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HomeMy WebLinkAbout0207 MIDPINE RD - Health 207 MID PINE DRIVE, BARNSTABLE A= 356-017 _ v F c � C. No V� � C`iV�, Fee . / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: LO PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for �Dioonl *pgtem Congtruction Permit Application for a Permit to Construct O Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ndividual Components Location Address or Lot No. r�/ //���' �1��� Owner's Name,Ad ess,and Tel.No. 6XP�sr*6Z� StEVr- Assessor's Map/Parcel3,5 — 0/7 r �vl/�i'Dh'I c!/ Installer's Name,Address and Tel No.Sv5_L 60~ `� Designer's Name,Address and Tel.No. Josz/✓�i Ore 90�d j`Srd115 W"//s Type of Building: Dwelling No.of Bedrooms v Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 94—�P�� Ew Date last inspected: P Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate,of Compliance has been issued by this Board of Hea th. Si Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued nn Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH.DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS. Yes ZIppYfcation for"piq-.oal *p5tem Conotruction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ® nl dtvtdual Components` r Location Address"or Lot No. ® /��Gl /��% �� Owner's Name,Address,and Tel.No. �r�r�1 T!Q Lr' �> Assessor's Map/Parcel 3 S'(p— 0,./7 _ Installer's Name,Address,and Tel.No. _ a� Designer's Name,Address and Tel.No. Type of Building: _ Dwelling No.of Bedrooms r Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures J jA '' Design Flow(min.required) gpd Design flow provided gpd i Plan Date s Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) , Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea th. f Signed-- - Date r� Application Approved by _ Date Application Disapproved by: Date for the following reasons I Permit No. �— /"Q Date Issued THE COMMONWEALTH OF MASSACHUSETTS _ BARNSTABLE, MASSACHUSETTS (Certificate of Comptiancr c �� THIS IS TO CERTIFY,-that the&site Sewage Disposal System Constructed ( ) Repaired ( I ) Upgraded ( ) Abandoned( )by i D Y F at l a = Di4r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Cons ruction Permit Not " /G�7 . dated F InstallerJ4�1 &_ z5 59 0_ _5 Designer #bedrooms /y Approved design flow / gpd The issuance of this permit shall not be construed as a guarantee that the system will tuaction as desig tit 1 Date a(� Inspector —_ No r -�4 ' /(i�/ g� lf'i1 �/ Lf1U�f Fee : _r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS ligpofSal *p6tem ConstructionPermit Permission is hereby granted to Construct ( ) 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 co pleted within three years of the date of thispermit. i o Date � / Approved by r Commonwealth of Massachusetts Title 5 Official Inspection Form subsurface sewage Disposal system Form-Nat for Voluntary Assessments ipeftyA ® l �/��d� r Ownef s Name kdonnartion is �vrr��l y�� ®G(o.� C Z3 2p2 req�,ired for every 0CitylTotnm P State Z1p Code Date of Inspe6gon Inspection results must be submitted on this formh inspection forms may not be aftered in any way.Please see completeness checklist at the end of the form. IMSM Wit:When A. Inspector Information on ttte computer. �D�a/g-�D To�✓� oe5e only tl,e tab key to move your Name of Inspector offsor-do not ,use'ft return Company Name m Company Address �.N� d✓i�f �,� C�Z�G.3 City/Tawn state zip Code Telephone Number License Number S. Certification I certify that:I am a DEP approved system Inspector in full compliance with Section 15.340 of Title 3 (310 CMR M000);1 have personally Inspected the sewage disposal system at the property address fisted above;the information reported below Is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. 7❑� Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Falls �Z z3 z�zo Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shalt submit the report to the appropriate regional office of the DEP,The original form should be sent to the system owner and copies sent to the buyer,if applicable,and the approving atttttority. Please note:This report only describes conditions at the time of inspection and tinder the A, 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. > gs dcr r� 7.'a'612bt8 Till s OMM hmped w Force Subsurface Savage Disposal System•Page 1 of Is f ' t .' •c 7 Commonwealth of Massachusetts F Title 5 Official Insertion Farm Unurtma Sewage Msposd Sysbm Fom-W for Voluntary Assessments Addms Owners Name irftrtnatton is t®q&ed for every C. own �v«?��-ca u�9 11Z�37 1 ZS Zo Page � State Zip Code Deft of inspecMm C. Inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: i 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: -7 / A 2) System Condltlonally Passes: [] O r more system components as described in the"Conditional Pass"section need to be rep! repaired The system,upon completion of the replacement or repair,as approved by the Board lth,will pass. Check the box for'Yes, o"or"not determiined"(Y,N,ND)for the following statements. if"not determined,"please expla' . The septic tank is metal and over 0 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltra or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if k is s cturally sound, not leaking and If a Certificate of Compliance indicating that the tank is less than 20 rs old is available. ❑ Y ❑ N Q ND(Explain below)_ ftapaloc•mv.7/2 Mig rNs 5 OMCW InspOdw FOM Subwftw SeWage MSPNW Syatem•Page 2 of 18 Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1707 A ee Ale A; Property Address Owner Owners Name -� rfarma 1 �Ayn a q va'— eoz,{ requrred fbor every ar pop- City/Town State Zip Code ' Date d Inspection C. inspection Summary (cont.) pjl 2) System Conditionally Passes(cont.): ❑ Pu Chamber pumps/alarms not operational. System will pass with Board of Health approval if pum alarms are repaired. ❑ Observation of wage backup or break out or high static water level in the distribution box due to broken or obs ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass Inspection if approval of Board of Healthy ❑ broken pipe(s)a replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is rem ❑ Y ❑ N ❑ ND(Explain below): D distribution box is leveled r replaced Q Y ❑ N Q ND(Explain below): ❑ The system required pumping more than 4 times a ye r due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the B of Health): ❑ broken pipe(s)are replaced ❑ Y N ❑ ND{Explain below): ❑ obstruction is removed Q Y Q ❑ ND (Explain below): N(� 3) Fu+#he laation is Required by the bard of Health: ❑ Conditions exis able quire further evaluation by the Board of Health in order to determine if the system is failing to pro lic heap,safety or the environment. a. System will pass unless Board of Her ermines in accordance with 310 CMR 1S.303(1)(b)that the system is not functioning In a r which will protect public health, safety and the environment: ftapAac•rev.MAM18 Tine b OMM Inspeckm F mx subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsuirf M Sewage Disposal System Form-Not for VduMary Assessments Z07 �9 P. ✓c i o � Property Adam Owner Owner's Name Wzmation is repaired for every /2Zjz paw City bwn State Zip Code Date of ftmpecti n C. Inspection Summary (cons.) �� ❑ Cesspool or privy is within 54 feet of a surface water ❑ pool or privy is within 50 feet of a bonging vegetated wetland or a salt marsh b. System. H Mess the Board of Health(and Public waster Supplier, If any) determines that a system is functioning In a manner that protects the public health, safety and env oft ❑ The system has a tic tank and soil absorption.system(SAS.)and the SAS is within 100 feet of a surface wa supply or tributary to a surface water supply. ❑ The system has a se ph k and SAS and the SAS is within a Zone 1 of a public water supply- ❑ The system has a septic to nd SAS and the SAS is within 50 feet of a private wafter supply well. ❑ The system has a septic tank and 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,pe ad at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of monla nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri are triggered.A copy of the analysis must be attached to this form. c. Other. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"i+to"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool -rev.7 AMIa Title 6 Oftial iru peckm Fomc Subsw*m Sewage Disposal System•Page 4 of 1B Commonwealth of Massachusetts Tale 5 Official Inspection Fora Subsurface Sewage D System Form-Not for Voluntary Assessments Property Address owner's Name OftarMon is dxil,e?a g(/i>7 llZ� ftqtkvd for every � 17.113/2 0 Pew. Fqf own State zip Code Date of Inspection .C. Inspection Summary(cone.) A) system failure Criteria Applicable to All systems: (cont) Yes No ❑ r)6 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 day flow ❑ M Required pumping more than 4 des 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 tugh ground water elevation. ❑ tp ,j�� 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 water supply wen. ❑ d),4 Any portion of a cesspool or privy is within 50 feet of a private water supply wen. ❑ rV/k Any portion of a cesspool or privy is less than 100 feet but greaterthan 50 feet from a private water supplywell with no acceptable ptable water quality analysis. system passes if the welt water anailysis,performed at a DEP certified ldoratory,for fecal coliform bacte ft indicates absent 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 trre analysis and chain of custody must be attached to this form.] ❑ � The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system foe.1 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. N� 5) Large ms: To be considered a large system the system must serve a facility war a design flow '10,000 gpd to 15,000 gpd. For lard systems, t indicate eider"yes!or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 400 fee a surface drinking water supply ❑ ❑ the system is within 200 feet of a bib a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area erim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water s ly well aoc•rev.MAM8 rft 5 MW InspecUm Fom SL6wrft=sewage DkPosei system•Page s of 18 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Vduntary Assessments ;;?,P7 Property Address A owrw Owner's Name ktonnation is IWW for everyPOW City/Town State Zip Code Date of4nspectlon . impection Summary (cunt.) If you have answered"yes"to any question in Section C.5 the system is considered a significant ant threat,or answered yes to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional offices of the Department. 6, You must Indicate"yes"or"no"for each of the following for an inspections: Yes No ❑ Pumping information was provided by th owner, upant,or Board of Health ❑ ( Were any of the system components pumped out in the previous two weeks? i ❑ Has the system received normal flows in the previous two week period? ❑ } Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 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,exelndir@ a 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 t �/� �r �(SAS esite him awvrccl been determined based on: � i ❑ Existing information. For example,a plan at the Board of Heaith,�s efer ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable).(310 CMR 15.302(5)j •rev.7 is '� I26/20 TiBe 5 Olfidal Inspection FomC Subaurtace Sewage[risposei Syetem•Fie 6 of 18 Commonwealth of Massachuse#t -1 70 Title 5 Official Inspection Form subsurface Sewage Qispwid Sysfiem Form-Not for voluntary Assessments 2ex 7 Af,o A✓C�t?y Pmpeq Aftm OWM Ownees Name MMMonis for every �1-19y -41/10 �( /2 Z j Z O t'equusd for Citylrown State Zip Cvd6 Date oflinspeAn D. System Information 1. Residentlal Row Conditions: Number of bedrooms(design): ¢ Number of bedrooms(actual): DESIGN flow based on_310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: Z Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes r'Q' No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No i/p Seasonal use? ❑ Yes ' No Water meter readings, if available(last 2 years usage(gpd)): Detail: 3 d `live 9tA -T0Q14,j0/ 'DAv 1C �1+��a1 �� lea Ire Sump pump? dot e C�> .Qa 41' y ❑ Yes No Last date of occupancy: d Date CAVpdoc•mv.7f26=18 Tide 5 O&M Inspedw fow She Sew Dispose!System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage bisposai System Form-Not for Voluntary Assessments 2�7 �✓� Properly address omm Owner's Nam kdbrma&m is ,required for every it�K2I� 0 O�G�• !L L3 �o POW City/Town state Zip Code Date of rnspecdon D. System information (cont.) d1A 2. Comm%Estab dustriai Flow Conditions: Type oment: Design flow(based o 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(sea rsons/sq.ft.,etc.): Grease.trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes,discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tide 5 system? ❑ Yes ❑ No 'w Water meter readings,if available: Last date of occupancy/use: to Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No N yes,volume pumped: A/ *- gallons How was quantity pumped determined? 14 aj�" Al�l"4 N Reason for pumping: "kapAoc•rev.7r awle T tte 5 th cia;Irwcoon Fomt Subsurface Sewage Disposal System•pap a of 1a Commonwealth of Massachusetts Title 5 Official Inspection Fawn subsurface sewage D;SPOSM system€onm-Not for uduntary Assessments Property Address p /�'o✓Ci Owner Owner's Name blibrMation is required for every y"!'�Gd4a�0 / 3� ,2 Z 3 Z D Me. CityfTown State. Z)p.Code Dal of ins ction D. System Information (cone.) 4. Type of System: Septic tank, distribution box, soil absorption system ///❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Aftemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract [i Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all compo nts,date installed(if known)and source of information: . Were sewage odors detected when arriving at the site? ❑ Yes No S. Bu'dding Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑other(explain): Distance from private water supply well or suction tine: feet Comments( n rendition of joi venting 'dense of leakag , etc.): ;- 0 he MIMPdoe•rev.?Minis We 5 O&W Inspedon Fomr Subsurkne sewage ois mm system•page 9 of is Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage ffisposaf System Foam-1 for Voluntary Assessments Za/ kfloe-, /r XY Pmperi r Address oemer Owmefs Name ir4offnabon is �y�p�19C�yy l ZG� reauir ed for every /a Z 3 Zp paw City/ToM State ZIP Code Date of KupecGon Q. System Information (coat.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑metal ❑fiberglass ❑ polyethylene yl []other(explain) N tank is metal,list age: N/4- years -/ Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No AI� Dimensions: 6' v Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 y� Mow were dimensions determined? U, //— /#-/ gan ��UaC ,ftmments(on pumping recomm itand tee or baff)e% c�1tfl��ptegn#y� liquid rev relate #o outlet inv idence of leakage,etc.): 7� doc•rev.7126l2018 Title 8 of W Inspection Fom:Subsurface Sewage Disposal System•Page 10 of!8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal}system Form-Not fir voluntary Assessments 211 2 ty,o ,v„c,-z- �n Property Address Or+irter owners Name Formation is �¢ /9- fequin3d for every City/Town - P�l9e State T_rp Code Date of Inspection Q. System Information (cone.) 9/, 7. Grease Trap(locate on.site plan): Depth be fo grade: feet 4 Material of con ction: ❑concrete metal ❑fiberglass ❑polyethylene ❑other(explain): III Dimensions: Scum thickness Distance from top of scum to top outlet tee or baffle Distance from bottom of scum to bott of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations,ini and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence eakage,etc.): 18. Tfg r Holding Tank(tank must be pumped at time of inspection)(locme on.site plan). � Depth befo rade: Material of cons tion: ❑Concrete eta] ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity' Rona Design Flow: gallons day •rev.MAM 8 rde 6 OMW ka FeM.subuds-sewep Dist'"sydem•fae 11 of Is Commonwealth of Massachusetts Witte 5 Official inspection Form Subsurface Sewage Dispc"System form-Not for Voluntary Assessments ,07 �td e-(Mer /Rv Property Address o owners Name s�tom►ation� v,�?/'r f/i l wired for every ► Crty/Town state Zip Code Date of Inspect n D. System Infofmati©n (cont) & Tight or. g Tank(coat.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and floats tches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No $. Distrr mWn Box(d present must be opened)(locate on site plan): Depth of liquid level above outlet invert. Comments(note ff box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Y� �� t4-.3 ore � �J� c `') Wkk doc•rev.7/AM8 Title 5 OtAois!Inspection Fomr Suhsurfeoe Sewage Dlsposef System•Page 12 of 18 I Commonweal#h of Massachusetts Tile 5 Official Inspection Form Subsu&oe Sewage Disposal Sysilem form-Not for Voluntary Assessments Property Address moaner owner's Name Wbm tdon is +eWired for every Pe. City/Town state Zip Code Date of t pecti n D. System Information (cone) 10. Pump Chamber(locate on site plant' Pum in working order. Q Yes Q No" Alarms in w ' g order. Q Yes ❑ No* Comments(note co n of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a co itional pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): WSAS M located,explain why: /4L X..P/ v Sties Type: leaching pits number: leaching chambers number: Q leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology. 9�&pp doc rev.712BJ2018 Tree 5 orr,cia;Inspection form:Subsurface Sewspe Divosal System•Pap 13 a19$ Commonwealth of Massachusetts Title 5 Official Inspection Form Suiturface Smt W Disposal System Form-Blot for Voluntary Assessments Property Address �2iA/4 00r Owner's Name h6rmadon is �j+�Is�l.¢Gtyas� /Z/Z��ZIf requked for every Paw. cityrrom State Zip Code Date of Insp coon D. System Information (cont.) 11. Soil Absorglon System (SAS)(cont.) Comments(n ditign of so�, gns of hydraulic failure evel of pondlny� amyp_soil�vegetation,etc. . rn �� �/ Y1Qr i R 1114t2. is(cesspool must be pumped as part of inspection)(locate on site plan): Number an configuration Depth—top of li id to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soli,signs of by ulic failure, level of ponding,condition of vegetation, etc.): f F .40c•Mv.Mal rift 5 OtficW inspection Fam SWmarkm Sewage Dkpnd System•pv4p 14 of 18 v Commonwealth of Massachusetts Title 5 Official Inspection Form Sulwurfacs Sewage DisPftei System Form-Not for Voluntary Assessments Property Address 4/y 9 O�emer O mer's Name Ww"tion is / required for every 7 R"e. Uty/Town State Lp Code Date t ction D. System Information' (coat.) 13. Privy(locate on site plan): Materials truction: I I Dimensions Depth of solids Comments(note condition of soil, signs o ratilic failure,level of ponding, condition of vegetation, etc.): GkV.aec•rev.r MIS rife s officm mvecs«+Fam Suesauhaoa Sewage[aiiaposw system•Page 15 of!8 r rA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisPosat System ice.-"for Voluntary Assessments Property Address Owner's Name irdbrmationis �y �l�V� required for every p _ ��J !4- W01 3 �D City/Townpaw State —Zip—Code-�-- L3ate ofn D. System Information (coat.) 14 Sketch of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all welts within 100 feet. Locate where public water supply enters the building.Check one of the boxes below. hand-sketch in the area below } drawing attached separately - 7 Gka 1 f l f p.doa•rev.?rdA o18 TOM&5 Of"i FomG Suhsurtace Serge 1)40sat System•Page 16 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 2a7 �,/a^-Air A, Property Address Oa�a+er Owner's Name IMom"on Is mired for every "q'W't PPl G 3 7 z123Z zz page• CIVfrown State Zip Code Date of Inspedon E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information:Complete all fields in this section. B.Certification:Signet!&Dated and 1,2, 3,or 4 checked ( C. Inspection Summary: 1,2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checldist)completed D.System Information: For 8:TightlHolding Tank—Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15:Explanation of estimated depth to high groundwater included 4 asp dDc•rev.72fi/2018 Tif1e 5 dffidal Ins padion fromr.Subsurface Sewage Ulsposel System•PaBe 18 Of le OCT 15 98 i i 50 BAMa a appuFaIR�i DAP ljcal Fire Department. P.2 + Fire Department retains original application and issues duplicate as Permit. � t� GiG�'�aaaa��GUSe� 3 al APPLICATION and PERMIT Fee: for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: Tank Owner Name(please print) R 1 nu j D&uw#L A. X mwa a �a,yamu Address_ ?07 Mi-A Pinto yp ► Cum a »i A , MA n7F+ S►,aw CIry ware +� . I I R�Moyjl. cqntractor , • • I l Company Narne Ael3ja nced En •3 rnnman t a i Co.or Individual I i PiGu P�tor I i Address R Pddress ,— vrrnr I Signature(if ap lying for pe it) Signature(if applying for permit) ' i IFCI Cenifle ther O IFCI Certified + ❑ LSP# Other _ Tank location 207 Mid Pi np 0ri vP CtmtnajaM i (Bar ns-ta +l a 1.• 'MA 02637 _ Srear A409:s Clr� Tank Capacity(gallons) 1000 Substance Last #2 Tank Dimensions(diameter x e ) I Remarks: YY ze Firm transporting wastA_Advanced Environmental /ate Lic. # V5083856100 Hazardous waste manifest# E.P.A.# Approved tank disposal yardJames G.Grant Co. Inc- Tank yard# ong Type of inert gas Tank yard address wni,coitt St N=R. .:i l 1 e-,; MA City or Town FDID# © t` l Permit r .— Date of issue I � l Date of expiration' 019 sale approval number: 284100851 Dig Safe Toll Free TPA Number-800.322-4844 i Signature/Title of Officer granting permit VV After removal(s)send Form FP-29OR signed by Local Fire DeplQdUST Regulatory Compliance Unit, One Ashburton Place, Room 1310, Boston,MA 02108.1618, 292(revisoa 9196) LOCATIONS ��_�SEW.�,C,E_ PERMIT IJO. VILLAGE_*--- - - " - - - . _ Lh1 ST-QLLER_5_►J�t�/lE -_�_. D.DRE:S.S _ -- -- -_ - --- -- -. IT _5UILDER S ME AD.D.RE.SS __ _DATE-P_ERtv�lT_:LSSUED__ _P, 97 -77 _ � - - �� � �� �' ` �., Z,.- . , � .._ �� r� �C"�' ��� ���� � �,� � � �� �• y� � � � . . . .i rL �. t,u .-.'.4 ..M.= f i L� rti �('7 DI � d-r9 2 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. . ..r - - ---!-.....OF..........., r..-.---- Appliration for lliipnsal Works Tonstrurti n Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a� � Location- dr s or Lot f ]_Owner ` � Ad s ,a......................... I/�. L� =' a 3 ......... ............. Installer / Address d Type of Building Size Lot____ 7 ....Sq. feet 4 V Dwelling�o. of Bedrooms .....................:. P ( ) t�g Ex ansion Attic Gar a e Grinder `4 Oth&—Type of Building No. of persons............................ Showers — Cafeteria 04 d Other fixtures --------------------------------------------------------------•-•--------•-•------•-----•--------•-----•-------..................................... w Design Flo}w��'.....,.�iJ�............................gallons per person per day. Total daily flow�__s, . ..........................gallons. f WSeptic Tan4--Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width ..p............. Total Length.................... Total leaching area....................sq. ft. # Seepage Pit No........f 6_.__.. Diameter...... .......... Depth below ijilet._ _._ ...._ Total leaching r sq. ft. Z Other Distribution box ( ) Dosing to ( ) - , !�C rl�r . q_Z��7 7ti �i'" ��-c Percolation Test Results Performed b .. l�,l_c _ ----------. Date----Y �- ` ............. Test Pit No. 1----------------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........................ a f - - I...r........ O Description of Soil.........O` � �`! ......2. Y-----If - - 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 iITL U 5 of the State Sanitary Code— The undersigned f her agrees not to place the system in operation until a Certificate of Compliance has bee i su by the boar f th. ned. -- .-• --_.. � .............•-••-••----•---•••----------•- Date Application Approved BY lm.-�... .. . .--••----• ........ --Date Application Disapproved for the following reasons--------------------------------------------------------•----••------•------•--...... -------•------••••-------. ....--••--------------••--••-----....-------•----...-•-------..............--------•••-•-------....•-------••-•-••--•-•-•--•----•---...------......----------•--•--•---------•......•----------......_.. Date PermitNo......................................................_. Issued....................................................... Date ,. A -. No..................-...... Fizz .��.a .`....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e.*d.+;o .........OF....... ..,6+!at+$c°�^ ..!..................................................... Appliration for Uhipaii al Iforks Tomitrnrtbui -Permit Application is hereby made for a Permit to Construct ( '. ) or Repair ( ).;an Individual Sewage vfDisposal Sysr a . C. ......I- .. .._..._. --• •-•-•--•- --••-•- ...........ion dr s or Lot Zr Owner Ad s. f ................ a..4. -------------------------------------- p `�% -,a '- ................. Instai'ler Address Type of Buildi ig Size Lot ____Sq. feet V Dwelling 9No. of Bedrooms..._.._:...............................Ex ansion.Attic Garba e Grinder g— P _ ( ) g (4 � p, Other—Type of Building ........................... No. of persons............................. Showers;..:( ) — Cafeteria ( ) Other fixtures .. IV---------- W Design Flo ____., __________________ ,._..gallons per person per day. Total daily flow _,�.� ___---_______---__-_.......gallons. WSeptic Tan —Liquid capacity.._._:.._.__gallons Length................ Width.__...__..._.... Di'ameter_______-_____-_- Depth................ xDisposal � De th belowngth____________________ Total leaching area__._ sq. ft. SSeepage P t No. .../ ____.. Diameter kith Depth bTotal o let__ Total leaching r ------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �M", ,a h Date O i'. �� . a Percolation Test Results Performed by...... �; __._ __._____._.'____. 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........................ J � Description of Soil------ ,��.�....: N` A -+.".. �`'r <. `-- � ` +' ' ................. --- 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 T ITLE 5 of.the State Sanitary Code— The undersigned f her agrees not to place the system in operation until a Certificate of Compliance has bee si by the?�Qarof ealth. . r , 5Sigirned � s Date Application Approved B �:...:.;_..__ ....�..... ......... '7-----_..._ PP PP y f.. ._.... > . Date Application Disapproved for the following reasons---------------••--------•------•----•----------------------•---------------------.............................. -----------------------------------------------------------------•--------•---...........--••----•---•---'-----------------------------------------------------------------------------------------_..... Date Permit No......................................................... .. Issued----•-----•---•---------------.---------...:_....•---- Date `S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............1.. .........OF... .. k ....................................... Tnrtifirate of (tent#4ittnrr Ills, TO -ER Y, That the Individual Sewage Disposal System constructed or Repaired ( ) f by-••.Ile& [.------ -----• --- ... ------•-•--•• --- •. -• ----- ... • . -- •------------------•------------- staIVr at..."� -•---------•-•------------- has been Installed in accordance:with the provisions of T 5 of The State Sanifar Cilode as described in the application for Disposal Works Construction Permit No.. ............ dated-.'" _ __________ _____________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. ......./.?_....._.. ... Inspector:..: / •----- ----------------- THE"COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH k< k ®r, / ....... ._.. ( No............ FEE.... '`:...... 111fiv a ft park U. `. #r Uan ermit Permission Is hereby granted_.. ......:........ ........ --' v to Constr t ( Repair ( ,)�,a Individual gag D> posal ystem at Street as shown on the application for Disposal Works Construction Per No Dated--f "` � .. '7 ----T----••----•---•--------........ .........` . oard of Healt DATE..- .................... ..................... ---•-•-•--....... .. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS.., 1- TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION 3 3 s'S� OWNER AND INSTALLER INFORMATION ( ADDRESS:c�C� / �t- 1' `� �` . .MAP NO. �s PARCEL NO. Q OWNER NAME: ( ,rAA aAf .� � ia� /1.±r. /�P �P �.�✓ , VILLAGE: INSTALLATION DATE: BY: G a.tt —e. ADDRESS: /L1f 1 CERT. NO. ,• "� ' ! TANK INFORMATION.,.,,,,,,," fk J ^` LOCATION OF TANK: `' +�° '• r'iC",+' • 4 0 CAPACITY TYPE' `Xi s°' - AGE A) FUEL/,CHEMICAL � F 11 Lr q ;TESTING CERTIFICATION C ] PASS C ] FAIL DATE T'. LEAK DETECTION C ] CHECK IF' N/A TYPE/BRAND ZONE OF CONTRIBUTION C I YES EJ4.. NO DATE TO BE REMOVED G,J+•.✓'U FIRE DEPT. PERMIT ISSUED C I YES' C ] NO DATE ^ LUNSERVATION C CHECK I .F.. N/A DATE 1 BOARD OF HEALTH TAG NO. M IC ]C ]C ] DATE t'3 PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCAT I OW ON THE BACK OF THIS CARD ':, E . P. Fotl,:LP-T!o } ! a r EL.l00. 'A5Si)r!�,E!D.: ALL 5La/��D � ET C�XGEPT As A1o7en) 1 jK l STI.r C� :. �jJ ��Vr . . .. _•,f!- ONG2GrG- nMIAI' / y..�.�..• - - '. �,�IO G�f(4A"/.7� /N,!LJ ... Irv __.r..�, �'L�Vct�. y � GvN�/t.�7'E CovCC p 1 a1 i`V7'�" lQv_EctN�• et_ M,ro2 —/g-/i. •s� k..y < �(�3�� �i.N v E�....9.� ALL � 'Y 60) • � ! - -,�.,;a,��"_�l '� - ��_ � i . i � � �5 0 0 �111 t� �j�•6?I�.. :�R i�3�. _ EL1�18`�� �j„ S ' �� � . . 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