HomeMy WebLinkAbout0567 OLD JAIL LANE - Health 567 Old Jail `bane
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A „1AP
CERTIFICATION PARCE4 . p S 7
p 5� d l�an LOB`
Property Address: - -� -`
Owner's Name: BeE17' o TRftf., j rt'r[ RECEIVEDOwner's Address:
Date of Inspection: 00,0213—boy APR O, 20�4
TOWN OF BARNSTABLE
Name of Inspector: pleas�j print) ��vC� �t�C0.� \ HEALTH DEPT.
Company Name: S ore\k^c o,,5
Mailing Address: two
Telephone Number: -S
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ r
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's SignatureV: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address hogs the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 1 1 .
OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5(07 014d O7 L L rle—
_8PA&K774 bhP, MA. oZ630
Owner: 8e6-7T t- 7RHtc4 )5&40
Date of Inspection: Chaje4*1 3, ZOOy
Inspection Summary: Check, A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
have not found any information which indicates that of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not`evaluated are indicated below:-.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repaii,as approved by the`Board of Health,will pass.
Answer yes, 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(whethermetal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.,'
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):,
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will a.
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 1
OFFICIAL'INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(continued)
Property Address: $(o7 01d c7Cu'L Lune.
Owner: 15 t
Date of Inspection: � �� Z�—
N;' ' '1 ,C ' +�' r s k
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health 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 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:
y
The system,has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a'public water supply.
_ The system has a septic tank and SAS and the SAS'is within 50 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 .'
I
Page 4 of 1 1
OFFICIAL.INSPECTION FORM—NOT
O FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL,SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: "] D j J6, L 14421
Owner: )BReMi- TreqC44
Date of Inspection: ajeo-1
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
1/ 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
.A Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day 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.
_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.] of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered.A copy of the analysis,m•ust be attached to this form.]
�O (Yes/No)The system fails. I have determined,that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow.of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the 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 II 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
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Page 5 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 6_*(o/'�7�OW Q�aLy{Lane,
Owner: &?&—Tt t./ ge_w 5 F .. ...
Date of Inspection: DiEr'l 31A ZGeV
Check if the following have been done. YQu must indicate"yes"or"no"as to each of the followins:
Yes No
_/ — Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period
✓" Have large volumes of water been introduced to the system recently or as part of this inspection?
— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
— Was the site inspected for signs of break out ?
Were all system components, excluding the SAS, located on site?
�_ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions, depth of liquid, depth of sludge and depth of scum ?
v"_—
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
Page 6 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:•S Old 'L Cane,
Owner: 33 TT-t E� �
Date
of Inspection• 3 200
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): kNumber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x# of bedrooms):
Number of current residents: 3
Does residence have a garbage grinder(yes or.no): NO
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): ^10
Water meter readings, if available(last 2 years usage(gpd)): oT
Sump pump(yes or no): /VO
Last date of occupancy: onto n
COMM ERCIAL/INDUSTRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd r
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: �eov_i 17 e— 12 00111
Was system pumped as part of the inspection (yes or no): 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): '
Approximpte age of all components, date installed (if known)and source f inform ion:
Anh ro,T Z l S L$arc cc q p
Were sewage odors detected when arriving at the site(yes or no): ND
6
Paae 7 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5rc,7 00 °L La Q�
Owner: BeETrt 7)2A-t e� Fte - �.•,', ;
Date of Inspection:
BUILDING SEWER(locate on site plan) r
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explain): C e nn c.A
Distance from private water supply well or suction line: IAMA
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: —(locate on site plan)
t
Depth below grade: �
Material of construction: Vconcrete_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: I S-60 69 1 /O
Sludge depth: /"
Distance from top of sludge to bottom of outlet tee or baffle: 30
Scum thickness: / 102/e _S
Distance from top of scum to top of outlet tee or baffle: 7 n
Distance from bottom of scum to bottom of outlet tee or baffle: 13
How were dimensions determined: /ycpqjc s7-,c/(
Comments(on pumping recommendations, inlet a d outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, `�y� /
N e lC'vC/AAI eyC� Lri!/�/ 7-1c Oc�wyc'
Ho
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
f
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address d
Owner: E7'f'ri772RGU Fit- n GZ�a30 s
Date of Inspection:jjjg�j'/ 3, ZGj�p
TIGHT or HOLDING TANK:
(tank must be pumped at time of inspect ion)(])( to on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacin,: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):,
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: 1//"(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: ZyCA
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
1`��s� ,�� ^ C\fir`-t-��--v � e.l.e.✓` J��^.��v�
PUMP CHAMBER: '40(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.):
4
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: 00 JiaiL
Owner: 8P_ETT t
Date of Inspection: j3pIQi 13,
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓leaching pits, number: I /vaoG � t
✓leaching chambers,number: 3 C.0 l c c 3 3U3
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 hydraulici'failure, level of ponding, damp soil, condition of vegetation,
etc.): P
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:`
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address (.0?OIJ J&AL. CC. W—
Owner: 6 0Zb j
--fT TR- F"rEzd
Date of Inspection: XFfaiz 3`06q
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.
S,PP)yE„9�rsPNM Pro()'
Pr LIJ,
o 13
No
a vile y
35�
(3?G
o
y
10
Page 1 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:5*G7 old cJb L Lane-,
l3artZ7-0 bl_0, IM. oZ6&
Owner: '&—Z,Q
Date of Inspection:/
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 6-6 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:
_ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you estab fished the high ground water elevf tion:
Qs1l)� /oc.. x ai Ie IJ//�� 7o�OQ2HDh'C 'T' Gv /c2 Co/t/0--r
rov.v e e'/ar 1" a� _Si/e DA
JTh�s r-e r+ ha. L-enm P aria - le'. sfe
i nspeC�C(_ and pa ssre CL (as o 4' - -e dC(+'e 0 '
i n s pec- ior) . rep0j^1r" /s r)OT a Lua rrccn4�j
o r g ua.ra n+ee -F-�c�� -�-he s ysf�m 1,))' 11
p roper l y l'n 4-e PL)40re. Tp" o rc have been no
Lv arr Yea.r4f-e s or gUC(rCrl+ ee-ss,
`�.n m I l e
w n or' 1 � c:Q , ram.(cc.-,n9' -fo +he
-t�e l h S jqeC {-i On CL nctl or- +his repo r- '
11
TOWN OF BA.RNSTABLE �
LOCATION—' 7 GQI,oJJi: LAv f SEWAGE # ' �/ e
VILLAGE__�)R,9-171f' ,t,� /ASSESSOR'S MAP & LOT 1
INSTALLER'S NAME&PHONE NO 1/Ac.�//if
SEPTIC TANK CAPACITY Ga J'k-,I
LEACHING FACILITY: (type) CL,1 CC-3,:',y (3) (size) /D
R -
NO.OFBEDROOMS
BUILDER OR OWNER
PERMITDATE: Nov. I / �! COMPLIANCE DATE: L
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
97
Sf '� �, SA7 I
�� Q
TOWN OF BARNSTABLE
LOCH' ON��,9'7 1QJQ n 12 d,A"E SEWAGE # f 8
VILLAGE e&WdlRTP L J ? ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO,-/ AC911i1 ,
SEPTIC TANK CAPACITY o 6A,(
A5 i
LEACHING FACILITY: (type) NI/cC"330 (size) /0 X,2Z
NO.OF BEDROOMS � 0
BUILDER OR OWNER 'J3f,6 77—Fi I f
PERMIT DATE: Ao v. J,i s 99 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�/ i
� 6 T
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-- i
,� � ���
1,.
S �I � I'
c� � d
� � ��
.� �- � �
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r 3 76 Q 7
No. /41[� Fee
l
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0[pprication for Mitpozar *pttem (Gouttruction i3ermit
Application for a Permit to Construct( )Repair(O Upgrade( )Abandon( ) -El Complete System EJ Individual Components
Location Address or Lot No. S6 7 O/,a as i 's'1C 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.
Type of Building:
Dwelling No.of Bedrooms �+ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) A0 0 :3 C y//CG 330 C1jam 6 GP.S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issuo by this ard of
Signed ��4 AAA���//1(' Date /—/ — 9F
Application Approved by Date
Application Disapproved for th ollowtng reasons 17
Permit No. 9Y, :Z/S Date Issued
I. No. 1 - _ ` "' Fee
THE COMMONWEALTHOF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
Zipplication for Migpogar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(O Upgrade( )Abandon( ) L1 Complete System .yD Individual Components
Location Address or Lot No. j 6� 6/O aA+ ( L,Aj�` Owner's Name,Address and Tel.No.77,
t�
a�i\E �c eit
��rr �lcU
Assessor's Map/Parcel cJ b� 1
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow s, gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) I) ) :3 r v//rr .33O
Date last inspected: y
Agreement:
_ The unaer signed agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in'accordance''with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
Cate of Compliance has been issue by this B iard of a h.
Signed A Date 9F
Application Approved by bate 44 i - S'rs
Application Disapproved for th ollo 'ng reasons
i
Permit No. 9 F_ "��/ Q 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 -'r r ,r e bar r �� ;`c r
at `s (i " n I" `C �' (.r�; �c>:� ,_:�; has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No., ��dated
Installer .V r. 'kirl, Designer
The issuance of • p rmi sh H 1 ci !be construed as a guarantee that the y terry will function as de igne . t(��
Date1 Inspector 1 e�- 1 f jt�1
( l � _l V
---------------------------------------
No. Fee— t�—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migpogar *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( i()Upgrade( )Abandon
System located at o fn z4 1 A AC ( . —4- A
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: T�-- _ of�/ Approved by
4 1/6/99,
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) ®/yccl= ps?
I,�&wC-e Ac,�� (: \s er , hereby certify that the application for disposal works
construction permit signed by me dated ��. �, i Cl concerning the
property located at ST2 0 k ai . /t g,LZ z,9�/I�'✓ h meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
a
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system 1
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation, .
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) /0�a
B) G.W.Elevation +the MAX.High G.W. Adjustment. = 3c5 3a
DIFFERENCE BETWEEN A and B
SIGNED : &C DATE: '7 ,1
[Sketch proposed plan of system on back].
q:health folder:cert
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5-7
TOWN OF BARNSTABLE 'Z 7 `o7
LOCATION ®� 17A;/ A IV L SEWAGE # 21' -56 41
XJiLLAGE A 14 ASSESSOR'S MAP& LOTA01- 57
INSTALLER'S NAME&PHONE NO. -
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) � !w� � �.� (size)
NO.OF BEDROOMS
BUILDER OR OWNS
PERMITDATE: .� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
r
..
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,� J S�PV`< �� �,
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No.... Fizic ...../. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
II TOWN OF BARNSTABLE
ApphrFativaa for Diipuiat Worbi Cfuaaitrurtiou Prrmit
Application is hereby made for a Permit to Construct (vl) or Repair ( ) an Individual Sewage Disposal
System at:
7 oG..� ................... �v.....�13 G -----------------------------------.'��¢-------•--•----....----•--•----------------•---
........ _........�As�
�^ Location-Address or Lot No.
............. ..........--------••-•......................... .............................
Owner 1 .Addre
.... s----------------------------------- .1.5.....�as �� r�/-.�����---�AAd......
a, Inst Iler Addddress
Type of Building Size Lot- �0�..�� ....Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons--_------_.-.------------- Showers ( ) — Cafeteria ( )
a' Other fixtures -_--------------------------- - -
Design Flow................. .........................gallons per person per day. Total daily flow........3� .........................W /S / '6 if Sao�> �� '.
WSeptic Tank—Liquid capacity.-..-ate-.gallons Length................ Width.-...........--. Diameter.----.---------- Depth_.-.._.._._.....
x Disposal Trench—No. .................... Width.................... Total Length........._--.-..:... Total leaching area....................sq. ft.
Seepage Pit No-----------/....... Diameter------- -5�------- Depth below inlet........ Total leaching area..-4 7.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'—' Percolation Test Results Performed by....��4� 67 �� ���................ Date.y ._.lo /9F5V
----------------- - -----------•--•---
,� Test Pit No. I..�.Z_---minutes per inch Depth of Test Pit....%�L�---__ Depth to ground water........................
Test Pit No. 2...G..Z...minutes per inch Depth of Test Pit...Z ....... Depth to ground water..................
P4 ------•-•••--------------------•-•-•----••---------------------•••------------------............---•.........................................................
Description of Soil... .`.�._. �` �?�' Ga 4-0,f eSc,r3—SO 30"—/ �ri� l>'*I i>
-----------------------------------------------------------------------------------
V -------------•-•-•••-•--••••-------•--•---•••••----••--•-••----•-----•----••------••••--------•-----------••--••••-•--•-••-•----••--•------•----•-----•••••---•--------••-----------..........----....•.
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has been issued by the board of health.
Signed .......
Application.Approved By ................� . ...{..........� ------------...___--------------------------------------------- ......
`lDate
Application Disapprovedfor the following reafons: ...................... -------- -------------------- --------------------------------------- ..........................
------ ----- ------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------- - .........................
Date
Permit No. ----------------- Issued .............
Date
1
THE COMMONWEALTH OF MASSACHUSETTS
c;I BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphrtt#inn for Dinpnittl Works Toutitrnr#inn ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
....�`G.Z._OG ... L•�A-n/G. I3 !?nisTi9/3G Lo7
----- --- ----------------------- -----------------------------•---------•---------••-•----.....
Location-Address or Lot No......................._��D.......................................................... ........... �►,tlT l M /? � 77r!_ .........................
j owner Addrc s's
i4b?rt7. �}�nA..
InstIller a
Address
d Type of Building Size Lot--- �....Sq. feet
Dwelling— No. of Bedrooms.__-__--.__-`'7__________________________.__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------- '------------------.-.------------------------------------------------ --------------------••---••-••-----•-----•----•-•------•-----
w Design Flow.................5 ................__gallons per person per day. Total daily flow........:33v........................gallons.
WSeptic Tank—Liquid capacity-/,5o_.e__galIons Length/B'G-".---- Width._5'9.''__. Diameter---------------- Depths_8':._-
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------/..------- Diameter------- c4._...... Depth below inlet........ ......... Total leaching area...Z_i 7_....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by 4-'P!AiA&4.... ----------------- Date.!.`. .?g:_ZQy_..y`f .__...
Test Pit No. I...4--M.-_--minutes per inch Depth of Test Pit... Depth to ground water-.__-_------___-_-.-.. _
(X4 Test Pit No. 2... ..z...minutes per inch Depth of Test Depth to ground water...... ..............
pd -------------------- --------------------------------------------------- --------------
•------------------•----------•--------
---------......
O Description of Soil G..= �'��, 1.f/oaGoy � 5`y13-tic-- 3� SA�!!a
x
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the _
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed .....a11 ' 4.1.7......-.)c......--. ...............
Application Approved Pp.roved By ----------- ...-... .ram.-�. ....-�{ .-
Application Disapproved for the fo owing reasons- ----------- ------------------------------------ --- ........ ............. ........................
------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ----------------- ---------------------------------------
Dare
Permit No. ....._.CI�" 6-�/_....... ......... Issued -.-.-.. -��+...-.._ ,..-3—
Dace
-----------------
_--------me---m®may ----m�m�.�.���.,�... -----.
THE COMMONWEALTH OF MASSACHUSETTS®o_• Y�z�y'r
BOARD OF HEALTH
TOWN OF BARNSTABLE
Qlertifirate of Q-1-nmplian.ce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
M
by _------------------- --=����� �� �< 1>--------------- ----..------------------...---- ---- - - - -
�� Installer
has been installed in accordance'with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _-� "-. ...-f----------- dated .._.3..._-.'..---....__........-------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.5. / �
DATE.-.-.. �` --...:/--.. .---------- Inspector`!,..-
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ropnnnl lVorkii Bunn#rur#inn "Vrrnti#
Permission is hereby granted------------aE �s� ,!•e ---------------------------------------------------------------------------------
f to Construct (I/) or Repair ( ) an Individual Sewage Dij0sal System
atNo---------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------•---------------
Street
as shown on the application for Disposal Works Construction Permit No.l`�f.�C2` _ Dated A-: .;2 ..........
....................................... t- J------------------------------------------•--------
Board of Health
DATE_.................... �-_" ,�..� �... --••-• . _.
FORM 3830E HOBBS&WARREN.INC..PUBLISHERS
L.
TOP OF FOUNDATION
] CONCRETE COVER
1' CONCRETE COVERS
2 13 ; 4'�CAST IRON II2"MAX. 12"MAX.
OR SCHEDULE 40 4°SCHEDULE 40 PV.C.(ONLY)
P.V.C. PIPE PIPE - MIN. LEACH
' PITCH I/4"PER.FT PITCH 1/4"PER.FT. PIT PRECAST
° -� LEACHING
o' INVE - ° Q �•`''
EL....57... INV RRT INV�DIS ¢RT n . < a•i PIT OR
SEPTIC TANK EL.. 9.7/„ BOX EL'�`'33' -. Tw
_ EQUIV.
INVERT 6, - ..'•
'je.. . .. GAL. INVERT �a 0:
INVERT :i: 3/4°TO I1/Z
EL.99•.;So w w WASHED
o � EL.4p oo ;e'� u
w STONE
et-43.eo :.:
�G 6 DIA. ,vevE
' f•�•---�o� DIA. ��ne�etD
PROFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
P 844-3
SOIL LOG WITNESSED BY :
DATE !!�R?•!4��/4S TIME.��:P�>.-!'X. L-'Dk//ar?D F !3A.e/�S/ BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 ENGINEER
ELEV. ./a/04 . . ELEV. /d/.•.SQ. . .
77=7' 77-IM F
Woe DLoAM WAfiDLosr�Y
gs"o-So.` 3e1, a Spa-Se,` DESIGN DATA :
Az- F8,S-o ErL.f/r,eo .3
4L� NUMBER OF BEDROOMS
Pm, TOTAL ESTIMATED FLOW GALLONS/DAY
BOTTOM LEACHING AREA . 78. . . . . SO.FT. /PIT/L:P.D.
SAID SAro SIDE LEACHING AREA . . .l88 S�. . SQ.FT./ PIT1471 Z
GARBAGE DISPOSAL (50% AREA INCREASE)
TOTAL LEACHING AREA ZC?eo SQ.FT
/4¢" lf1.
dgrf" EZ.
PERCOLATION RATE .��-SS ?1!!�''� 774'0. MIN/INCH
�,o o 8y�o
LEACHING AREA PER PERCOLATION RATE .54�-.7. SQ.FT/6;pp•
No .WATER ENCOUNTERED NUMBER OF LEACHING PITS o'�!e. PT.w1rx/
APPROVED . . . . . . . . BOARD OF HEALTH �o G��T aF�S�DNE� DN A2G S/ZD&-5
DATE..
AGENT OR INSPECTOR
iN OF ��ytY►Gi
�as'�F E 0 cyo
L. T . . . . . . � �. EDWA �l o� A m►
o l
I`•_� i-E LEY 0N, 7 y
c�. 26100TA
Lazo
PETITIONER : �,rC.2.a77 �q&Z.a
LOCATION
SCALE .���:ec . . . . . DATE M,9rL. i99�
PLAN REFERENCE
8C , Ss �7e
cGssaru. '�?? '. . . . .
=�04.06 7
99 / �� #.
T
BIC
"—� 8'1
111,001 jaiiii
17
An\J fan /B . Q I ` i ` \ \ . �,9
lot
370 o s
I MW
DJ*sr. J,' 'e'E7zv boo, I y
�Y,
6 r.
1
APPLICA'.1.iuN FOR
LOCATION l-o7- '57- oGD Ti L L.9�v� / ';7 a NO. �
VILLAGE DATE
APPLICANT Boed-1- '' `4LD I'Lm
ADDRESS 00?4- TELEPHONE NO. . . .. (Non-refundable)
ENGINEER 62>1w*AZ2;1 e, � ���/ fi�RLC. `t'ELEPIIONE NO. 3LZ-So7�
DATE SCHEDULED /VJA/ZCA/
(Applicants s si lature)
ASSESSOR'S MAP & LOT NO:
Ma ' �7C PAC S7' SOIL LOG
/J��s -TIME //,'6 O IVY
SUB-DIVISION NAME /�GB� .�-f�Z �'• 84 DATE /1'1.�12• �',
EXPANSION AREA.: YES ✓NO o &.A A*Atr_ENG INFER
TOWN WATERjZPRIVATE WELL L'rrL(ilt,�,j;(�-z+';i Nl�/l.%'Iti " BOARD OF HEALTH
&e477- j9ErLd EXCAVATOR
SKETCH: (Street name, etc.:.,,dimensions of lot:, exact- location of test holes and
percolation tests, locate wetlands in proximity to 'Lost: holes )
NOTES :
ZZq•840
I Z3g7 -sue
loot
-ow F
3d i t'f r Z
jr; Lo
Z.33 Ac.
Zoo.00 '
PERCOLATION RATE: Zl-,5S 7'714-✓731/o A111^1 /"/
TEST HOLE NO: ELEVATION: TEST HOLE NO: 1w ' ELEVATION:
2 F. s'"�3-:Sa/
_7 0° "3-
4 4
5 5
G G
7 7 111,Al�'
9
,r/aNA 9
10 10 '
11 11
12 / °� 12
13 13
14 -14
15 15
1G 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD "EA RING PITS
LEACHING 'TREN.CI-IES
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS :
NOTE: ENGINEERING PLANS MUST SI-10W NUMBER .ASSIGNED ON PERC TEST APPLICATION
ORIGINAL: COMP],ETrD 7N T�ITxRP'TY 1)Y P . Imo . AND RETURNED TO BOARD OF I-IEALTI-I
COPY: RETAINED BY APPLICANT