s or more system
repaired The s'�n% upon com�� ribed in the"Conditional pass"of Ike section n
md Awer moment or reps.as appro<,ed by the> rd of H be�
ns ealtl;will pass,
explain Yes.no or not determined(Y.N,ND)in the
for the following statements,If"not determiaW ply
The c ink is metal and over 20 years old"or the se
unsound,exhibits�
A �is infiltration e�+lt mtion or Septic tank(whether metal or not)is scpdc tank ieplaced with a comply' is'mini,= structurallj,
indicating t will pan i�tiunngif i c ��roved by the Board of Heal System will p� �n if the
tank is less than 20 SOUyears old is available.
N not D if a Certificate�CompLance
ND explain;
—_ Observation of Vwac backup or break out
obstructed Ppe(s)or due to a broken,settled or or hi the distri static water Level in
plxoval of Board of Health); uneven distribution box System will paw inspection if(with but'on box due to broken or
-- broken Pipe(s)are replaced
obstruction is retnpv�
distribution box is leveled or replaced
ND explain:
The system required
Pass inspectioe.if(with � 8 more Year due to broken or obstructed
approval of the Boa than 4 tinxS a Yrd of Health): Pit�(s). The
system will
broken pipe(s)are replaced
fiction is removed
ND explain:
Pose 3 of 11
OFFICIAL INSPECTION FORM_NOT F /J' SUBSURFACE SEWAGE UIS OR VOLUNTARY ASSE
P4SAI.SYSTE �MENTS
M
PART A INSPECTION FORM
7 CERTJFICATION
Properly Address:—,
Owner• L-- r� e Nth L
IIate et Iaspe a. _ 0
C. Further lhvalation 18
A / w4ulred by the Board of Health:
Coaftions
is failin 'o �which require further evaluation the
P'"c-heailk safety-or the envf pi Board of Health in order to determine if the system
System wilt pass unless Board of Health determines system is mal"CdQuing Ina wal in accordance witit 310
+set which will P10ded Public CMR 11303(1)(b)that the
C h+ ety sad
— esSpool or privy is witl�tin s0 feet of a �eft:
— Cesspool or posy is within 50 ft of a surface
vegetated Kurd or a salt nush
2. System will Pail pal
s ess the ward of Health
system is functioning (and Public 0°mg in a,manner that Protects the publicWater Supplier,if an3')determinCs that the
m has a health,safety and eavironment;
;Wfa�!Water y�ic tank soil absoq*on system(SAS)
y to a surface water may. )and the SAS is within 100 feet of a
— Ths 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 t a nk surf SAS and the
SAS is within SO feet of a private water supply well.
_ The system has a septic tank and SAS Private water stWy sea**.Method used to SAS s less than 1AO feet but St)feet or more from a
distance
'`*This system passes if the well water
analysi
bacteria and volatile organic con S'Aerformed at a DEP cc lifned
the presence of ammonia nitro motes that well isfree laboratory,
fur colifgrtn
failure criteria are trigger Acopy�nitrate nitrogen is equalto or lea�Pollution from that facility and
of the analysis must be� d t than Provided�no other
3, Other. t
(JJ�
Poo 4ofII
OFFICIAL INSPECTION FOIE_
NOT SUBSURFACE SEWAGE DISPOSAL FOR
VOLUNTARY ASSESSMENTS
STEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PrWrV Addre.- 0'1
Owner: ,�,��✓t c oa 6 3a
Date of]Gtshectwea / /u - p
D, System Failure Criteria apD1lCahle to all
You mustindicate`Yes"or-nW to each of the following for all moons:
Yes IVo --,--
of sewage into facility or system component due to overloaded or clogged
N or
inv
! SAS or�g of ea]uent to the surface of the ground or surface orate c e °r cesspool
Stattc quid level overload or
spool �bntion box above outlet invert due to an ovedoa ded or
dqXh
l clogged SAS or
�PoOrS less than 6 below invert
�8 more than 4 tunes is the>aa y �T.due or lteo llogge����flow
Portion of PrPe(s�Number
SAS,cesspool or privy is below high ground water elevation,
�Y portion of cesspool or Privy�within 100 feet of a
�PP1Y� srface water supply or tributary to a surface
Am portion.of a Po�on a cesspool or Privy is within a Zone 1 of a public well,
AZW Portion of cesspoolor�vy is within 50 feet of a pdvate water
suPPIy well with no or privy is less than 100 fed but grew �'�'well.
! 'formed at a DIi;P cede water Sty than 50 feet from a private water
rbttied labot'ato analysis. [This system Passes if the ryep water analysis,
indicates that the well is free f ry%for coliform bacteria and volatile o
nitrr►gen and nitrate nitrog�!$equal to or Ifrom that facility and the presenceGamic mow ands
are erect.A copy of the anal lea than S ppm, Mvi}ed that no other failure criteria
ysis must be attached to this form,
(Yewo)The sy"em tab I have determined
described in 310 CMR 15.303 that°�or move of the above failure criteria exist as
Health to determine w ,then fore the system fails.The system owner should criteria
hat will be necessary to system
the failure, ntact the Board of
E. Large Systems;
p be considered a large system the system must serve a facility with a desiga how
gPd. Of 1_0,0"You must indicate either`Ye4"or"no"to each of the following; gPd to ts,000
(The following criteria apply to large systems in addition to the criteria stave) ,
s a
the system is within 400 feet of a surface drinlang water supply
the system is within 200 feet of a tributary to a surface drinking water su
POY
myis located in a nitrogen sensitive
Zonc 11 of a Public water supply well arcs(Interim Wellhead ft0tection Area—IWPA)or a mapped I'
If You have answered"yes" to arty question in
"yes" in Scction D above tb�e tar won E system is considered a si
significant threat under has failed,The
owner or operator of a_ scant threat,or answered under Section E or failed under Section D shall u ny a-ge system consi
15,304, The system owner should contact the a PBmde the stem in tiered a
Ppropriate regional Officc of the De accordance with 3l0 CM1t
jr.,.. l�ttcnenl.
Page S of 11
• OFFICIAL WSPECTION FORM_NOT
SUBSURFACE SEWAGE DISPOS FOR VOLUNTARY ASSESSMENTS
AL SYSTEM[INSPECTION FORM
PART R
�C'KLIST
ProPe+ty Address; 'J'D
/ rvu �vt vtvl (�
Owner. givren ce OoZ 6�p
Date of Inspection:
Check if the followin have been done.You most indipte ce
O14n „as to each of the followin
Yes o
Gg'ormation was Provided by the own% er.���Board of Health
��the system
c'O mPoneft pumped out in the Previous two weeks
syskm received norW
in the lre +ous two weak Period
Have ladle volmmes Gfwater been mooed to the system recently or as
Were put plans of the system obtained �° Part ofshis inspection
"am
Was the facility or dwellin available not.as N/A)
g inspected far l(If they were�t
signs of sewage back up
TWas the'site for signs of break out
Were all system c
f °mP000ts,. the SAS,Iogted on site
Were the
of the battles or tees,materiall o f Manholes. openeQ and the for of the tank
4imens�— — "'as the fit}'owner(and �'depth of tiqui�depth of sludge andMSPected depth(If for �n
maintenance of sewage l systems owner)
different from owner)Provided with information on the proper
Tile she and location of the Soil Absorption Syste®(SAS)o Yes no ) n the site has been
determined based on:
xistM8 Infonnatiom For examPk a plan at the Board of Health•
Determined in the Geld(if any of the failure criteria related top C is at issue
Is unacceptable)1310 CMR 15.302(3)(b)j a
PProximation of distance
' Page 6 of 1 T
Off'�ICIAL INSPECTION FORM_
SUBSURFACE SAGE DISPOSAL NOT FOR VOL�TARY
POSAL SYSTEM INSPECTION`,S MENTS
PART C FORM
PJMpWy Ad SYSTEM FORMATION
�7Ynlr; G✓rQyl 4P i,4 Al vl
Date of to
ENTI,�, FLOW CONDITIONS
Number of ems(design
8n):� Number
IIoR`based on 310�15.203of bedrooms(actual):Number . 10
D 1 gpd x#of b_e_&W • .�
Domes woe have a garbage grader o �)'-- �
Is �y on a s (yes or no):�
Seasonal system inspected(Yes or n .L�or�)��[if Yes ate inspection
water meter orno
Sump pump(yes or no):if avj�(last 2 years,.� '
'AM date of
COMWERCTALANO TRIAL T
TYPe of establislimeM
Design flow(basedon 3I0
Basis of deli �15.203);
G In flow Oeats/perso��etc.):
cease trap pint,(Yes or no):
Este holdia
NO B tames(yes or no);
L-Mdaot �a'ailabl :tie Title S sY em(yes.or I*).
0°�T/use. _
OTHER(descnbe):
pumping records. GEVEV_U INFORMATIorf
Source ofi*anwon;
Was system punVedIf YC%
hmie Aped i_&,dltion(yes or no)• -t�
Ramon for Now was quantity pumped
SYSTEM
— a*distribution bo -
Sing►e x, soil absor n ,stem
Over&wp°ut
Rhy
_.Shared system(yes or
no)(If yam'attachpreWous
obt ftomire technology.A of�Pc curQ
tion records;if arty)
systTight
tarp —AUach a copy of the DEp approval Operatran and mawenaam contract(to be
— Other(describe):
A
Ppm,dnM a e of all c mp° �date; I nas a/ ed(if known)mW� sou
Ice fio nfon anon:op
Were sewage odors dctectcd when azriving at the sr (Yes
or no):/filf)
OFMCIAI.INSPECTION FORM
S�SURFAtL"E SEWAGE DISppOT FS VOLUNTARY
INSPECTION FORM ASSESSM[INTS
PARTC
SYSTEM INFORMATION(conQ;�
i�opert�r Address: ��D _
���
rc
Owner. G✓/`C n
Date of Inspection: �oZ
BOICDWG SEWER(locate on site Plan)
Depth below grade:
Materials o[const
mc,�i
Distance from on; iron _p C.
Corm(� . %,sq*well(Mr suction line;other( �)'
vendr
& of lea ,A etc.):
SEPTIC TANIG e_� .
/ site plan)
. DqXh below tea°: `30
if tit mew 11,i aid:— Is age oonStmed by a Cenifigie of Complies(yes or no
Sludge >C ) _(attach a copy of
Dhftwg
�tOP to bottom of •�
Scnnr � � , outlet tee or battle; �/ •
Distance h�bottom of tV of o�tee or bale:
me dimen*M tee
How vml
outletComiments �
fated on P°mPng naooa me .inlet and C'eLi
outlet invert, et tee or 1>a�le conditio
H ✓L! r y no wee I etc.): �[n,structuml integrity,liquid levels
a N Givr c� R 4-
GREASE TRAP;/ on site plan)
Depth below grade;
Material(explain)of construction:—concrete_metal_fiberglass
Di Polyeklene_other
Scum mensions:
ehiclmej ;
Dim�bow of top of outlet We or bafrle;
scum to bottom of outlet tee or bn81— e•
Commee Pumping(on put4 ------
png�ndatioM inlet and outlet tee or
��>�to outlet invert,evidence of leaks battle condition,�uchirat Se,etc.): uftgity, liquid levels
• PAR08of11
OFFICIAL INSPECTION FORM-NOT FOR VOLU14TAR.• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECI'IO ASSESSMENTS
PART C N FORM
SYSTEM INFORMATION(contra,
Propert'A//ddrZE02,14j1,1a,,, ti 4
Owner: �liti/ � oa�3o
Date o(In3V=0a —/,t- o
TIGHT or HOLDING T (tank mug be ,
Pumped at lime of inspection)Qopte on sift Plan)
Depth below grade:
Material of cons ion: commw metal
�P�_._._polyethylene o�(explain):
Di neasions:
Design Flow; � � F
Alum
lev PMM(yes or noA)larm in
Date of last puffing; w°f°g odw(ya
Comments(condtim Of alarm and float switches,etc.):
DISTRIBUTION BO e
7K. (ifPreseat mus be ope Wocate on site
/ Pam)Depth oflignidlevel above outlet invert:l�O/✓`z� L
Commerus(note if box is level and distnbu n to outlets equak any evidence of solids
leakage' to or out of box,etc.): YOVer,any evidence of
Levi� do
PUMP CHAMBER (lopte on site
Pam)
Pumps in worldng order(yes or no);
Alarms in working order(Ves or no): M
Comments(note coa ti(m of pump chamber condition of
' PmPs and appurtenancM ctc.):
a
r.,
t Page 9 of 11
' OFRCIAL
' SUSU INSPECTION FORM_NOT FO
SEWAGE DISPOSALS S VOLUNTARY ASSESSA�NT3
SYSTEM IlITSPE
Pao SYSTEM�P MTA CTION FORM
'Adder TION(contim
All
t �' �✓ vl G L �fKvl
Date ctlnsp on:
S
SOIL ABS0RPn0N SVSTjM
s
AS)' (locate on site plan. avatlon not
If SAS not located Baia why required)
Type
leading Pftnumber
leaching
' e""s'number ��o ti
ov«thow cat
77— Munter
etc..)., (n0le CO=Won of soil,stiga of
technology:
1,2
H �/ c Affu,�level of
ponding damp soil,con
_ fton
Pumped as part
Numb and cow of mvection�l�on site plan)
Depth of s�o 6h�on:
li wet invert:
Depth of scion layer
Di
? -oils of cesspool
�l
c 'on ofc gmaftundIcwtaion inflo
°u (note conaaO fowik
hYdraulic fail
tme,level ofpodg.condition ofVegeWoq etc.):
P$I'y : site QU Plan)
Matedais of consftcpon
Dimensions:
Depth Of soli
ds:
Comme (note
on of soil,sig[ts of hydraulic failure,level ofponding,condition of v
egetatioq etc.):
/ Cj
PaSe 10 of 11
OFFICIAL INSPECTION FORM_NOT'FOR VOLUNT
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INS EC ASSESSMENTS
PART C "I'ION FORM
SYSTEM INFORMATION(con¢imaeco
Property Addne
owner:—.A-
Date of inspection: _f_m—off'
SKETCH OF SEWAGE DUMSAL SYSTF24
Provide a sketch of ft sewage disposal system includin
benchmarks.Locate all wells within 100 ties
feet,Locate where to at least two Pem anent ladmarks or'
Public water suPPIY enters the building
O
t. t ,
O
33
JA
0
�9
f ,
i
PaS+e l l of l l
. S
OFFICIAL INSPECTION FORM T NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
n SYSTEM INFORMATION(contra .
Pt+oPett9 Address: ® / / r/ ,/?4 k j,7 �Q f
&Ate of impection: /— c; =
SILIM Lum
Slope
Surface water
Check cellar
Shallow wells €a 4
Estimated depth to ground water 6'b?,
` v
Please indicate(check)all methods used to determine the high ground water ek ration:
ONOW from system design plans on record If checked,date of design plan reviewed:
site(abutting property/observation hole Within 150 feet of SAS)
Q =Checked with local Board of Health-explain.-- Y"'A/p S
— Checked with local excavators,installers(Mach doca6wrtation)
Accessed USGS database-explain:
You must 0
how you high ground vfater dev J
v o V7
�o K H w d 6 �✓ c�'c. c� ,
�j ��7
e 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 k- L, Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Re airs o f'• Iterations(Answer when a pl�'cable) V& `mil t rCJU A 1 0 N
I-ep ck ► : a!� ► c.� 71 LlC C A-,* % U e c,,j
- .nf j o1,C '
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 S of Pe Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is b s d of th.
Signed Date 6 6
Application Approved b Date
Application Disapproved for the following reasons
Permit No. '" Date Issued '9 " ;-:rod &
- --1---- ---------------- ---------
THE COMMONWEALTH`OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C TIFY,,that the n-site Sewage Disppsal'System Constructed( Repaired( )Upgraded( )
Abandoned( )by ON S IC C IA C.)t4 ►�.,
at /-3 v'7 A/L c- n c}rr n has.been constructed in accordance
with the P�vision of TitleAand the for Dis sal System Construction Penmi , � "' ���dated �► ' / 6��t l
Installer ic,c 4-L l IV ► Designer
The issuance of this permit shO not be construed as a guarantee that the syst ill des' ne
Date C Inspector
--------------------- ------ -----
Na X�3Q� � Fee
THE COMMONWEALTH OF MASSACHUSETTS.
PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS
Mfgpogaf *pgtem Construction Permit :77 �1-. 0,0Z-►va7
Permission is hereby granted to Construct( )Repair Upgrade( )Abando ) r
System located at A-'' AIAt 0-.-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and-the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of thi t.
Date: —Approved
NOTICE: This Form'Is To Be Used For the Repair Of Failed j
Septic Systems Only. ---------------
CERTIFICATION OF SKETCH kiYD APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PM- IIT CW=0UT DESIGNED PLANS) #.
o AA .
I, � h (��e hereby certify that the application for disposal-works
construction permit signe;.d by me dated �j�f /0J_ concetzinQ the
property located at -� AI A tL Y (7 y WJ- V L meets all of the
following criteria: Ir
• The failed system is conne^ed to a residential dwelling only. There are no commercial or business
uses associated with the dwelline.
• 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 wirhin 100 fee;of the proposed septic system
• . There are no private wells within 1140 fey;of the proposed septic system
• There is no.increase in flow and/or change in use proposed
• There are no variances requested or ne r+ed.
• i ne bottom of the proposed leschin;facility will not be located less than five fe"above the
tnasimum adjusted groundwater table elevation. (Adjust the zoundwater table using the Frimmor
method when applicable]
• If the S.A.S. will be located with'_40 fee;of any vegetated wetlands, the boaom of the proposed
leaching facility will not be located less than tureen(14) fee;above the maximum adjusted
roundwater table elevaLlon,
Please complete the following:
A) Too of Ground Surface Sievation(usng'GIS information)'
B) G.W. Elevation _the ALA C. ;sigh G.W. Adjustment . _
D �E`i C.c BE--W EZ A and B � • � .
SIGNED
(Sire;ca proposed plan of s✓sent on back].
a.3' x � ^1�M.- .,s`fi;.-ka „y: < t - Yr 4 3. ^S 'v^ ..,..,a+•."� s...sK -�..;r,i...•:t...f'7.�-^iR � iE '�c4 T}�'�'3 `� 't` .��. ..sec ,:,.�. -� '4 tn4f. -4' �+...- ,.� _ ,erns""'�y ml
1.30, TOWN OF BARNSTABLE ( v
• ' LOrATIONzO.. 7� 011e!/� SEWAGE # LVO I- qO
VILLAGE. 17 taldc ASSESSOR'S MAP & LOT 3 3 y -Z-1
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) X
NO.OF BEDROOMS 3
BUILDER OR OWNER -A I l o rl�{J
PERMITDATE: - 1 I COMPLIANCE DATE: Zt D
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet`'
Private Water Supply Well and Leaching Facility :(If any wells exist
on,site;or within 200 feet of;leaching,facility). Feet. .
Edge of Wetland an aching FadlityA any.wetlands exist
within 300:f. leac ' facili Feet
Furnished 6y
. I
1---
. _ I
TOWN OF BARNS'TAI3LE
COCA �D / D SEWAGE # Z-W :3
VILLAGE /'�/ /.° � . ASSESSOR'S MAP & LOT 3 3 4-2-1
i
INSTALLER'S NAME&'PHONE NO.6�tio S 0112?
SEPTIC TANK CAPACITY //
LEACHING FACILITY: (type) Sf 1 CZ - C'9 (size) _13 eV
NO.OF BEDROOMS 3
BUILDER OR OWNER /4 I(�r►�� _
PERMITDATE: G J I COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well andLeaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland an aching Facility 'any wetlands exist
within-3 f leac ' facili Feet
Furnished by —
, > ZI 7 ��
No. G� I" G� Fee �Cf%
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippliLotion for Oigpogal bpgtem Congtrurtion Permit
Application for a Permit to Construct( )Repair( )Upgrade(. Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. V'7 D U lv 14 Owner's Name,Adjsse�d Tel.No.
sAw04 6�d4-(�( t
Assessor's Map/Parcel 3 3 L/— o C)d� 1 \3 0 7 01 10-Kt.( t'J U N a
Installer's Name,Address,and Tel. o. 77 Designer's Name,Address and Tel.No.
j�vN "vI77 �o
aG v&1\e. NLb hi10, e
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 Rerirs or Alterations(Answer when a phcable) hd`-a l 1 a "r-ciU GA-0
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 is b s d of lth.
Signed Date 6 6
Application Approved b Date
Application Disapproved for the following reasons
Permit No. �°� � Date Issued
Fee F �7
in
�'•:
THE COMMONWEALTH OF MASSACHUSETTS tered incomputer: Wi
le-
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for Migo!gal *pgtem Construction Ver tit
Upgrade Abandon( ) ❑Complete System ❑Individual Components
Application for a Permit to Construct( . )Repair( )Upg ( p y po
Location Address or Lot No. /3 V-7 U 1V t4 Owner's Name,Address a Tel.No.
SAwhK t, (l� M 'e
Assessor's Map/Parcel 3 3 L/_ C)dZ�, _ C)0 1307 k1j A h k r)V W N rL 4
Installer's Name,Address,and Tel. o. 1,/7"7,— U,�'� '� Designer's Name,Address and Tel.No.
IZ� I� S � iCGl4� 1tiS /r t R
Type of Building: 3
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 k� C,' Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
Nature of Re$airs orA/lterations(Answer when an 1-cable) �!Y S� "%� 02` .S'�-►(i GA 0 U u
-P A C ft ! ',r��'`G G 1 f¢f1 e�r L�t yi C� f' o ,,,,g t U C. W
t O tz
Date last inspected:
Agreement:
The undersigned agrees tb 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 is je b this oard of! ealth.
Signed /I Date 6 /,:1�12
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued
————————— ———————— — ————————————————
THE COMMONWEALTH'OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CF TIFY,Is
the On-site Sewage Disppsal'System Constructed( Repaired ( )Upgraded( )
Abandoned( )by 'C y � S K C M cj ra� i Ai C; "
at /3 v 7 k /L YJ u iv rL- / has been constructed in accordance
with the p�gvisio ;of Title 5 and the for Disp�sal System Construction Permit o 4W — 'X0dated
Installer} [(4JY�11 1C:C z4.u Ea- i+�q t Designer
The issuance of this pe t s al"1 not be construed as a guarantee that the syst ill %�s des' `ne
Date �� Inspector
i"
No.;FyQl� �U� ------------------------Fee
G� THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migooar *ps�tem Congtruction Permit 7:F Y^ aOZ--00 7
Permission is hereby granted to Construct(�vJ)�Repair Upgrade( )Abandon,( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of thi t.
Date: /"` 0V Approved
U6i99
NOTICE: This Farm Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SI{ETCH A.t`TD APPLICATION FORA DISPOSAL
WORKS CONSTRUCTION PERtiIIT (VM'HOUT DESIGNiED PLAYS)
}
I, {'1 f' ► e!'n• he:eby ce Zi1y that the application for disposal works
construction permit signed by me dated concernins the
property located ar Al A rL L( 17 y w meets all of the
following criteria:
• The failed system is cone:-zed to a residential dwelling only. T-nere are no commercial or business
uses associated with the dweilins.
• The soil is c!a_ssified as CLASS I and the percolation race is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 fe`;of the or000sed septic s+sem
• There are no orivate wells within 130 fe`t of the proposed sepdc srsern
• There is no,increase in flow and/or change in use proposed
• There e are no variances requested or needed_
• ine bottom of the proposed teaching facdlity-will not be located less than five fe_;above the `
ma.=um adjusted groundwater table e!eration. (Adjust the 2--oundwater table using the Frimntor
meshed when applicable]
• If the S.A.S. will be located with 2,-50 fee;of any vegetated wetlands, the tonorn of the proposed
leaching facility will not be located!ess than ,ouneen(14) fee;above the maximum adiusted
uoundwater table t!evation,
Please complete the.following:
C->
A) Too of Ground Surace Elevation(using rm CIS infoadon) ''S
6) G.W. Elevation -the NLa (. :L.igh G.W. Adjustment, _
Dl'r ERENCE BETINEF`+a and B
SIGNED : DATE. /
(Sk;e ch proposed plan of 5-;stem on bac!cf.
q:icaith;oldc.:zr,
yl-
IV (�
C
1 �
Lk
yr
L` C-A T IONP S E G U PE RMIT N0.
=b
.VILLAGE
INSTAALER'S �NAME", -& ADDRESS F
Lo-
B U I L D E R OR OWNER"
OA T E P,ER.MIT ISSY tll) 7
DATE- COMPLIANCE" ISSUED -,71-3•-7Q
,L
b
a x
L iy�y
Fizic
THE COMMONWEALTH OF MASSACHUSETTS
C��ZId� BOARD OF HEALTH
Power..................OF....... ' � _.....---......._...---•-
Appliration for Bispos ai Works Tons#rnrtion 1hrmit
Application is hereby made for a Permit to Construct ( v) or Repair ( ) an Individual Sewage Disposal
System at: ��h S k`/e �T
_.®r-�..�✓ ..... ® ... ....._........... ........ ........L - .........................._......
Locat�io`n/-A�ddress�j r� or Lot No. 1. �¢ y� �
.... ................................ . ----Leah C .4,J ......---...x....`.�..Ee!5<.. :!!! .:..........
Owner P �j,/'p� ` ' / Address ,p
eV. ee! ��. ....E�`�-O 14 J`4 �/----•----��!�s. ...............
Installer Address ,��,�
Type of Building Size Lot____Z� ..------------St1-fw+
a Dwelling—No. of Bedrooms---
........... ........................Expansion Attic Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p" Other fixtures ...........................
W Design Flow.............s3,.Q---------------.gallons per person per day. Total daily flow............ -_.__..._.---._-___gallons.
WSeptic Tank—Liquid capacity/MO.gallons Length--------------- Width-----------_.... Diameter.-_____.••__-___ Depth._--_-----•---__
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-------------------- ft.
Seepage Pit No-----_------------- Diameter..-,,/6 0------- Depth bel4iinlle ...�______....Totalleachin area.,0e-2----sq. ft.
Z Other Distribution box ( ) Dosing to � ) 6, / G �',2�-7fPercolation Test Results Performed by .�f.. .--------------------------- Date--- ��- -------
Test Pit No. I�-)�_--minutes per inch Depth of Te .._� Depth to ground water..:t� ... .
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...............
--------------------.----.---------------..._...........i.......*--------------------�;-----------------------?---------------
✓`OA/ Description of Soil.... /........... l ---.ti � � .. � ..............
....... f ---.....
ry .. .g /�
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 TL ITf:w, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of lth.
Sign `.. 3 - .................
._.. _......R-
Application Approved By--------- --- --- --�-------
-------------------------— Date ....
Application Disapproved for the following reasons----------------------•----------------------------------------------------------------------------------------
--•••-------------------••-•---------•----•-•---....-----._...-------•--.................------------------•--------•-•--••------•---------------------------......-------••-----•-- ...............
Date
PermitNo------------------------------------------------------N � �IssuecL-•--------------------------.. ��....
Date
VPP1
No.. .. .1�.1...... FEz...� ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,� rlira ilai� for 11isp,agal Works C ontitrurtion rrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
..... . _='? ._. ...... ►........................ ----................... �..........................................................
Location-Address r
,
o t No
....:.::..:. .... / ' ++ :�............
ow Address
Installer Address
Type of Building Size Lot.___ •..:: .......:._
U Dwelling—No. of Bedrooms.............. _________________-------Expansion Attic ($ Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures -------------------------------- - _-• ---•--
W Design Flow___.._ __J,3.,1 ___ ______gallons per person per day. Total daily flow _.._ + _..gallons.
WSeptic Tank—Liquid',capacity��'?a6�.gallons Length________________ Width---------------- Diameter................_ Depth___:.______.__--
x Disposal Trench—No_.................... Width _._._.__._. _ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.... " ______. Depth below 4inl otal leachin area__a�K:��t_..__sq. ft.
Other Distribution box ( ) Dosingz Percolation Test Results Performed by._. .._ ____._____ Date_: ` °" _...
,--a Test Pit No. 1/#. __minutes per inch Depth of Test P ..'____. Depth to ground water � _..
(i Test Pit No. 2......_'_"........minutes per inch Depth of Test Pit................_..... Depth to ground water........................
O Description of So>1C.� _ y" ' ,+ �� ------------
x �{
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 TI:L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss4ed by the board of 1111alth.
Sign d-- -- ' - -- ------ --._.... ._.. ............................ ...... ......... ..
Application Approved BY---- ^' r .._. :. --------.••......---
Date
Application Disapproved for the following reasons--------------------------•----------------------------------------------------------------------------.....-•-•-
...................................................... -------•-----------------•-----•-------._...--..•.-----------------•------------------------------------------------- _...
Date
PermitNo......................................................... IssuecL
Date
T.H`E„COMMONWEALTH OF MASSACHUSETTS
BOARD. OF EALTH
r
..-. OF..... .......'. .- .. �i*'. ................. ........
;.. �� i��rtt�� laf (�la�t�liaitre
TH TO CE IFY, That the Individual Sewage Disposal System constructed ( J or Repaired ( )
at-•«_ l .__ i_�� allf�--w l-"-'iCr has been installed in accordance with the provisions of TI r 5 of The State Sanitary Code as described in the
application for.Disposal Works Construction Permit No.__� -�_�_�._______._. dated_.7. z3`t74` _ ______________
THE ISSUANCE OFJHIS,.CERTIFICATE SHALL NOT BE CONSTRUED AS A%GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector::___________-•-------------------- ...........................................
THE COMMONWEALTH OF MASSACHUSETTS
F BOARD O -HEALTH .
OF._..---... :_- --------------------------................................................... 4
No........ FEE....._.:.
- .
prkii onstrudiatt Trutt
Perm> slon s ereby ranted.•-- L ------ ----- ----- .....-------
to Constr t
D_i sal System
►a �
Street
as shown on the application for Disposal Works Construction Per Na __ ADated____ _ _' '________________f Healt
DATEcad{ ...............................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
7a �� W
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3
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24 -14
407- # QQ
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rgi�I�G'
&�/HeAI T� ,
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n�orF— EZEVs�nnys [�s�v �� CERTIFIED PLOT PLAN -
wcmim
EDWARD E. KELLEY PLAN !OFFER04CE dE7NG..laT.�l . . .. .
,
CUMMA um, 02637
SNow/v a/v :� jJGt!�i •Fad.
4.3
I CERTIFY THAT THE �• . .
SHOWN ON THIS PLAA � ON THE OROIiNO
AS SHOWN HEREON Al IT 6ONFORMS TO THE .
G sl
Y SETBACK 1NS OF THE TOWN OF
�� � WHEN CONSTRUCTED.
3/Z�'C'S LAti� DATE A� .. .
PETITIONER: QAAli 7`A43C.6c`
REa1S 'Zft]FD LANA SURVEYOR
Z. BG Z 5W&eT-5
L.
��.00
TOP OF FOUNDATION CONCRETE COVER
CONCRETE COVERS
e,
4 CAST IRONr�lr •
'° PIPE (0R 12 MAX, 12"MAX.
• 4 ORANGEBURG(OR EQUIV.)
EAUIV.)— MIN. PIPE- MIN. LEACH
' PITCH 1/4"PER. PITCH 1/4"PER.FT PIT PRECAST
LEACHING
p' N VEST
a EL.. oQ., INVERT INVERT PIT OR
SEPTIC TANK G�a.o7. DOST. ELA7.3c, . % >= EQUIV.
o INVERT B0l( .. a. Q: to
!a 40. .. .. GAL INVERT INVERT e' w 0: :,�: 3/4'�TO I V2
EL. :. .. EL.G T�7 W
'o EL64,/q �+ p 0' r,� WASHED
o U.
W \. eP• STONE
DIA.
PRQFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
pRRL,o m OM&no V
SOIL LOG WITNESSED BY :
I-1-� y•
(0A BOARD OF HEALTH
DATE .. . ,. . TIME. . . . . . . .
TEST HOLE I TEST HOLE 2 Tj-�o!�a3 �, •��?�-t�"� �< ENGINEER
ELEV. . ��./o . . . ELEV. .
n DESIGN DATA .
gL ,NUMBER OF BEDROOMS
TOTAL ESTIMATED FLOW . .`��. . . . GALLONS/DAY
rf3
BOTTOM LEACHING AREA 74?-47? . SO.FT. /PIT
SIDE LEACHING AREA . . .� •°�`? SQ.FT./ PIT
' D S D GARBAGE DISPOSAL .NOV4 .(5O% AREA INCREASE)
TOTAL LEACHING AREA . Z`7�oa SQ.FT
, ,, PERCOLATION RATE . . l!2�!��.SS� ,� MIN/INCH
- - - -
LEACHING AREA PER PERCOLATION RATE . . SQ.FT.
.!VQ.WATER ENCOUNTERED
NUSLEACHING PITS . . .�.�%.9. !
o T 5'TDi�E" TW A9 F,KELLEY CO.
APPROVED . :'. . . . BOARD OF HEALTH w" Fes: ? a 3 ��—SURVEYORS
oi✓ At. . -Y/jk".. RIVE
146 L �r ON POND D
DATE . 'SO�l"X`f t Y-Alkmot T'1 l MASS.
AGENT OR INSPECTOR 03664
-V�f]F Ay,�s
teOIr
T s��� c THOMAS
1 U EfARD �� KELLEY �.
KELIt Y -' A 9o.24260 O
9
PETITIONER : 6 � D �`