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1408 MARY DUNN ROAD - Health
1408 Mary Dunn Rd. , Barnstable A= 335-056-002 r" A d' G� I I' . RECEIVE-11 f COMMONWEALTH OF MASSACHUSETTS ^(� , EXECUTIVE OFFICE OF ENVIRONMENTAL AFF.'IRS APR 1 1 200a 1 DEPARTMENT OF ENVIRONMENTAL PROTEC IVNN OF BARNSTA13LE HEALTH DEPT. TITLE OFFICIAL INSPECTION FORINI - NOT FOR VOLUNTARY ASSESSMENTS S.T'BST-RF.Ai�E PART A CERTIFICATION 33 5 MAP ...- Property Address: lT r hn p/ ©O2 PARCEL Owner's Name: Owner's .address: Or _ LOT � - - r�t Date of Inspection: -/—C>3 .Name of Inspector: le e print /1 G Company Name: ; NIailin'g..-ddress: Cc /t E. rK 0,P63& Telephone Number: CERTIFICATION STATEMENT cernfv that I have personally inspected the sewage disposal system at this address and that the informadon reported belowis true. accurate and complete as of the time of the inspection. The inspection was performed based on my trairung 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 CNIR 15.000). The system: yPasses Conditionally Passes Needs Further Evaluation b e Local Approving Authori:%• - ils ,/ Inspector's Signature: Date: `t — 'd3 Tne system inspector shall submit a copy of this inspection report to the Approving Authoriry(Board of Health or DEP) Mdiin 30 days of complering this inspection. If the system is a shared system or has a design flow of 10.000 trpd 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 authority. Notes and Comments .—This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSUP,FACE SEWAGE'DlSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property .address: r O•.ner: Date of Inspection: — — Inspection Summary: Check A.B.C.D or E /.ALWAYS complete all of Section D A. System Passes: v I have not found any information which indicates that any of the failure criteria described iri 310 CNIR 1�.303 or in 3.10 CMR 15.30 3 exist. Any failure criteria not evaluated are indicated below: Comments:,__.f B. System Conditionally Passes: One:or more system components as described-in;the "Condirional-E_ass -.s..ecdon need.to be replaced or- ^^ The s.st ^. u onc,om 1,ion of the re lacement.or_re av,.as.a roved..by;the Board of.Health.. ill pass. ..:..P.. P.'. P P PP Answer ves. no or not determined (Y,\'\7D) in the for the following statements. If"not.determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally -r.sound. exhibits substantial infiltration or exfiltradon or tank failure is imminent. System will pass inspection if the exis,inz tarik: is replaced Aith a corrtplyins septic tank:as approved by the Board of Health. `.� metal septic tank .;ill pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicarin2 that the tank is less than 20 years old is available. \`D explain: . Observation of sewage back-up or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box: System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced \-D explain: ,; The s�stem`required pumping more than 4 times a year due to-broken or obstructed pipe(s). The system will pass inspecnon'if(,::t i approval of the Board of Health). broken pipe(s) are replaced obstruction is removed \-D explain: Pate 3 of 1 1 OFFICIAL INSPECTION- FORM;- NOT FOR VOLUNTARY, ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL-SYSTEM INSPECTION FORM t , _. .PART'A CERTIFICATION (continued), Property address: l7o &411, Owner: Date of Inspection: — p3 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board_ of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health'deterriiines in`accordaiice with MO CNfR115.303(1)(b) that the system is not functioning in a manner which will protect public,healih, safety and the environment: Cesspool or privy is within 50 feet of a surface water , ' Y _ Cesspool or privy is within 50 feet of a bordering veeetated�•etland or a salt marsh '-. System will fail.unless.the Board.of Health"(and Public Wa'ter Supplier, tf any) deterriiines that the_.... .._:. system:is'functioni:n -in a manner-that=protects the public, safetyand`eiiNjfonttient ;. r _ The system has a septic tank and soil absorption system(SAS) and the SAS is,within 100 feet of a' surface water supply:or tributary to a surface water-supply _ The system has a septic tank and SAS and the SAS is within a Zone 1 of,a public water supply. The system has a septic tank:and SAS and the SAS is within 50 fee't of a private kater,supply-,vell_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more.from a prnvate water supply well!*. Method used to determine distance` "This system passes if the'weli'water analysis,performed at a DEP certified laboratory, for coliforin= bacteria and volatile organic compounds indicates that-the well is free from pollution from that facility and dlie presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5'pprrL provided that no other failure criteria are thQ,2ered. A copy of the analysis must be attached to this form. , u 3. Other: F Pate 4 of I 1 • OFFICIAL INSPECTION FORM —'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A'. CERTIFICATION:('continued) k S /� 1. � Propert}' Address: Art, p/ /A r... ON%ner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "ves"or"no" to each of the following for all inspections: Yes NXack-up of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /dogged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or wesspool ' uid depth in cesspool is less than 6"below invert or available volume is less than '! day flow Required pumping more than 4 times in the last vear NOT due to clogged or-obstructed pipe(s). Number _�f times pumped y portion of the SAS,_cesspool.or privy is below high ground«•a.ter.elevation. Any portion of cesspool or pricy is within 100 feet of a surface water supply or tributary to a surface water supply. _. _ E>'Lny y portion of a cesspool or priv v is within a Zone l of a public well. y portion of a cesspool or privy is within 50 feetof aprivate water.suppl:y,,well. portion of a cesspool or privy is less than 100 feet but o-T eaterthan 50 feet from a private water, supply well with no acceptable water quality analysis. [This system passes if the well water analysis. performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than _5 ppm. provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10.000 gpd to 15.000 gpd• You must indicate either"yes" or"no" to each of the followine: (The following criteria apply to large systems in addition to the criteria above) yes no _ — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered "ves" to any question in Section E the system is considered a significant threat, or ansN ered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 Cy1R 15.304. The system owner should contact the appropriate regional office of the Department. Page of 1 I OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTkRYi ASSESSMENTS SUBSU.RFACE•SEWAGE_DISPOSAL.SYSTEM INSPECTION FORM, PART•B CHECKLIST Property .-address: - - t • Ov,-ner: Date of Inspection: -/-63 Check if the following have been done. You must indicate "ves"or"no"as to each of the following: 1�es 0 - Y Purnpin, informarion was provided by the owner, occupant;or Board of Health /were anv of the system components pumped but in the previous nLo weeks.'?' Has the system received normal flows in the previous twoG week period ' ' � t 1/—Have large•voluines of water been introduced to the Oiem recently or as part•of this inspe6tion? Were as built plans-of the s�--stem-obtained and-examined?(If they were ndt available°not, ss\'/A).• •Y// %Vas the facility or dwelling inspected for stows of sewage back up:' .• ti NVas the site inspected-for stops of break out "- r 1, a ii W,-re all's%stein components, excludins the SAS, located on site L — %'ere the septic tank manholes uncovered. opened. and the interior of the tank: inspected for the condinon of the bafflesor tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from oxvner)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 bee-n determined based,on: no a /— Existing information. For example, a plan at the Board of Health., — Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distant: is unacceptable) [310 CNIR 15302(3)(b)) «� j` Page 6 of 1 I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSNMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEMINSPECTION FOR J PART.C SYSTEVF/INFORlVI�iTION d r Property .-address: � Q / r.�n - •, ' " Owner: Date of Inspection: - - 3 FLOW CONDITIONS RESIDENTLaL Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 C. 15.203 (for example: 1 10 gp f b d x oedrooms): qqo Number of current residents: _ Does residence have a.garba_e grinder(yes or no):A110 - - - .-••- a - Is laundry on a separate sewage system es or no): (&p[if yes separate inspection required) Laundry system inspected (v s or no): v Seasonal use: (yes or no): p %Vater meter readings, if a • ilable (last 2 years usage (gpd)): Sump pump (yes or no): , Last date of occupancy: -J-Q C O:•'l.NIERCIAL/II\rD L STRIAL Tvoe of establishment: Design flow(based on 310 CNIR 15.2.03):_. ...._.. ._.___.....__. d_.._.... - . .. .. _..._... Easis of de'sien flow(seats;`peisonsisgfr;etc.). :. Grease trap present(yes or no): Indusmal 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 occuoanc%- use: OTHER (describe): GENERAL INFORMATION Pumping Records Q Source ofirtforrnatior.: Qr,J�I /' DO". 09 ;(al Dkrs Was system pumped as pan of th pecrion(yes or no):7&5. If yes, volume pumped: OCP allonsI- How was quannry pumped determined? �5' zt O it K Reason for pumping: y�°a/` /I&n {1.44nee_ TYPf_OF SYSTEM Sepric tank. distribution box. soil absorption system Siri2le cesspool _Overflow cesspool _Privy — Shared system(yes or no) (if ves, attach previous inspection records, if any' Innoyanve!Alternative technology. Attach a copy of the current operanon and maintenance contract to be obtained from system owner) - _�Tignt tank, _A_nach a copy of the DEP approval n.' �,�.,Q�S V Other(describe): OO - 4'a p? /DQ, (;4/ Approximate age of all omponents, da e,.nstalled (if known) and source of information %Were sew•a2e odors detected when arriving at the site (yes or no):A Paee of 11 OFFICIAL INSPECTIOIN FORM — NOT TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM.I,NSPECTIO`N.FORM -PART C SYSTEM.INFORIVIAT ION;(coritinued) PropertN .address: � AA '< L �" 4: 4` ,•. Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 17 %laterals of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction on line: r " . Comments (on condirion of joints, venring,'evidence of leakage. etc.): SEPTIC T.kN*K: _(locate on site plan) Depth below grade: dy Material of construcrion: —concrete_metal_fiberglass Polyethylene other(explain) If tank is metal list age: _ Is age confirmed by a Certiifcate-of Compliance,(yes or,no) .(anach.a;copv of- certificate) Dimensions: t Sludsze depth: •� - Distance from top of sludge to bottom of outlet tee or'baffle: 'Z Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ r� Distance from bottom of scum to bon gm ggAf outlet tee or baffle: How were dimensions determined: &7Z a f/ Comments(on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels as rel ed to outlet invert evi ence of leakage, etc.): GREASE TRAP: _(locate on site plan) Depth below grade: _ \'laterial of consmucrion: _concrete_metal—fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: - t Distance'fiom boti6' ofscum to bonom'of out tee or`baffle. Date of last pumping: 'i} 3 k, ,:Comments Ion,pumping recommenclarions, inlet and outlet te1`6r baffle`tondition. stiu&6u l ihte^nry, liquid as re-lated Jo ouilet`invert, evidence of leakage, etc.) r. Pate S of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESS;INIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART-C SYSTEM INFORMATION(c'dnfriniied) / o'- t 101.44 1?4 a> a Property .address: •` � � - " - ' Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(iuc:ate un site plan) Depth below --rade: Material of construction: _ . ..concrete metal fiberslass_polyethvlene other(explain): Dimensions: Capaciry: eallons Desien Flow: oallonsiday .alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIB'L-`T105N.BO1. l/ (ifpresent--must be opened)'faocate.on site plan) Death of liquid level above outlet invert: Comments(note if box is level and disco upon to outlets equal, any evidence of solids cam'over.•any evidence of leakaze into gr out of box.,Vrc. L-e_ 1 G,,.2c/ Q• s1 i�bw �y eUe.14 PL1IP CT-L-OIBER: (locate on siteplan.) Pumps in working order(yes or no): - Alarms in working order :yes or no 1, ) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Paee 9 of I 1 OFFICIAL INSPECTION FORM.— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE.DISPOSAL, SYSTEM INSPECTION FORAM, PART C SYSTEM INFORi1L�TION (•conrinued). Propern• :address: NWtt, r Owner: , Date of Inspection: IL .AB SOR-PTIO. S1''STEavI (SAS): ✓ (locate on site plan, escavation not required) If S. - n t located explain why: W , u1 a✓e .� •-l-S wee �o�v eK /�n /'ease Type leachin_pits. number: leaching chambers,number: leaching Galleries, number: �1 aching trenches, number, length: " ✓leachins fields.number, dimensions: - D X7, ; p{a/`$ overflow cesspool. number: tnnovanve•'alternative sysier�t Tvpe.'name of iechnologti 1 Comments'(note'condition of soil; suns"of hydraulic-fadNiire, lei el of ponding;da-rap soi corid[tion ofvegetation. " etc.): S ed as not o e CESSPOOLS: m st be pumped as part oYf-utsPectio n1(locat - , 'onst[, plan) Number and confl2uration: Depth— top of liquid to inlet inve Depth of solids layer: Depth of scum laver: Dimensions of cesspool: ylatenals of construction: ; s - Indication of Groundwater inflow(yes or no): Comments (note condition of soil, signs of hvdraulic failure, level of pondinG, condition of vegetation. etc.): PRIVY: (locate on site plan) .%•Iaterials of construction: Dimensions: Depth of solids: _ Comments(note condition of soil, signs of hydraulic failure, level of pondino;condition of vegetation, etc..):' 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSiNIENTS .SUBSUUACE;SEWAGE,DISPOSAL-SYSTEM INSPECTION,FORM PART C SYSTENI-'INF:O.RMATI.ON' ((;onrinued)' Property .-address: N ca/ AA �p e Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide 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. .: D G O B o� G A-C- Iq ' A-0- ao-' -0- a3 A-E Y(y 8-E- 3a' A-F- 31' A.G - go' g t p,„ ! of ; OFFICIAL INSPECTION FORM - NOT'FOR VOLUNTARY' ASSESSMENTS SU,BSGRFACE'SEWAGE:bISPOS:�L`SY•STEM INSPECT-IO:\ FOR:I PART C ,�A S�'STnnE,IITNF/OR�I �TIO\ Ce'onti ued) Property .address: &6 4 ,t��SN11 A47Aa 0Ns ner: Uatc of Inspection: - — siope Sur:ace water Check cellar Es[;T.ated depth :o ground wa[er st feet ?!:astiindica[e (check) all methods used to determine the high around water elevation: I/Ohtamtd :Tom system design plans on record - Ifchecked, date of design plan reVle��ed: _ Obse-ved site (aburnng properryiobsen•anon hgle �x}thin 150 feet of S-%S) / ✓C:necked %vith local Board of Health-explain: 5•l�k:�'�' 4- P6s 10erG Tes �aecked ,�,[h local excavators, installers- (attach documentation) _ .-\..essed L'SGS database-explain: i Y3,.: must desloe ho" v u�established the hiah around «at r elevatyo'n': �f' D/a.� �5�i 5 'zrYto•� C' Ion: �. G/ 5S� _ K o c06rC& a,- ct I Af f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS }; DEPARTMENT OF ENVIRONMENTAL PROTEC RECEIVED s y Y APR 4 2001 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOWd ..PART A CERTIFICATION Property Address: N Ot AeY 11#10 rr►s Owner's Name: Owner's Address: . rn Date of Inspection: —C9 Name of Inspector: lease print) Company!tat Mailing Address: ,I .� � ash 3 Telephone Plumber: CEItTIFICATION STATEMENT l,certify':that I have personally inspected the sewage disposal system at this address and that the information reported below is true,Accurate and.compiete 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 systein.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: le Date: 3-2�-61 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 setitto the buyer, ifapplicab:e, and the approving authority, Notes and Coriiments' `w t E ****This report only describes.conditions at the time of inspection and under the conditions of use at that time.This inspection does not address hove the system will perform in the future under the same or different conditions of use. Page 2 of I I OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1qaw Owner- Date of Inspection: S�D Inspection Summary: Check A,B.C.D or E/ALWAYS complete all of Section D A. System Passes: —ZI have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any,failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,N�D) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound. exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level.in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced NO explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- Ma .M c%O+ l[ , Owner: Date of Inspection: 3` SDI C. Further Evaluation is Required by the Bnard of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water T Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the' system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance *"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3. Other: i Page 4 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1401",g&t Owner: Date of Inspection: -PI-of D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '-i2 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. -k Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No) The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no"to each of the fallowing: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply , _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well i` If you have answered"yes"to any question in Section E the system is considered a significant threat. or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 1 5.304. The system owner should contact the appropriate regional office of the Department. T'-1 t � .i. • nnnn Page 5 of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST Property Address: u,n�rt cal, P . T Owner:_ Date of Inspection: '�—Ot Check if the following have beer,done. You must indicate"ves"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant, or-Board of Health Were any of the system components'purnped out in the previous two weeks ? _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection'? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for.signs of break out? Were all system components, excluding the SAS,located on site ? _ Were the septic tank manholes uncovered, opened. and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum'' 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) (3.10 C1v1R 15.302(3)(b)) s • Page 6 of 11 ,. OFFICIAL INSPECTION FORIINI — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIVI PART C SYSTEM INFORMATION Properh, Address: �r,,n , Owner: Date of Inspection: —p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based on 310 CIMR 15.203 (for example: 110 gpd x #of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or no): �3 Is laundry on a separate sewage system(yes or no): Ab[if yes separate inspection required; Laundry system inspected(fv�e�s or no)/� Seasonal use: (yes or no):L L1 Water meter readings, if available (last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: o�Gl CO MMERCIAL/IND USTRIAL Type of establishment: Design flow(based on 310 CNM 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ I —' Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):y Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORIMATION . Source of information: 'Alas system pumped as pan of the 6specdon(y4s�or no): _ if yes, volume pumped _gallons -- How was quantity pumped determined? Reason for pumping: 7 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) _Innovative/Alternative technology. Attach a copy.of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attach a copy of the DEP approval' t� Other' describe ) Approxsmate age of all components. date installed(if known)and source of Lnformatio02 / Were sewage odors detected when arriving at the site(yes or no) -v T; . _ r ......... (i Page i of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Le& Owner: Date of Inspection: - -4f BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: !cast iron r/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: (locate on site plan) Depth below grade: 3�` Material of construction: Lo6oncrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:, Is age confirmed by a Certificate.of Compliance(yes or no): _(attach a copy of certificate) r Dimensions:_ �`_'�Iry- Sludge depth; Distance from top of sludge to bottom of outlet tee or baffle: cZ(0 Scum thickness: b''`,, Distance from top of scum to top of outlet tee or baffle: 16"" Distance from bottom of scum to bocta of outlet tee or baffle: —O� How were dimensions determined: .��ua /�it�aski %afs Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): GREASE TRAP:_(locate on site plan) Depth below grade: _ Material of construction: _concrete_metal_fiberglass___polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from,bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8ofII OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property address: lax z4- a ad in Owner: Date of Inspection: —p( TIGHT or HOLDING T.INK: (tank must be pumped at time of inspection)(iocate un site plan) 1 Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity: gallons Design Flow; gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no); Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leak ge into r out of box, etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances,etc:): R Page 9 of 1 1 OFFICIAL, INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,` SYSTEM INFORMATION (continued) � A Property Address: 66 "ey &'t�a(, Owner: Date of Inspection: — SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tvp " leaching pits, number: . leaching chambers,number: leaching galleries,number: aching trenches,number, length: :Zlleeaching fields,number,dimensions: �. ,ia.vqPI'tnlTa�� overflow cesspool,number: innovadveialtemanve system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): pt'i to :-... ". .�-� �'� a -{V < CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n J Paee 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAIN C SYSTEM INFORMATION(continued) Property Address: Owner: Hate of Inspection: SKETCH OF SEWAGE DISPOSAL. SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all weds within 100 feet. Locate where public water supply enters the building. Y+ G C A .e_ C o� - '�= 30L` = Iq' i 10 Pale I 1 of 11 OFFICIAL.INSPECTION FORM — NOT FOR VOLUNTARY ASSESSNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �/ SYSTEM INFORMATION(continued) Property ,address: TO��,��11dt Owner: Date of inspection: _R-023za SITE EXAM Slope Surface water ' Check cellar Shallow wells Estimated depth to eround water 5_0 Meet Please indicate (check; all methods.used to detertrine the high ground water elevation: y Obtained from system design plans on record-If checked, date of design plan reviewed: -bserved site (abutting property/observation hoI within 150 feet of SS S) hecked with local Board of Health-explain: _ Checked with local excavators, installers-(attach dogumentation) Accessed USGS database-explain: — i r You must describe how you establis ed the high round orate elevation: ` TOWN OF BARNSTABLE 3,a 7p J cR(I SEWAGE #9 VILLAGE MMI T ASSESSOR'S /MAP& LOT al! INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) u�-n �S _ (size) LD (J C t ✓�� NO.OF BEDROOMS ,�" 's `J'`�'�- BUILDER OR OWNER C()T-cr(Nr-- ".PERMTTDATE: �-COMPLIANCE DATE: Separation Distance Between the: = ~" Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �Jw , �1 "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 ds exist within 300 feet of leaching facility) IL, Feet Furnished by 4m A At [Aim o d �(o A wJNn , `O t�t si,b s- o�� �; s rr� !3 �7 — No. D -___ - - - - - _.rl;' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Migool *pgtem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. C -A_� 4 Q)�C-C-_ c() C_ O..-- Assessor's Map/Parcel NOR O , M!/+r N ®N i n d `(I pb �M(� ���� Q-J- Installe's Name,Address,and Tel.No. l[- Designer's Name,Address and Tel.No. SCAC> �. ' 1�4 P l w- icr Aky c,.^^` S ar*C% 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 V soG Ck Type of S.A.S. Description of Soil r- Nature of Repairs or Alterations(Answer when applicable) Add _ I yq S tir? -\- 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 iss d by this BpoarkHtaW. Signed _ Date Application Approved by �3� Date Application Disapproved for the following reasons Permit No 2) Date Issued TOWN OF BARNSTABffLE SEWAGE e � ;.LOCATION ASSESSOR'S MAP &LOT .: VILLAGE '111 N O -o INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY (size) < <( C k 6�S✓�- LEACHING FACILITY' pe) NO.OF BEDROOMS C <-CAr— (' BUILDER OR OWNER �s I e11 • r COMPLIANCE DATE: PERMITDATE ; 1 0� Feet Separation Distance Between the: ng Facility �Adjusted Groundwater Table and Bottom an�Wells exist Feet M Facility (H y — gri�ate Water Supply Well and Leaching on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If ai►Y ds exist ` Fee, within 300 feet of leaching facili ) Furnished by �'A ►. p10 Y' C) ok, r<. No. -7 v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes 4 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for �Oigooar *pgtem Construction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C � v\9_I O er's Name,Address and Tel.No. r Cti C 0 r- C.r'C&_, _ Assessor's Map/Parcel NOR O nll ®,,j no n Installer. Narne,Ad§`ss,and Tel.No. - 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-'i Title Size of Septic Tank \©OU CZ-%` Type of S.A.S. Description of Soil Nat}re of Repairs or Alterations(Answer when applicable) Add (.i r�r'`�1��5CUf S �l R Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance wi6the 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 d by�this Boar . Signe Date a Application Approved by Date Applicatign Disapproved for the following reasons Permit No. 272 Date Issued ————————————————————————————--——-------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS t Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(V)Upgraded( ) Abandoned( by �bc(I �C C C'Gs. at k L1 o t''�G.T\./ YJ VI r-1 1�cd• C (iJ-;, ",'h L". 7 _ has been constructed in accordance with the pr �tisio of Title 5 and the for Disposal System Construction Permit No. = dated 1� r , - , j Installer f1 ��^^^-�_ M�5 S G CAC>4esigner The issuance of this pe t shall not be construed as a guarantee that the system will function as designed. Date - Inspector l -------- '-Oc5J. -------Fee�3O0.- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5pogal *pttem �tCon�truction Permit Permission is hereby granted to Construct( ))Repair(//)/Upgrade( Abandon System located at AZ6 T Py-r Y O V---r-- Rd 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:Constn}cr"ton ust�elcompleted within three years of the date of this pe Date: `� 7 Approved by. c����/?Z� 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 PERMIT (WITHOUT DESIGNED PLANS);. I, � cy ��t-t,�,•��/, hereby certify that the application for disposat'Morks construction permit signed by me dated �C�.�q '7 , concerning the property located at Mir 4N-n �J a meets'Al of the following criteria: t There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system Z- The observed groundwater table is' 14 feet or greater below.the bottom of the leaching facility R There is no increase in flow and/or change in use proposed —.. ere are no variances requested or needed. f SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. , t CXr��ao �`h .� LOT NO. : ADDRESS :^140-- j YflPI`( 1�oP OWNERS NAME: . SEWAGE PERMIT N0 /0-5 NEW: REPAIR:_ DATE ISSUEDS—t-66 DATE INSTALLED: 8(7-85 It7STALLERS NAME : s �' INSTALLATION OF: WATER TABLE :/qA_FINAL INSPECTION BY: DRAWINd OF INSTALLATION ON REVERSE SIDE : `nNi ICAO GAL'dT - e�w,G�,L!CEp��sRw+� _ �etiiNla i o 131 - �3�3'04 �i�� f�TDNir � pWEL�-tN(9 i e L 10N _ S E W A E PERMITA. _MQ. VILLAGE I N S T A LLER'S NAME S ADD E S S r F N o a �2T� BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 4 No. QS '7QS Fini ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .... ... ..... ............................. . .. C ...... .... _OF............. Appliration for Dispasal Workii Tomitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ......................... Lnp........................................ <_ Location-Address or Lot No. ..........P_d�.Xr_ a.........C0_C—_e._>.V—ja. ........ ............... -------------------------------------------------—----- Own Address K:�;; ...........�—Z. X .. .. . .. ........ ......... .....T—_ ✓ %)................... . ........................ ♦ Installer Address Type of Building Size Lot............................Sq. feet U ...S...............................Expansion Attic Garbage Grinder (Dwelling—No. of Bedrooms--- Other—Type of Building -----...................... No. of persons............................ Showers Cafeteria ( P4 04 Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------ Design Flow.......75<5 ...........:.........gallons per person per day. Total daily flow......._ a<9...................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width._.............. Diameter__._-___-___-__- Depth................ Disposal Trench—No..................... Width_....._......_...... Total Length.................._. Total leaching area....................sq. f t. Seepage Pit No--------------------- Diameter............._...... Depth below inlet.........__._.._.... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit------------....... Depth to ground water...._................._. Test Pit No. 2................minutes per inch Depth of Test Pit................._.. Depth to ground water........................ Ri ........................................................................................................................................................... 0 Description of Soil........................................................................................................................................................................ x ---------------------------------------*------------------------------------------------------------------------------------------- -----------*-----------------------**---------- ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable___.j4.Ve;7...zvlellv.... ...... ...................I............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 4 the provisions of 1.1 ME 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 healt e : :d Sig�ne� ............ .... ........... --- . .. ............... 7�1- S"57. ............... ate Application Approved By.................. - .. .. .................................. . .....Date ---—----- Application Disapproved for the fol ing reasons:.............................................................................................................. 6y" • .......................I................................................................................................................................................................................ Date PermitNo----------------------- IssuedL....................................................... Date ------------ —------------------------------------------------------------------------------ pr No....................... FRic............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....OF..... .... Appilration for Disposal Works Tomitrurtion "amit V Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ..... .. ... DV .2�r�....kJQ..... ...................... ......................................... Location-Address or Lot No. ........ .............. . ........................................................................ Own Address Own..7; ........�_.ca ......... ........ ........................ Installer Addresst Type of Building Size Lot.............................Sq. feet U Dwelling—No. of Bedrooms... ---------------------------------Expansion Attic Garbage Grinder 04 Other—Type of Building ..... ...................... No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow......��.......................gallons per person per day. Total daily flow......._Z. c�.....................gallons. 1:4 Septic 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. f t. Z Other Distribution box ( ) Dosing tank ( ) 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____._._......._..._._.. C4 ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ x U ........................................................................................................................................................................................................ ......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable.....l.tv-v -------a......STI k.,Z......... ....... Z...................................................................... .......... .......(_ ......7..... . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has befDiss=d_by the board of heal Signed.,_._ Date ApplicationApproved By.................. . . ......................................... ......... ...... Date Application Disapproved for the fol ..ing reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF..... ......................................................................... THIS LS—T-0,CER FY, That the-i�d�; idu4l Sewage Disposal System constructed or Repaired by................ ;;._• ......er.........t. a.�M-,:,i t ......................................................................................... at............ ns 7�5<........ . :�!Z .. 5P� _ _t�jne..........41��. . .............................................................................................. has been installed in accordanc'e with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_..._______._.._....._______.__.._..._._.__..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUADANTEE THAT THE SYSTEM WILL TUt4CTION SATISFACTORY. _— DATE._......... . ................................................ Inspector......... ........... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... ..................**.............OF..�......._"T ..... ................................. FEE.... ............... .................... Permission is hereby granted..��K. t...... .�.�an��rnnr�i�n ............ ........................................................................ to Construct or-Repair at No.............. ....... )6,a n Individual Sewage s al Sy stem / " * ..... --------------------------------*---------------------------------------Street as shown on the application for Disposal',Works Construction Permit No.9S�_7P_7 Dated.......................................... ............................... ------------------------ and ea th DATE---------------- —2.5 . .... ..... . .................................. FORM 1255 A. M. SULKIN, INC., BOSTON l0_t<�Art10N -`' SEWA PER 1T NO. . 'G 7-.tom lIrg,4% VA-"- ,lllf4 _ VILLAGE ,&AX?A4, 7_41 " INSTALLER'S NAME i ADDRESS . BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �` a2L � f No....................... Fim.... THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH �� ✓.................OF..... �� ! � Appliration for Ili;sposal Works Tonstrnrtion .unit Application is hereby made for a Permit to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal System at: ............................... �.� ��.�°.?15 � ......: ............... ` Location ,-,Address _ - .. .z4 F�................................... .. Lot , W wner �...Address �a �� a ...li d -----..6.r ....................•---......... r .... ......_..... Installer Addr s..... Type of Building Size Lot. �<<6., Sq. feet ng— ............................Expansion Attic ( ) Garbage Grinder � Dwelling No. of Bedrooms___..._.._. aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------- ------------•-•-•-•---------•-•---=-•----•••----------...••-•----•-••-------------------•....---••••----------•.....---------------- Design Flow........... 10........ gallons per person per day. Total daily flow____-_-..�-�O.....................gallons. W --� ,1 -- P P P Y• Y � - WSeptic Tank—Liquid capacity '...gallons Length................ Width................ Diameter---------------- Depth................. x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No....../___........ Diameter.,;e�..__..... Depth below inlet......6........... Total leaching area.., . .d.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY........................................................................... Date......................................... Test Pit No. 1................minutes per inch Depth of Test Pit.__,':~.......... Depth,to ground water.__-QbA24d-_-_._. f=, Test Pit No. 2................minutes per. inch Depth of-Test Pit...s ........ Depth to ground water-------- a ---------------•----------------..............-•-------- O Description of Soil................ .' i. ._ /l... •. - = s' '` !2-------------- x U Nature 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 iI'i U 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 heal Sign ..........�!.. -=-------------------- --- - - -- ---- ate Application Approved BY ...... ..... J ....... Date Application Disapproved for the following reasons:-------••-•-------------------------•---•----••-----•--------•----•--•------••-----•---••- -••---........_.... ...-------•...........................•-----•------...------........--------...-----------•-------•--....__........------------....--------------------------------------------------------------------- Date PermitNo..................................................._--_. Issued........................................................ Date No 1/V Fim THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH ... ........... ....................... .....OF......... . ....OF.......<Y.......................................................................... Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal 0e44AQ -C4,90 le.Ia.. _"d................................... .............**. ................. .00456czsnw��� or ..........*'**"*......------- C7 ............................................... ................................ ......................................;-..d............ ........................................ 2W.............. dcoo .................................................................................................. ..........0........................................... ...............0----------------------- Installer Address Type l of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........Z............................Expansion Attic Garbage Grinder ( Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( P4 Other ------------- ----------------- ----- ----- --------- --- ----- - --- ---------- -- ------ ------------ ---------------- Design 4%w..................................;;Ogmgallons per person per day. Total daily flow____......___. gal 1:4 Septic Tank—Liquid capacity.............gallons Length................ Width....._.__....... Diameter......_......... Depth....._......._.. Disposal Trench—IN Total leaching area....................sq. ft. --------_---------- Width, Total Length._.__....__�740. ............ e,"� Seepage Pit No.................... Diameter.................... Depth below inlet..............._..... Total leaching area....zej:�...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--------------*.............................. ..............*..... Date_.._... .......*...... Test Pit No. I................minutes per inch Depth of Test Pit____ ---- Depth to ground water.._ti.... .d...... Test Pit No. 2................minutes per inch Depth of Test Pit.._............._... Depth to ground water.__.....:'.'..........__. pifit ------;15; .........0.......................... 0 ---------- ------------ Descriptionof Soil-----...............................................................�Z ............................ ..............w.......... .0............ ...................................0. ;Z" .- - -A..................... U ........... -------------et-L;-7- 4.7. *------------------ ----------------C........... _1�4,ya W Ile 41,0*✓... Z ............................ . ............................................................. ---- -------- ............................................... U Nature of Repairs 6 r Alterations—Answer when applicable............................................................................................... .................................................................................................... ............................................................. .................................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposhl System in accordance with the provisions of'iTT , 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a CertiWcate of Compliance has bee e y the board Afrheallih. -----•------ .......... S d ignp ................................................ ................................... ................. .. V/ Date Application Approved By-------- ----- .................... ...... Date Application Disapproved for the following reasons:......................... ...................................................................................... .......................................................................................................................................................................................................... Date PermitNo......................................................... Issued.................................... Date THE COMMONWEALTH OF MASSACHUSE4TS BOARD OF HEALTH OF......... ...................... . ......... ampltanre .4.........................Tprfifiratr of TO CE.R FY, That the Individual Sewage Disposal System constructed (jam or Repaired bi A -et>............................................................................................................................................. staller at -----------7...................................................................... in accordXce with the provisions of 5 of The State Sanitary Cod6'as described in the -Y........ .....has been installed application'for Disposal Works Construction Permit N . ....... Z/ .............. dated_--.. ----------- 7 'f THE. ISSUANCE OF THIS CERTIFICATE SHALPNO�T BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL _.FUNCTION SATISFACTORY. DATE...... 'I. YA............................. Inspector....._._.,(;Z--- .............................................. THE COMMONWEALTH OF MASSACHUSETTS No BOARD 0 HEALTH .... . ........I—:...OF.........., ..................... .... ........ Fim..3644:!� - Pernii sion is hereby gr rited.:n... XI—P 's M, .................................................... to Cons r ct Repa' an di Sewage Disposa�System .......................Dlic 10 ?r r;ni�i�/t o D ted as shown on the applica ton for Disposal Works Constructien Pe ........ __/_/------- ...... Z,........... -- -- --- .............. oardof It DATE.............. ?/........ ................................ FORM 1255 HOIB13S & WARREN. INC.. PUBLISHERS lrl;�e' SNEZrT' / of Z 5Per7 5 1 / 4-Z lea i 0 51 Fy 7 Ilk 4-L-?V ��' Norte- EL�-�/i97�so*vs ? � �o`tea ��". RsSvMtrD DATv�y CERTIFIED PLOT PLAN LOCATION .!jj! �/sTA'T3�t';. /1,-ts s . / C o' 0 Z4 r a �. SCALE . DATE . .�T, . . .�. . 9. . . PLAN REFERENCE 43&7'-.!G. .407•y-3. . . . . . . . . WiGG/A/y � SWIFT �w�c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / I CERTIFY THAT THE �Sn�Ylr'..!�✓.vDA7so�v. / SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF ... . . . . . . . WHEN CONSTRUCTED. W/G-61" or,- DATE 0!0-r'. 21 IYAD . PETITIONER: 13q�,e,�/,$Tjr �E- /Lj/� S.S £: 9 REGISTERED LAND SURV OR I • w SFf�g7- z 2 S/fEyc�� TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS e; 47 CAST IRON 12� � r , PIPE (OR 12"MAX. 4��ORANGEBURG(OR EQUIV) EQUIV.)— MIN. PIPE- MIN. LEACH ° PITCH I/4"PER.FT PITCH 1/4 PER.FT PIT o ° � PRECAST J LEACHING EL.V4�T3�.. INVERT INVERT o o W oYi PIT OR SEPTIC TANK .off DIST. C EQUIV. c INVERT EL.. '`fig. . . . . BOX EL'9 47.. 8 /va o GAL. INVERT V a O INVERT W W 0: :,% 3/4"TO I I& EL.`I�.� • u.o o� e EL 4ti?c�o e.' W WAS H E D W STONE :. i3 s'olA. PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE PREd0AIlA�V SOIL LOG WITNESSED BY : DATE�.7 ./y8P. TIME.��)%Po /��e.G . C, /!'1cieeAy BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ENGINEER ELEV. '¢Z•�T. . . . . ELEV. •.Z. . . . /. Woo A'►y WooOGo/�r/ � Sol L sto6oSoo ` DESIGN DATA NUMBER OF BEDROOMS . . . . . ;-� . TOTAL ESTIMATED FLOW . 2 ZO, GALLONS/DAY 481, FINE BOTTOM LEACHING AREA SQ.FT. /PIT SAD Sq�✓o . SIDE LEACHING AREA SQ.FT./ PIT GARBAGE DISPOSAL NO^/! . (50% AREA INCREASE) TOTAL LEACHING AREA ZG 7 0 . SQ.FT PERCOLATION RATE 4q5S .7NA' MIN/INCH LEACHING AREA PER PERCOLATION RATE Z SQ.FT. ND WATER ENCOUNTERED NUMBER OF LEACHING PITS .J.P!T APPROVED . . . . . . . . . . . . . BOARD OF HEALTH �" "b�'rG/-S7>7�!� Q/��9'LC S/AES,.^,�•�'� 7r+N5 OF S7yNt' P�i2 P T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . . . . . . . . I L<�.(� AGENT OR INSPECTOR Of MASS ��P��H OF M9s T La i jy3. . . . . . . . . FDWACA R ,A No.Y42b0 2 1 J:)Q71H AS E.KELLEY CO. ENG' EERS—SURVEYOR cFs STE ����• NA PETITIONER : � ��� . . . Gg� 5.�`39 LONG POND DRIVE LEN tS VTU YARMOUTH,MAS SAI& r of= Z 5146€73 0 oh✓ up 2 -Sz ti� �e.''�'�- �y11 ��' Nort- �ZEN•9To.v.S 8/15CD CIA-) s CERTIFIED PLOT PLAN / asr LOCATION .l3f12,✓s /ys�s s . . . .. . . . . . .. . . . . SCALE DATE 0,4T..9. 198,. PLAN REFERENCE a�NG..40�ar3. . . . . . . . 2co,ea�-r� RL. B.C. . . . oZ• )j . 8.7 . . . . . . . . . . . . . . . . . . I CERTIFY THAT THE �Sn�!!�i . .:�✓FDA-no�v. SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF � ST9�iGC . . . . . . . . WHEN CONSTRUCTED. DATE 4Xr. 24 1400 PETITIONER: 43.9VW.S7;w�e4e- 55 �� r REGISTERED LAND SURV OR r-• SSG Z o/C- Z '5/1/- L. . . �4•.Q. . ... . TOP OF FOUNDATION s CONCRETE COVER CONCRETE COVERS e; 4'�CAST IRON 12� MAX. ° 12"MAX. '"�" TO. PIPE (OR 4"ORANGEBURG(OR EQUIV. ) EQUIV.)— MIN. PIPE - MIN. LEACH PITCH 1/4"PER.FT PITCH 1/4"PER.FT PIT PRECAST •. a EL..4�c3�.. INVERT INVERT na W SEPTIC TANK �/ DIST. 6 c INVERT BOX .. /8 Joao GAL. INVERT v c~ia 4 " INVERT w W 0: 2 EL9�• u-0 0 o o EL.46'.4? a.' u- �. PROF1 LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED BY : DATES �/80. TIME./�%oo I P !L . C, P2Ay BOARD OF HEALTH TEST HOLE I TEST HOLE 2 7aHf ; �LL�"/ !��'. ENGINEER ELEV. 4?AV . . . ELEV. 1�4.?". . . . �wsrizp. �, •�tx.iP.L S Woo DLO s, Toe$stl� DESIGN DATA 30' NUMBER OF BEDROOMS . . . t C TOTAL ESTIMATED FLOW . 2- P. . . . GALLONS/DAY BOTTOM LEACHING AREA SQ.FT. /PIT S�D S�h✓D SIDE LEACHING AREA . . . SQ.FT./ PIT GARBAGE DISPOSAL (50% AREA INCREASE) TOTAL LEACHING AREA . .E'G7-.0 . . . SQ.FT PERCOLATION RATE 'S .�?'"' .�° 1!4. MIN/INCH LEACHING AREA PER PERCOLATION RATE'?-. SQ.FT. No WATER ENCOUNTERED NUMBER OF LEACHING PITS .1.P/T W! i7)►/. jWo APPROVED . . . . . . . . . . . BOARD OF HEALTH DATE . . . . . . . . . . . . . . f� AGENT OR INSPECTOR L OF Mqs�� P��tl GFM9 �0T0.3. . . . . . . . tom' EDWA �, o trio AS a LEY CO EI�EY . . . . . . .` '+ >-1T,+ �T yOMAS E.KEL w/LUg1"7 f� SW/� � INEERS—SURVEYO No.T42 T �4EN r'' 9 PETITIONER ,tom =c��� of , R Q6J?'?�/STff�'! � ��ND �����F•� 6 LONG POND DRIVE& •css��NA f • SOUTH YARMOUTH� ,l o lJ