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HomeMy WebLinkAbout0089 OLD JAIL LANE - Health 89 OLD JAIL LANE,*BARNSTABLE oo r : - e, - Y r v j + r. � f 4 • a, w r_ y r : u TOWN OF BARNSTABLE LOCATION 8 q OC L'�, 54 1L QV SEWAGE# 2014 -3 d4 . VILLAGE 3VA RA074fML" ASSESSOR'S MAP&PARCEL 24 ^1 INSTALLER'S NAME.&PHONE NO. JPF4k_MrA1V L�?('CAVA7hVS STB43LSS S- SEPTIC TANK CAPACITY fj7 JbGO LEACHING FACILITY;(type) DR yw«1-s (size) g!�'5/4 L X 3 NO.OF BEDROOMS 4- OWNER Cm R /S?/^ k/ PERMIT DATE: / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland an ' acility(If any wetlands exist within 300 feet of lea ng facility Feet FURNISHED BY A17 ')IbvIr, <- _ y % fi o47 V No. ��`�— ®� Fee vo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21pplication for 33ispoSAY 6p m Construction Permit Application for a Permit to Construct( ) Repair(Z) Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No. 8q 000 -f#q IL_ L.IV Owner's Name,Address,and Tel.No. 34,02Asr611 cnaixngN Dee Assessor's Map/Parcel SA/4 E Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. SXbWMnN L-,X-W j1W u.c 0a 43Z Dgu CaAts Wc71-uA-, /S ATAK L^ ft4alor" S's /SS P~ VAAY h4 Aj ICr'1 Type of Building: Dwelling No.of Bedrooms Lot Size LI, 68-7 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 440 f 0 gpd Design flow provided gpd Plan Date 6�Z`/.1.1 q Number of sheets Revision Date Title 517'Lc ►�1W Or ?il ?005 t!d,-417AY_7/UN Size of Septic Tank i V vv 0374, Type of S.A.S. dG' Description of Soil LA/� AZA.]E Z'134 a4 Nature of Repairs or Alterations(Answer when applicable) S;iY OF (444.cd_ erL% 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 Tit 5 o e Environmental Code and not to place the system in operation until a Certificate f Compliance has been issued by this Bo d of H)alth. /rq� Signed Date 7 ` i Application.Approved by � Date Application Disapproved by Date for the following reasons Permit No. �O ®I Date Issued 9 i �,�a4�.+'� ""�"`' E..,. ••a�n„a'a t,y'�4.,.-�'+T "''s ,• �',7aM F'p .� 4". a f +rr 1..^"r' M v k n i. .t.`� .... 4. � g©t9- 3 l (rig THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1j l PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �pIicationjor jBisposal 6p lem Construction Permit lot Application for a Permit to Construct( ) Repair(-'.) Upgrade ) Abandon( )3 ❑Complete System ❑Individual Components Location Address or Lot No. c '61 G c!J ,'1--1)(. Lf1! Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. , Designer's Name,Address,and Tel.No.' :Vlf-1In/7' i_(( Jg(,~'> Jt�«/Ilwel7 J)L�5 /5 .S l��!L( `,lr�� el��i1�1f t Type of Building: k Dwelling No.of Bedrooms Lot Size 4q sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers ��. YP g ( Cafeteria( ) l Other Fixtures Design Flow(mini.required) U 4 D gpd Design flow provided ' ! gpd .; Plan Date 0' _7 119 Number of sheets 1 Revision Date J4c�+s•_' 2 Title - 'A f t�f�M Ui^ lr°p,��?Sc�� J'&A,,Si'?V7rtJ/V Size of Septic Tank j- 10 r;, ��i s�v, Type of S.A.S. Description of Soil �,('f ��^� � CIA5-41` .a � r, f;,.r/Nature of Rep irit�orAlter'ationg,(�Anns�ye`r,when=pplicable). 1)- ��1s �' �.�15 ,'ar Date last inspected: Agreement: "t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Tilt e S oo'f the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. /n Signed _ ,,,�-�(,�i^@ � Date Application Approved by +y G (!• z S Date �� y Application Disapproved by Date for the following reasons Permit No. Oil a Date Issued - ---------------- ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of-Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( )° Repaired( ) Upgraded( ) Abandoned( )by 'f,A IX ,#-CCC/1 at 7 0 c j<i '( /�! has been constructed in accordance � 9 with the provisions of Title 5 and the for Disposal.System Construction Pe'rmit Notr yp1a dated 0 r Installer "` _ Designer #•bedrooms L4 Approved design flow 7� '-/ gpd The issuance of this pee it shall not be construed as a guarantee that the system will n" cloti� ' s'designeh'. Date C 0 Inspector (ANJ ------ -- ---- No: 0C9 Fee THE COMMONWEALTH OF MASSACHUSETTS j PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS fNsposal 6pstem Construction i3ermit Permission}is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at, (f P t> -5,1 e C L,NJ i. . . a and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. - ^ e Provided:Construction must be fcompl eted within three years of the date of this permit. ell`'�• Date ` k Approved by 1 Town of Barnstable , Inspectional Services BAMWAat s, Public Health Division p01 �A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: �10 9 Sewage Permit# ZUI f- 3n4-Assessor's Map\Parcel 2 �S G Designer: "N. Installer: .SPE W1%1AA/ ACC.I✓4 71n/� Address: l J JA'64Ar 4✓4-7 Address: 7.S .S 904K 4✓4-'7 On I 1 S ACID/ W L-KCAL fl71ngvas issued a permit to install a (date) (installer) septic system at ac� -14lL Ln/ ° based on a design drawn by (address) L'Aym1> rv4-SvA/ dated A k k 9 Rr'y ' 8 l y/l ti (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed ' ce with the to rms of he I1A approval letters (if applicable) �N OF lyq�sq D AVID (Installer's Signature) � ... 2 MASON of ,9 No.1066 q c?~ Gls-rS esig is Ignature) (Affix amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BAR NSTABLE PUBLIC HEALTH DIVISION. THANK YOU. khoWeptMEALTMSEWER connecASEPTIODesigner Certification Form Rev&14-13.DOC TROY WILLIAMS L - t-/- SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, UA 02660 COMMONWEALTH OF MASSACHUSET'I'S EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y ` TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ProperiN Address: 89 Old Jail Lane Barnstable,MA Owner's Name: Nichola Dee RECEli�/�p Owner's Address: 89 Old Jail Lane Barnstable,MA 02630 MAR 1 4 2001 Date of Inspection: March 13,2001 TOWN OF Name of Inspector: TroyM. Williams HEALTHpFpT'BLE Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508)385-1300 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that.the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP apprm ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sysiem ✓ Passes. Conditional)-,- Passes Needs Further Evaluation b} the Local Approving Authorn) Fails Inspector's Signature: S � ?�,�PQ. __ Date: .3 jt 3 Io I The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 89 Old Jail Lane Property Address: Barnstable,MA Nichola Dee Owner: March 13, 2001. Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that anv of the failure criteria described in 310 C►v1R 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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 ement or repair,as approved by the Board of Health will pass. Answers es. no or not determined(Y,N,ND) 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 indicatine 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 ND 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: 2 Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 Old Jail Lane Barnstable,MA Owner: Nichola Dee Date of frtspection: March 13, 2001 C. Further Evaluation is Required by the Board of Health:All'�q 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. L System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will y 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 eater 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 89 Old Jail Lane Property Address: Barnstable,MA Nichola Dee Owner: March 13, 2001 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No 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 y/.4 Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. i 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 \%ater 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 forma Nv (Yes/No)The system fails. 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. E. Large Systems: w/,q 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 following: (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 11 of a public water supply well 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 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 89 Old Jail Lane Barnstable,MA Owner: Nichola Dee Date of Inspection: March 13, 2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ('..;;;ping information was provided by the owner. occupant. or Board of I Laid, _ y 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,excluding the SAS, located on site '? Wass the septic tank manhole%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) [310 CMR 15.302(3)(b)] 5 f Page 6 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 89 Old Jail Lane Barnstable,MA Owner: Nichola Dee Date of inspection: March 13, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): '330 PI Number of current residents:.�-S Does residence have a garbage grinder(yes.or no): YIE s Is laundn on a separate sewage system (yes o: no):AN Iif}les separate inspection required) Laundry system inspected(yes or no):_&ZA Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): ?9-y0_ 7i�(Jou 0 Sump pump(yes or no): Ato Last date of occupancy: COMM ERCIALANDUSTRIAL /v/,v Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): _ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) _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 _Other(describe):. Approximate ate of all components. date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): va 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Old Jail Lane Barnstable,MA Owner: Nichola Dee Date of Inspection: March 13, 2001 BUILDING SEWER(locate on site plan) Depth belo« grade: �2' (- Materials of construction: _cast iron V40 PVC_other(explain): Distance frorr, private water supply well or suction line: n/g Comments(on condition of joints,venting,evidence of leakage, etc.): 1 tot 3 -J c If-c g!C,J -k c 1 t u r 4'l, fi do.c ram' / h f v c c fi O v+ SEPTIC TANK: V/(locate on site plan) Depth below grade: i8" Material of construction: concrete_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) Dimensions: S 'k- 2 'x 6 ' l cot/ oI/,,. Sludge depth: I' __ Distance from top of sludge to bottom of outlet tee or baffle: ,2 'S"' Scum thickness: Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom of outlet tee or baffle: �} „ How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Wh�// �./-�.-. ..._.,_._. � e✓.G�`f�cl 7 J'i�i.tt ✓L�r �7✓hi lJ / h} �.�-C 4�� �✓N'1 .N �j CS 4r N k GREASE TRAP:d//i(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.): 7 I Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) t Property Address: 89 Old Jail Lane Barnstable, MA Owner: Nichola Dee Date of Inspection: March 13, 2001 TIGHT or HOLDING TANK:Aj/2 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flo�� 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: v1 (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 leakage into or out of box,etc.): u !�' 16-a..K 't1 PUMP CHAMBER:N_/9 (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.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 Old Jail Lane Barnstable,MA Owner: Nichola Dee Date of inspection: March 13, 2001 SOIL ABSORPTION SYSTEM (SAS): V/ (locate on site plan,excavation not required) If SAS not located explain why Type leaching pits, number: —7 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): 1 / LUi -• T 4..s j,—o'� 00.+ `.. t rla�,o SO l 0✓ �c4 �rj.-h _�.✓ .-3 urcfc .. �-- -/^. S I S n:} o• Y✓c::.�..tc.� U i. �A!.h,r.t. CESSPOOLS: J,//9(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 laN er: ---. - -_._ 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: 14 (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.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 89 Old Jail Lane Property Address:, Barnstable,MA Nichola Dee Owner: March 13, 2001 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. i IL) y« 3 z' kit t � a a 10 Page 11 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 Old Jail Lane Barnstable,MA Owner: Nichola Dee Date of Inspection: March 13, 2001 SITE EXAM ✓ Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water S a feet Adjusted high ground water elevation feet Please indicate(check),all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: k t v/ Observed site(abutting property/observation hole within 150 feet of SAS) SIP-. � 1 Checked with local Board of Health-explain: ( ;' Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation:lI in.. � T4S I h IX r— -' 4e 5 4 a --c R NJ .✓tt i--�✓ 1'tl n,�t c n o - 1 2 /75> r i _% G. ( s /tj c.c 4' -e AJ 1, A✓a�. �. c.i- ��..�< o /' t-f w t ti t 1 0 + < a 6,: sa,tea;✓ .A wcu 11 IU I" COKMO\`tLrEALTH OF MASSACHliSETTS EXECUTIVE OFFICE OF E:N'VIROIME\TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON NiA 021OF i61 r i 292-550u TRUDY CORE Secretan- ARGEO PAUL CELLUCCI DAVID B. STRL•HS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop"Address: 89 Old. Jail Lane Name of Owner Peter Robbins Barnstable , MA Address of Owner:Same Date of Inspection: Name of Inspector:(Please Point)Wm. E . Robinson Sr . 1 am a DEP approved systerq inspector rsuarrt to Section 15.340 of Tile 5(310 CMR 15.000) Company Name: Wm. E . Robinson leptic Service Mailing Address: PO Box 10d9, Centerville , MA Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site/sew e disposal systems. The system: o s Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 41, Date: The System Inspector shall submit'a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 1,9 � l® .. tee, �• � �� AUG z 0 1999 • � 10 HEAUHOM� 1 revised 9/2/98 Page Iof11 F "n-led on Recvcied Pap(,,, w , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART A CERTIFICATION (continued) 'rop"Address: 89 Old. Jail Lane, Barnstable Jwne►: Peter Ro bins Date of Inspection:,, — INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. C ENTS: B. S STEM 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. Indicate s, no, or not determined(Y, N, or ND).' Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed oy` i revised 9/2/98 page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Old. Jail Lane , Barnstable Owner: Peter Robbins Date of Inspection: 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 the public health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,OF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less, than 5 ppm. Method used to determine distance (approximation not valid). 31 OTHER revised 9/2/98. Pagc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 89 Old. Jail Lane, Barnstable owner: Peter Robbins Date of Inspection: 9--16- ?I D. SYSTEM FAILS: You m Nt indicate either "Yes" or "No" to each of the following: \have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. It the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. RGE SYSTEM FAILS: You ust indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well) The ow er or operator of any such system,shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 �a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address:89 old. Jail Lane , . Barnstable Owner: Peter Robb Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. J _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. ` ✓/ _ As built plans have been obtained and examined. Note if they are not available with NIA. t/ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Ll _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] The facility owner (and occupants,if different from owner) were provided with information on the properinaintanaara-of SubSurface Disposal Systems. revised 9/2/98 - Page 5orl] SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C ` SYSTEM INFORMATION Prop"Address: 89 Old. Jail Lane, Barnstable Owner: Peter Nohbins Date of Inspection: Ia-/ FLOW CONDITIONS RESIDENTIAL: Design flow:!;. ,6 d g.p.d.lbedroom. Number of bedrooms(design):V Number of bedrooms(actual): Total DESIGN flow 940 4 0 Number of current residents: Z=, Garbage grinder(yes or no):/LO Laundry(separate system) (yes or no)"; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):iL6 Water meter readings, if available (last two year's usage(gpd): 1998 83, 000 gal. Sump Pump(yes or no): n d I 99'� b2T, 000 gal. Last date of occupancy: O - COMMERCIAL/INDUSTRIAL: Ty of establishment: Desi n flow: qpd ( Based on 15.203) Basis of design flow Grea trap present: (yes or no)_ Indus rial Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Wate meter readings,if available: Last ate of occupancy: O R:(Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS d source of information: System p6mped as part of inspection: (yes or no)A 4 If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other c APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no) V revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontimied) 'ropertyAddress:89 Old. Jail Lane, Barnstable ;. owner: Peter Robbins Date of Inspection: BUI ING SEWER: (Loc eon site plan) Depth below grade:_ Materi I of construction:_cast iron_40 PVC other(explain) Dist) a from private water supply well or suction line Diam ter Co ents:.(condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:, Material of construction:_ oncrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: :3 Ll Scum thickness: Distance from top of scum to top of outlet tee or baffle:: l Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: D rc, 'omments: (recommendation for pumping, condition of inlet and outlet ties or be les, dap h of liqujo level in relation to ou let invert, structural integrity, evidence of leakage, etc.) [' GREA E TRAP: (locate n site plan) Depth be w grade:_ Material construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensio s: Scum thi Hess: Distance rom top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Corn ants: Ire mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage,etc.) IL revised 9/2/98 Page 7of11 o , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) property Add►ess: 89 Old Jail Lane , Barnstab'le Owner: Peter Robbins Date of Inspection: TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iaocat on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensi ns: Capacity gallons Design ow: gallons/day Alarm p esent Alarm I vel: Alarm in working order: Yes_ No Date o previous pumping: Comm nts: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidn of solids carryover, evidence of leakage into or out of box, etc.) - PUM CHAMBER:_ (looat on site plan) Pump in working order: (Yes or No) War in working order(Yes or No) Com ants: (no condition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8oftt i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtinued) 'rop"Address: 89 Old. Jail Lane , Barnstable Owrw: Peter Rokbins Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_I,-/ „ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number._ leaching chambers, number:' leaching galleries, number._ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of ydraul'c failyre, level of ponds g, da soil, condition of vegetation, etc.),,,. ,07 CES OOLS:_ (locate n site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of olids layer: iepth of s um layer. t w e Dimension of cesspool: } Materials o construction: Indication f groundwater: i low (cesspool must be pumped as part of inspection) - t I Comment r (note co ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI _ (locat on site plan) Materi Is of construction: Dimensions: Depth f solids: Comm nts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 5/2!ytS Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Nop"Address: 89 Old. dZail Lane, Barnstable t �W�o fInspePOeter Robbins SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) O r � a revised 9/2/98 Pagcloof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ropertyAddress: 89 Old. Jail Lane, - Barnstable Owe: Peter Robbins Date of Inspection: /6— NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep . SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions / r v Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) rL 3 revised 9/2/98 Pagcttorli LO CAT 100i � SEWAGE PERMIT p0• OL9 T/¢r J°1 S /I �'6 vo1 VILLAGE 1_4�#Iet ML1 I N S T A LLER'S DAME & ADDRESS GUILDER OR OWltER ILI DATE PEIt III IT IS-SUED DAT E COMPLIA. N-CE ISSUED 6 v M No....... ............... THE COMMONWEALTH OF MASSACHUSETTS , BOAR®r®F HEALTH ...----...�1-64-o-V..........OF....... gasT/4 G.G' Appliration for Diipatittl 10orkg Tomitrurtion amit Application is hereby made for a Permit to Construct (&< or Repair ( ) an Individual Sewage Disposal System at: b 0. ..............•---...--•................._. -•.....--••--------------.......--•------• Location-Address or Lot No. W Owner Address r1 ...........................i . . h�.L?_.._ —=........................_.._.. Installer Address d Type of Building Size Lot. ...... -...............Sq. feet U Dwelling—No. of Bedrooms............................. .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ...................................................... W Design Flow............ ________________________gallons per person per day. Total daily flow..__._.-_-� '------..._._______.__.gallons. 9Septic Tank—Liquid capacity.ova®._gallons Length 8. ._:_ Width.. .'�."'. Diameter................ x Disposal Trench-No. ......./.......... Width....` ........ Total Length_... '___.__ Total leaching area..© __.__....sq. ft. Seepage Pit No________ _________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-Rk/ o.. � �°. � fi f1VeDate_ ' ZI 4Y ...... W a Test Pit No.dC.t�_ o-_-minutes per inch Depth of Test Pit---- `..... Depth to ground water......._____-_--.-_--- G%4 Test Pit No. &!�r?..minutes per inch Depth of Test Pit...fz��....... Depth to ground water........................ --------•--------------------------------•-•---------------.......-•--------..............--•'-'....--• ........ O Description of Soil... /cock ?• -_ __Sul3�-5oi 4- 60`-/zb" �N�- .�'4,L.4� U7- AIC4 --•--- .................... ------------------------ ••-•------------------- -------------------------W ------------------------------------------------------------------------------------------•--------------------------------------------------------...--••----------•-•............................... 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 I II1_2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b su b the b r of health. Signe -- . ..-- -----•-•...........................................•----......... Date Application Approved By. / ... %%,% ------------•-•-------------------- --• .. L ' Date Application Disapproved for the following reasons---------------•--•-------------------------------- ............................................................. -----------------------------•----............---••-----------••-•----------------.......------._.........__...............------•---------------------------------•------------------------•-----•...... Date PermitNo......................................................... Issued....................................................... Date No......................... r Fim............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ . te,i/Xe-..--......OF....... STf�'GG Appliratinn for lliipusal Works Tonstrurtiun ibrutit Application is hereby made for a Permit to Construct (i--j or Repair ( ) an Individual Sewage Disposal System at: i r?c: .. .4 ��`i. 3;J ..... { ................ .....•-----.....----------' -L / b ........................... ..... Looation,rxAdress or Lot No. ...................................... .. ... ./45 X ./...... s S . Owner Address WrC.._.. ........_... Installer _ Address Type of Building Size Lot_'A?_.-��r' ......Sq. feet -, Dwelling—No. of Bedrooms..........._�3' ............................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building Pk Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures Design Flow___..__...-5-�_ ________________________gallons per person per day. Total daily flow.......... .......................gal�ons. W /aava 9 Septic Tank—Liquid capacity__ _.gallons Length__'___!___..___ Width_.��_•__G____. Diameter________________ Depth_s._!�'_...... Disposal Trench—No......../_......_.. Width_._.!i-!_._._._ Total Length_.__2 0 0._.._. Total leaching area._'3?"o.....sq. ft. Seepage Pit No.._.____#.......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by. :'�?^!!`?lzp t- �lclGy, C_,(2:5/,�„ �_ ate.rr.2/ a > ------------------- Test Pit No. � .5!t�+U___minutes per inch Depth of Test Pit....�"¢'�....... Depth to ground water.____:..""'______... r=, Test Pit No. SA.!k�__minutes per inch Depth of Test Pit__.................. Depth to ground water....... ........... . ..--•----------------------------------•-------•-•------.......----..._..--•-•--...._...-------•--..........__.............----......------•-----•---_--•--- O Description of Soil..._f"-C6� WacveoA�71K � (o'= iz4" /",wC-- -__.___ -- _ Ski :- - ------------------------•---------•-•-----__------------•---•-----•----___-------••--------- -----• x •-•--------•---...._...-•-----•------•---•---.....-•--•-------•--•--_..-•----- .___.--•--•---•-•-••----•.........................•-----____...-•-•-•-•--•-----._....._.__.._._.--••----....-•---------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .-----------•----•--_-_...----••---...-----•---••-----•------•-----------•---------•----•--•--•-•--•-•-_•...................... Agreement: The undersigned agrees to install the aforedese. ibed Individual S wage Disposal System in accordance with the provisions of TITIZ� 5 of the State Sanitar /Ce u d Bees not to place the system in operation until a Certificate of Compliance has be s ued e P p � y the and of health. >g d .-- ApplicationApproved By---.....--................................ -- --••-•-•----•-•------------------------- _......_---------------------••-•------ Date Application Disapproved for the following reasons----------------•--------------------•-----------------------•------------------•----------..._.__._....-------- ......--•------•.....................••-----•-----••----------••----------....-----.....-----•------•----•-----•------•-------•-•-----------------•--------••---------------------------•-_.._...------ Date PermitNo......................................................._. Issued------------•-----••---............................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............�! n1........OF...... �'R7 .......................................................... Tntif irtar of Tuutlrlianrr THIS IS TO CERTIFY, That the Individual Sewage L)4posal System constructed (✓) or Repaired ( ) bya �..' .: ---------------------------------------------------------------------- s Installer at................................................................................................. has been installed in accordance with the provisions of TIT " State Sanitary Code 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 OF HEALTH No........................ FEE........................ Dispoiial Works T-FaInstrurtion Permit Permiss1w is 4rebq granted......... �,,a(y r ' to Co Repair ( atf .I,t�djfr3ial See Dispoaa " at No ,,r�'srre� as shown on the application for Disposal Works Construction&P:err t,N,a ag-......................................... 100, .............•---------...-----------•------------------------••----------•--••------------••-------_..._ DATE............................................................................... Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS DRAWING TO SCALE IF THIS DIMENSION MEASURES 3" — ED � s w 4 � � U � - _ • a Qz � O.w (2)3'x3'GLASS ROOF PANELS(GRP) W/TEMPERED INSULATED GLASS o 10 EXISTING I 6'SUPER FOAM ROOF W —J - 4L-!_l- o I II I I I I 1 m � c Z o J rn ' I I � a O F- o Q Ull TEMPERED INSULATED GLASS Q to Q N w a ,I WINDOW W/SCREEN UO m N o ono / a - J O w Z n' >- Q z Z ss Z 3 G _ w ce [� 18" o I � W M tt _ 0 W co = . I U JQm Z I � ( ) J co � Z 1` Ckd I I 1 I tf, I I NEW DECK Z 00 uj TEMPERED INSULATED Q_ Q p o GLASS KNEEWALLS I i i i' i I ~ OU) 0 U M Z i a W Of I I I I I U m o z L J L—J L J a NEW CONCRETE PIER FOOTERS 144"—� co W NOTES: ELEVATION -`."B"WALL o 1.ALLVIEW (AVI) ROOM;-WHITE 1N COLOR M 2. CONSTRUCT ENCLOSURE ON NEW DECK BY GDI a o 3. NO HEAT, PLUMBING, OR ELECTRICAL BY GDIOf CD 4. GUTTERS AND DOWNSPOUTS BY GDI _ o �, DATE � 5.ALL CONCRETE TO BE 3000 PSI MINIMUM 02-25-16 w 6.ALL LUMBER TO BE SPF#2 OR BETTER, PRESSURE TREATED WHERE REQUIRED DRAWN of 7. ROOM CONSIDERED AS NON-CONDITIONED SPACE, EXEMPT FROM ENERGY vNc 0 SCALE z REQUIREMENTS (PER 2012 IRC SECTION N1101.6, NOTE 2) 114'=11-0. SHEET N 1 OF 4 ° g% .SSVW `SINN3a ONI OHS -- -- — -- -- -- — -- ��vfa�lne ONINDIsIa o ®* JNIHI�NIDN� 01 a9194 000 , , 3 1N'?� 1� 1 No LLV.70 oz.+i c�Nfl 50, � XOG Noyrra lxLslo ;MNVJ,-;),u.d39 mow.. :.. . __prat{.. y+��• �i � � ' � •.� V �� �'��•,f h ; }`J? =. _ 1`IMQ�- awl � .LL-i -G ass 1 nib eAcW ? 9 oJ/ : /VNO N�1�o'�Q x �� ' �C.3'U,a3 .3dO'J '1�d.LN�UVNO?! 1�n3 *: ' n rr 'SSti�W 3H.L CZL W?,ic �Na� "1"itYHS _Fx .�' NoU:on zsJ-5 ido� vV�15�S o:p l Lj3s oo oz ao/ Q y � a i 09 E'er L rdM a bd o7,yl . „b � „. �► tia- 2 'ice ran L b 1,401'1�1�J �y►�r✓��r-rc � � �r d3H 17, o LHo� wto ^Nm Z °d t l W . r' „ ,=.WOZO 1 n� __ SsAdwl xQ6 � •'ta (jviW o�} rtoluv1711y10 H'7V'a.'1 213 AO HSi r -J � 1004 SNo M IKLI c 0 NNo/ z of da nab o; J�5czv p gi4it wnwrliw h2LbQ �rs,►nssy.No ct.�'tbB: '�N.la��.�//Le1►l.� .r�o�/ a�,�•,�7 N g Fr � ,10 dcu '�Z�. .04 ; o Cb G� ��' _ C • �'?� �` '��"�' 1st � ,rob-� 'Z3' .¢-�X� 0 . <71 ON/ a �norca,3' 10 r i lN:ibo}400pry,: ra,► �?L l� �� . t ^�. s:``E .: s `J_ d l V t Irv`° E .. � 4 i M 'J �- � � � ' - s AJ07-6 S � Ccx-J -f Z)'Zo)e c 20 7`C; 7t) -;'op of -Pgunc/ p &C 4-JI Sof A.0 40/'r/7-- 106C 4F Is S��Rx covers 74t�_ '�0,3 o-, if r o-P .40 Pvr- DAVEZ 7N710AJ e. c-o/'ry7in. e4_11 77/k�6rSS 4S-,0 4 YA UI in 9 1A v '00- V. 0 7S C'e PC- 'p 4 /T 0 tnin. ; e e,- -F �)Ex!xog"Jaz ax, T-7. CA,i -Pow 1':*,-;e- -7 t Mi 92 26 6 6 3 iis.04L:" 0-7- , Tlqq )4LL AQ A base. 50 AJ '47v- 9L 1AZOT tyo;WE roc--).i3 ee-)ll 7L=/ o Y/-e 7 41 aez 0c) ef A ir 4e 7- -%5,A 3 3 ------- eiev ILI sc�cL A DU 07-Z Y ,4) lee, 10 r f t (t 8,,'N f-, P- 01:- 5 T H 0 4- C-- 4M C) G l F f - ciS l- C,/3 Tr- -TLJA�E Avc . I7� - GAL. R- L Al T 'e'q 7 E- 5R.1; TV age ; 'j H 0 L ca E P 4 5, A4 /S c 7- 3Y 3 A-06ESC-)eve \J SA KZ Q3 '5',� LAJO�ekMAAISHIP AA10 (117PTERYPLS /oy't-?/Y a i /Gt a '�'?; I 1 C10q 4- L 7-0 0.4e-P. T1 T,( C- 5 ki -T"H�=- -7-04-vAJ OF F9AjD ieEGUL ?4:i:/0A.;S L-;P- :SUfi�!Ff9CC- L)ISPOSA4- C>)= A), 7 ,,q R SE -IN /n/olp 0 R&-GG'4-tq7-loA/-.S -i IS� q - EA ,V7JA f U/4-D/1V Cv Alf S p� c WoR. 7 / c two,E. r1q,L -1 4!E: --5,C -'q PP)r.-a c, v 1A.IVL-.> 9 '-5eX:F1-16 LSD. OF HEqLTH �-��'tom?/o/ -70 1A1S7VJ-,qT10A1 T G E- AJ C zolil-'r- 341 K/.. ..� � I i _�;d��,os�1� I l �15E�ie�J7" - i� �- y � � � 0 iz 0 P 03 �e LD C, 0 AJ S T k=- UC 7-/0 ok/ �4 I SCO. 1-4 21, -Tuloe '/9 DAVID A. SPF.AKI#& 01-7'PC op. I IL '71-p-'S rr,::;he. c -,t 47 10 1pl