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HomeMy WebLinkAbout0021 SCUDDER'S LANE - Health 21 Scudder Lane Barnstable P A = 258 011 r a o � I e a F a i o o , o COM11ONW-EALTH OF AlksS ACHti SETTS =` E_xEcum/-E OFFICE OF E\TVIRO\r1IEN'TAL ArFAIES DEPARTMENT OF ENVIRONMENT4L PROTECTION f ASSESSORS MAP N0: PAR D PARCEL N0: TITLE S OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSE'SSA-IENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM FORM ; PART A CERTIFICATION Property,Property Address: C�— / S� �, o�Np✓ z/--G c_. va6SO , Owner's Name: e.- Z' • � �j Owner's Address: 1 4zc. 0d, Date of Inspection: o2S D9 Name of Inspector:,LPlease print) eZ V O (S2 f Company Name: C/l/Y/0 TE Mailing Address: o 02 ��S cvvl ©oZ��oZ Telephone Number: Sod 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: aapproved system inspector pursuant to Sec '. 5.340 of Title 5(310 CMR 15.000). The s'Vstem: LU Passes Conditionally Passes � = Needs Further Evaluation by the Local Appro-,ring Authority Fails co `13 n/� - Ins ector's Signature: � /dCA Date: .sp b G3 The.system inspector shall submit a copy of this inspection report to the Approving At thorny(Boa d e Health or ~ DEP)within 30 days of completing this inspection.If the system is a shared sv� m or has a design ilO-'.'o=1G;OOJ gpd or greater; the inspector and the system owner shall subnut 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 applicaoie; and the anpro� na authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the condition:of use a that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. R 6 Title 5 Inspection Form 6/15/2000 page 1 'Page 2 of l l ` OFFICIAL, INSPECTION FORM-NOT FOR,VOLUNITARY ASSESKVIEN`TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\ FORM PART A CER/TI/FICATION(continued) Property Address: jc� c'�'��— �G�'►t� 9,16.7v Owner: Date of Inspection: Inspection Summary: Check A.B,C.D or E/ALNN4YS complete"aIl of Section D A. Svst asses: I have not found any information which indicates that any of the failure criteria described in 310 CNIR 15.303 or in 310 CVR 15.304 exist. any failure criteria not-valua ed are•indicated belov:. Comments: B.,�Sv-stem Conditional1v Passes: ✓�/ One or more system components as described in the"Conditional Pass"section need to be replaced or, repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes;no or not determined(Y;N,\TD) in the for the follow-in-statements. If"not deterrined"please i explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " *A metal septic tank will pass inspection if it is structurally sound;not leaking and if a Certificate of Compliance . indicating that the tank is less than 20 years old is available. . ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System 11 pass inspection ir-(,v:i: ., 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 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed \ND explain: — - - i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY---kSSESSANTENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM 11TSPECTION FORR1f PART ai CERTIFICATION(continued) Property address: I Sc y C NB,. : G 4 _ Owner: G vh Date of Inspection: 02 0 C. Further Evaluation is Required by the Board of Health: ✓Y Conditions exist�, hich require further evaluation by the Board of Health i-n order to dete_wnine if the s-,-srern �I B• I is failing to protect public health: safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b)that the system is not furctioning in a.manner which will protect public health,safety and the enNironment: — Cesspool or ur i%-v is \within 50 f et of a surface water _ Cesspool o, u1 ivy is«ithir_�0 feet ofa borderin-vegetated wetland or a salt marsh Il 2. System will fail unless the Board of Health(and Public Water Supplier. if any determines that the system is functioning in a manner that protects the public health.safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is vi-ihin 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«-ater supply. The system has a septic tank and SAS and the.SAS is within 50 feet of a private -,veer supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 Meet 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.laborator,'. for coliform bacteria and volatile organic compounds indicates that the weli is free from pollution fiom that=aclliz,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: ,T:N.. C T_^--'`-' Paste 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLL-N,TARY'ASSESSALENTS i SUBSURFACE SE"AGE DISPOSAL SYSTEMIC INSPECTION= FnRA-_i PANT A CERTIFICATION(contnued) Property Address: (.;:2— SC-1 �Ild r Z� - Owner LG � 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/ �/—mockup of sewage into facility or system component due to overloaded or cloa2ed SAS or cesspool Discharge or pondina of effluent to the surface of the Around or surface waters due to an•overloaded or �_QQed SAS or cesspool �/ Static liquid level in the distribution box_above outlet invert due to an overloaded or lo6sed SAS or esspool _ 11--TC ,iquid depth in cesspool is less than 6"below invert or available volume is less than , aas:fio11 t/ Required pumping more than 4 times in the last year NOT due to clogged or obsii-ucted pipes'. \'umber 9ftimes pumped �/Any portion of the SAS, cesspool or privy is below high ground water elevation. � Any portion of cesspool or privy is within 160 feet of a surface water suppl,,or tr-ibutar<-to a surface cater supply. r/�y portion of a cesspool or privy is within.a Zone 1 of a public well. _ fZny portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet aom a private water, supply well with no acceptable water quality analysis. [This system passes if thee-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,prosided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] I (Yes/No)The system fails.I have determined that one or more of the above failure criteria elist as described in 310 CVIR 15.303,therefore the system fails.The system.owner should contact-die 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 f1oNF-of 10.000 gpd-to 15.000 gpd. You must indicate either"yes"or"no".to each of the follol�-ing: (The following criteria apply to large systems in addition to the criteria above) ,3I jr s n 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— �TN-D ) or Zone II of a public water supply well If you have nswered"yes"to any question in SectionE the system' considered a sinnificart:hrea , o: "yes"in,Section D above the large system has failed. The owner or operator of any lag `a significant threat under Section E.or failed under Section D shall upgrade the syster?z un acco_d2 cL r, A f 15.; ^04. The system owner,should contact the appropriate regional office of the Depa tment.. C`-` i` Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,i k. 1' SUBSURFACE SEWAGE DISPOSAL SYSTEM INS-PE'ECTION FORIT . PAIN B. /CHECKLIST Property Address: / V Cr µ�N2 0 w ner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the folllo"z-i_ng: Yes _ o 3 Pum=;i:; -:; _icn ,vas provided by the owner, occupant. or Board of Health �Vere ai : o th ,stem components pumped out in the previous two weeks Has the s -stem recei,ed 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'? r"- Was the site inspected for signs of break out? V C-11�_ 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 houid,depth of sludge and depth of scan'! P �_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? f 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. v _ Determined in the field(if any of the failure criteria related to Part C is at issue a oro� �: n p, �-n�noL.o�d_staL,,, is unacceptable) [310 CMR 15.302(3)(b)] I I I� Page 6 of 11 I�. OFFICIAL INSPECTION FORM—NOT FOR VOLUNT-A-RY ASSESSI \IETS " « SUBSURFACE SE 'AGE DISPOSAL SYSTEM INSPECTION FORAM . PART C SYSTEM INFORMATION Property-Address: 67?-- SG / QoZG 0 Owner: G--.0c Date of Inspection: L0«" CO\DITTO\S : RESIDENTIAL Number of bedrooms (design):­7 \umber of bedrooms(actual): DESIGN flow based on 3 10 C-N7R 15.220333 (for example: 1 I0 gpd xof bedrooms). Number of current residents`_ Does residence have a garbage grinder(yes or no): A0 t Is laundry on a separate seu age system(yes or no): [if yes separate inspection required] Laundry system inspected (yes or no): <' Seasonal use: (yes or no): --(;Z 2f Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): /64 Last date of occupancy: CO VLVIERCI_AL/lNDti STRIAE Type of establishment: Design flow(based on 3 10 CVIR 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): GE\TERAL L\FOR-NIATION h Pumping Records Source of information: O�O 0 �'- C✓U-t/` Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T OF SYSTEM tic tank, distribution box, soil ab— sorption system _Single cesspool _Overflow cesspool _ Priw 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 cor •act(te be obtained from system owner) —Tight tank Attach a copy of the DEP approval Other(describe): Approximate age:of all components,date insta ed if known) as urce of infotrnaaan: Were sewage odors detected when arriving at the site(yes or no): T;tlo ; incnon};nn Lnr,, �/i GNnnn r , it Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLL'�NNTA.RY_ASSESSAIEITS'. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIIIATION(continued) Property Address: Owner: Date of Inspection: a S D BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_ ast iron L—To PVC_other(explain): Distance from private'water supply weli or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TAi\K:_(l</ ocate on site plan) Depth below grade: Material of construction: o`ncrete_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 cemficate) Dimensions: Sludge depth: Distance from top 9f sludge to bottom of outlet tee or baffle: ! i Scum thickness: 2SS— // ell- Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto} f outlet tee or baffle: How were dimensions determined: for S Comments(on pumping recommendations,inlet and ouTfet tee or baffle condition,structural integrity, liquid levels ' as r&bited to outlet invert, evidence of leakage,/etc.): J / GREASE TRAP: N(locate on site plan) Depth below grade:_ ` Material of construction:_concrete_metal fiberglass. olvethylene_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 :e_TiZ 1 ci_uid -is as related to outlet invert,evidence of leakage, etc.):' I PaQe 8 of 11 OFFICIAL INSPECTION. FORM—NOT FOR VOLUNTARY ASSESSA•TE_NTS f SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTIOIN ORI P ART C SYST -/Al INFORINIATION(continued} PropertN-Address: 0aG3-0 Owner: /_ctc..,v Date of Inspection: oZ flq TIGHT or HOLDING TANK:h: /✓ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construe corc_e e metal_fiberglass_polyethylene other(elplGin). Dimensions: Capacity: - Eons Design Flog: _ callons'day Alarm present(ye: Alarm level: _ __»l in \ orking order(yes or no): Date of last pumpin,: Comments(condition o{'alarm and float switches, etc.): - DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ltlo/ , Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover.any--,idence of leakage intojogut of box, etc.): ; � X vie,6 /� S0/ e/s . li-V PUMP CHAMBER:&0ocate 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.) Title T..cnartinn T=nrm (.(1�I'M0 l i Page 9 of i l • � OFFICIAL INSPECTION FORM—.'VOT FOR VOLLINT_4RY_kSSESSANIENTS` SUBSURFACE SEWAGE ,DISPOSAL, SYSTEMINSPECTION F022AI PART C SYSTEM IN'F/OR.1'L4,TION(continued) Property Address: / �C�v New Owner: 'Z_Orw7 — Date of Inspection: c _C D 9- SOIL ABSORPTION SYSTEM (SAS):) (locate on site plan,excavation not required) If SAS not located explain NVIIV. Type G /lam leaching pits, number:_ G` leaching chambers, number: leaching galleries;number: a S 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 veQeta�:on. etc.): O 6 h o b-G1 t14 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) \umber and configuration: t Depth-top of liquid to inlet invert: Depth of solids layer: } Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure;level ofpondina, condition of vegetation, etc.): PRIVY: d" locate( on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure. level ofponding, condition of� cetat o etc•j: f s ILI S1 ft ',i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS'SESSAIE-TS SUBSURFACE SEWAGE D - - ISPOSAL SYSTEM I�SPECTIO` � f .. _ . FORA PART C SYSTEM INFORA'IATION(continued) Property,Address: u Owner: !f—e-wr y Date of Inspection: O�' SKETCH OF SEWAGE DISPOSAL SYSTEM `gg Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmark;or, benchmarks. Locate all wells within 100 feet.Locate where public eater supply enters the building. 0n _ W 60 �'it�o Tncro�tinn 1-7n.-m (.%1,/')AAA - - f Page 11 of i 1 OFFICI_aL, INSPECTION FORM-NOT FOR N%OLUNTARY ASSESSNIE\TS I SUBSURFACE SEWAGE DISPOSAL SYS'TEMINSPECTIO\ FORtiI PART C ` SYSTEM IN'FORNIATION(con inued) It Property Address: Owner 4�G wr Date of Inspection: a �� SITE EXANJ Slope Surface water Check cellar Shallow wells Estimated depth to - ` ..r 'eet Please indicate(check.) c..,used to determine the high ground water elevation: Obta' ed from -design,plans on record-If checked,date of design plan revdetved: served site (abL_ ing propern-.obse:--,•ation hole wit 50 et S ) Checked with local Board of Health-explain: a � Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe, y established the h*o grou at7elevation: ' o p rM cs 4 Scze c•, ( ,(; (r i Tit1P {7ncnortinn l:?nr.n �/1 G!')nnn 7 TOWN OF BARNSTABLE LOCATION 2_I uUlr&EWAGE# _Z4f_ LAGE ASSESSOR'S MAP&PARCEL2-5� INSTALLER'S NATa&PHONE NO.e'l SEPTIC TAMLP C�Y t 4 At V 1 ` trams LEACHING FACILITY:(type) 1 (size) hl bn NO.OF BED OMS OWNER 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 and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY co W � I Q 1 f d t d 1 1 U9 �U� x .� Lnx N � — m , rn �, T► COMMONWEALTH OF MAwACHUSETTg EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENMONMZNTAL PROTECTION MAP PARCEL OFFICIAL INSPECTION FORM-��E 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM F ORSSMENTg S PART A M ( / CERTIFICATION , Property Addre c 02 JC d%rj$Z n , owner's Name: ,� �Sv a Oat G 3,0 G�;�i 2 1 21004 Owner'sAddreas: 1 e/sr LA,�G Date of hopecdom ,^,•� (, Oa.L,�p TOWN OF BARN ABLE HEALTH DEPPTT.. .Z O— O V / Loam of Nspector. (per pit) 7I)G?r'� pant' ame: yr 7-4L=C Mailing Addresc ov Telephone Number: 0 7 CERTIFICATION STATEMENT I certify awl lave personallicted the sewage ftow system at this below is tree,=Uffate and complete as of the time of the inspection The' address and that the information reported approved d experience in the peti�per functia and of on site sews ��Xformed�on my system inspector 3 pursuant to °II 13.340 of T1de 3( 10 CMR 11000 SY�ms.I am a DEP � The system: Passes Needs ft1ther Evaluation by the Local Fails `Ang Authority Inspectos Signature: Date: ne system mspsctor shall submit copy of this inspecho' DEP)within 30 days of completing this inspection a report to the Approving Ate,Moardd oaf Health or, gpd or 1 .the' system is a shared system or has a deli mspactor and the system owner shall submit the gn flow of 10,000 DEP.TU o ty original should be seat to the system owner and copies��buyer, o Of the aNficabk and the moving Notes and Comments 'tom UT21sreport only describes conditions at the time of inspection does not address how the �pection and ender the conditions of use at that , conditions of use. system will perform in the femme under the sane or diffe rent Page2ofli OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(conti=4 Property Address: -Owner lrPen. Date of Inspection: Q— o Inspection S°mmary. Check AAC,D or E/AL MAY complete aQ Secdon D A. S Passes: I have not found any information which indicts that any of the Fa = 15.303 or in 310 CMR 13.304 adsL Any failure caiteria not described in 31Q Cd1Rt . evaluated are d halos Commenft a System Coaditionally Passes: . �w One or more system components as de=ftd in the"CondibouW past•sectm need to be hftd or reparred The system,LVW c',omp On of the meat or repw,as aPPnNd by the Board of HrealvW pass, Answeryes,no or not d(y,N,ND)in the , for the followin expbaia, g statemmta If"not fined'ply The septic tank is metal and oven 20 years old'or the .ex1>ibitt steal infiltration a exH] SePdc tank(whethe<metal a not)is*Wmay tcation or Sys' Pass will inspecti the 8 t2uk is w0aced with i bomplyin8 septic tank as Pass on if *A metal septic tank will P�inspection if it is structurally sound,not 1 Board of Health. g that the tank is less than 20 yearn old is available �°n and if a Ctrdficatc of coruPtiance ND explain: won of sewage NNAW or break out at high stack water level in the apQroval of Board of Healthy broken,settled or uneven�box Syst=will demon if(w broken pdpe(s)me replaced obstruction is removed distribution box is leveled or repo ND expiaia: T C system Xquired Pig more than 4 times a year due to broken or obstructed pipe(s).The stem Pass inspection if(with approval of the Board of Health): win will broken pipes)are replaced dxhvcfm is removed r ND explain: f • Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES&mMS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERT/MCATION(cominu4 Property Address Owner: hI ec ✓�v� .c ���} Ooi�3� Date of Inspection: Z—of O— O y G Evaluation is Required by the Board of Health: , ons is�gC tO aOt w� am eavlronmebrtba r the Board of Health in order � miaez system pdft 1- System will pass unless Board erf Health determines in accordance system is not liutcdoning is a manner which wig rdance wrt6 310 CM A303(i�)that the protect public health,safety and the enwroument: — Cesspool Of privy is within 50 foet of a surlaoe water, C=Pro1 or Privy is within 30 fuel of a bordering vegotated wetland or a salt marsh �. System will fail Mae"the Board of Health(and Public Water Supplier,if any)determines that the system lt g is a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption water QVply or tributary system(�) }the SAS is within 100 feet of a �0° ibutary to a s udaoe water supply. — The system has a septic tack and SAS and the SAS Is within a?Are I of a public water — The system has a septc task and SAS and the SAS is within 50 feet of a private water Supply M* well. private water supply has a se�tank ands and 100 foot but SO feet or more from a well Method *'This system passes If the wen water, Wftu and volatile wrowk formed at a DEP cmdfwd lgbonftry,for colibm �Pry cfammoma intro m��me wren Dee fad=Cntex are triggered.A ropy of the � less than S MR,P w*,Idod that no other analgsis must be attached to this form. 3. Other. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR . VOLUNTARY ASSESSMENTSSDBSIIRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6�- Owner: h/ Date of Inspection: D. System Failure Criteria applicable to an systems: You MO-9indicate`des"or`W to each of the following for all inspections: Yes � � t/ SeNa� fwili1Y or system Component due to oven oaded (/olo �°�8 ot cnuent to the mf=of the g� orcioggedsASorcempool cesspool overloaded or Stalk liquid levd in the won box above outlet invert due to an overloaded Or cloggd SAS a qmd depth in cesspool is less than 6"below invest or available vohmse is less —/ p°O�°g men 4 in the last year gc�e to cl �'Sow _ �/ tim o�or odd pipe(s).Number portion of the SAS,c0sp001or PUY is/ below f water f rfcsoorpivy s mPPlyormbtaytoasace v An1��Zq ►1�on of a cesspool or pry is within a Zeno 1 of a portion of a cesspool privy is within 30 feet of a pivafw�ywpply well. pion ad a Cesspool orprivy is less thaw 100 feet but supply well with no accePW*water q�, a Mbar passes feet Sum a private watts Performed at a DEW certified laborato for Psi if the web water anal ry, coliform bacteria ys� nhrnen aounds nted n�itraeni�en from e �nafloa f a t that facility and the Presence e Of ammonia am fired•A copy of the equal to or leas than 3 PPm,provided that no other faflnre criteria analysis must be attached to this form.] (Yes/No)The system t I�, described in system C11olt I have therefore the fined that one or mono of the above failure Criteria exist as Heft to determine what will �system � �Owner should contact the Board of E. Large Systems: poi considered a loge System lire system must serve a facility with a dW flow O1r of 1000 gpd to 15,000 You must indicate either`yes"or"no"to each of the following: (The following Criteria apply to WV systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water sup* — the system is within 200 feet of a m'butary to a arfam d Hilda g water supply � ._ - .._- � a pn ti upp tlwe azea(lnteriea Wdhrod prctign "A)or a �-1 mapper IfYOU have answered"yes"to say question in Section E the "yea"in Section D above the system���red a sigoifiCad answered signi8c�nt threat under Section Wed MOM iced The owner or operator of �or �mdM Section D shall upgrade the ,, in system considered a 15.304.The system owner should cow the appropriate regional office with 310 dan of ce CML I Page s of 1l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMWS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART R CHECKLIST Property Adam: H m t- G /v at r Vol Owner: 1,Ke C;�6 e2 Date of a .1-020— Q(f Check if the Wwmg bave been dof,You most indicate ee Or"no"as to each of the fo%win Yes�fo t/ �?WnPu8 Mmllmift vvas p vided by the owner,oocquat,or Bond otHealth were way Of ft system composts pumped out in the pevlous two years Haw the**m'eCdvod normal ors in the Have L P volumes of water been Wm&ced to the Wstem receotty or as pot of this inspewon were as ba>7t plans of the system obtained and examined' (Ir they were mt availabknote as N/A) V was the faciay or d"elting ioXW hr gs<of sevvalp beck uP was the site petted f+)r son of break out ✓ _ were au system components, the 7mukks, g ►�cated on site of bates ar tees,material am° and the inteaos of the tank inspected for the condhom WaSeonsttnetion,dimensions,depth of liquid,depth of and depth of scum from owner)PmAd ma mbmahm on the proper The size and location of the&a Absorption System(SAS)on the site has beendummined based on: Yes/no g inf madm Fot example,a pl=at the Board of H fk is�)[ CMR 1S.3a2(if any offt h&m criteria 3 waled to Pit Cis at issue ofdistance 310 ( ��� r Pop 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES SMyNa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C RM SYSTEM INFORMATION P�VpeKYAddnss: �l 56,1 dCle v- Z-Itl owne,: k,eC Date Of><nspecum o— R>�s1 1ENT7AL �WCUWDMONS Number of bedrooms(dedpl): Number of bedroomsN DE (RI Bow based on 310 CMR 15.203(for ammpk 110 x# Number of curtest mddeds: 0 t of bedrooms): Does reddeaoe have a garbage grim(yes or no): Is on a separate s sys or„0);12 C¢Jcs separa�e inspection noq I 1-anndq►system iaspocted Seasondl us*:(yes or no):A/o Water rc3d0M Sumpp xMilaNg(Isar 2 years Last data ofooarpaW. w iK. C011II1 �of estate IISTIttAL Design Now(ased on 310 CM R 15.216): Basis of design flow(seat8/pets=dSgfk Grease trap pit Eyes or no):Indoat ial waft holding(salt p�— (Yes or nod— Non-sanitary waste diacharsed to the rwe 3 system(yes ofWater Last date of 'IrwailablL OOcepancY/= OTHER(describe): PumAin6 Records GENERAL EM MATTON waff Sourm of informs; no �, wr�e .� z e�-systexapumped S of the mq3Kd= If yet,volume part �ll (yes or no):,t v Reason far —How w� p�P�detened� OR SYSTEM sin— tack distribution boa.soil absorption V,,Mm —Overflow cespod _.P*7 —InamativdAhtech(if attach Previous intipoction records,ifa�,) obtained from system�) fly. Attach a copy of the cunest lion and maims conirO(to be TrSk tank ._.Attach a COPY of the DEP approval --Other(descrft). APproxmate age of all components,dfe insbdW(if lmown)and source of Lnfw m a ion 199s— zip axrl Were sewage odors detected when arriving at the site(yes or no): pap 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C J SYSTEM7":7L, RMATION(confirmed) Addin. l ✓�l �. �� /1j/� 6oZ C �� Date of of aspectlow_ •7—o-2 p— p BUMDING SEWER(locate 0�sift Plan) Depth below grade: /It Materials of consul c—d inn 4—PVC_ (Cgdwn)• Comments OR oonfid=af: evidence, 16 eta.): SEPTIC TANL site on) DqA Mater,'aof � --��berglasa polyethylene ongrWidow 1f tank is meW list agt:— is am by a Certificate of . x I Compiianx(yes or no): (attach a copy of Dimensions-Sludge depth: , Dlstaooe fraun top of dude to bottom of tee or baffle: 3 SCUM thictmess: �0 ---.L— top of sam to top of outletDi ftM tee or baffle:bottom How were �mum to bottom 0° / e Cow(on P8omsy inlet and tee or battle conditio liquid to ou"rove of etc.): n'�'�al v�egdty, quid levels ..1 a•-► � ' ✓� ,p�t GREASE TRAP:`/"ou site plan) Depith below Wade: Material of cmil (explain): concrete metal —Pol3'eth3'lene---othw Diine�ioms: Sam thick, ; Distance from top of sun fo tnp of outlet tee or bait. D of scam to bottom of outlet tee ar baffle: Comments(on p n*g rem as r 12W to outlet invert, ��outlet�0r baffle condition, �VV.bgnid levels Papa of 11 OFFICIAL:INSPECTION FORM- NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI NO FORM PART C SYSTEM INFORMATION(contimmM Pmperty Addmm SL�., Z— rvi Owner. �+/C c Date of Inspecd m TIGHT or HOLDING TANK; mst be Pnn1ed at time Of hLVmti0RX10cft an sib per) Depth below glade Material of conmmdon: conceals neetal `polyethylene ). Dincndoma: Sri►: Design Flow: Almang Alm �senor Al Dace of I v - Alarm in wo8dng order(yes or no): Ccrnments(coon ofalum and flog switches,ego.): DISTRIB>OTION B0X (if Present must be opezbod)(locate on site plan) Depth of>i W levd above outlet invert !�0/.�-ro► Ccmmmems(noft if box is level and&sufiW n to 001ft equa%any evidence of solids lealcags Woo out of box,e�r < ,say evidence of - PUMP CHAMEM. (locate on site ice) Pumps in woaddag cyder(yes or nor Alamos in woddug cyder(yes orno): Commeds(mft MOM of pmnp dMmber,condition of pumps and qVmleance%etc.): IL Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address` -S O�c19„ G- Gl/ �n 4 Owner. Date of Inspection: G— O ele SO11L ABSORPTION SYSTEM(SAS): (locate on site Plan,e=wation not regnlred) X SAS not located explain why. Type J � >� s �✓ ` Jr fit, leaching g"es,number: leaching ,number,leagge leg fi ft number,dimensions: overflow cesspool,number: mnovativewte Md"system Typ hone of technology; Commats(note cabman of soil,signs of hydraulic failu%level of pmubng,damp soil,condition of vegetation, ': 0 � CESSPOOLS: `� (Mwoal must be pumped as part of inspxdoa)0o c to on site plan) Number and comfigoradon: Depth—top of liquid to inlet invert: Depth of solids*W Depth of scum layer. Dimions of cesspool: Materials of construction: won of groundwater hallow(yes or no): Comments(PIC conftm of soil,siVx of hydraulic Wam level of pon*&condut=of vCg mdM etc.): PR1Y:G`��Qocft on Site Phu) Materials of consbud(a: Dimasions: Depth of solids; Comments(note condWon of soil,signs of hydraulic failure,level of ponding,condition of ve gelation,etc.): r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued Addrem: oZ t SG N 64�- G./(/ Owner: A—e,tn/ DaftarbRecdow SHETCH OF SEVAGH DISPOSAL SYSTEM Provide a snatch of the sewar dsposal estem mdu ft ties to at least two permanent refeceoce at benchmarks Locate aH wells within 100 fleet Locate where public water supply enters the buWng. Pro") �- 1/4 53 ✓l O�cJ { 3 -t- �j�of S K 1 S e r r Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(condmmM rropely Date of laspedion: -a o— o y Srrlt iiAM Slope Surface water c�heckcaar sballaw wens ftbimaoed depth to voond water of f Please indicate(cbe&)an metha t used to d*=be the high Smund water elevation: Obtained from system deslSp An on mwd-Mche&ed date of de p on reviewed d st<e(abutk8 p a mtylobsesvation We within 150 feet of SAS) , wit1!Ioral 8oscd of lieattit explain: Y"�g� Clod with 1ocd amakal.installers-(attach doc�ion) Ames.ud UMS database-elcplain: you most you establishedthe I r -�' gground water elevafot: • moo , Ile- Ir v r jT�®Y III of Barnstablepg THE PE••,,. ;�. °F , DePartrrlont of Reglllato.y Serviceslic fi'= �• + 1ARNBTAELE, .L�: r*iw • ...+ y - _ 200 Main Street,Hyanuis MA,.�02G01 • �,a e6y q. rya ��'� ttwJ �. � : �`—•. �XyC/(� ; � . Date Scheduled ) Time r fee�'d Foil Suitability Assessrizentfor Sewage Disposal � Witness V` y` !GPcrYonned B ( aCd � (, ey: II,OOA7 ION &�`GE E' AJL llNTQRIVIA7 IQN Location Address Owner's Name a� „L „ `+ ,��1✓�� ;��J �Y„" ' �Qr�t� ��'� ,/„�e•�4,,,``'�'., Address " ,: �..�. Assessors Map/Parcel: oZ 5(�°. '�t' �r` �., r Crigineer's Namc UW (/ VS'� NEW CONSTRUCTION REPAIR; ' ` Tele6phone ` J!/ Land Use 1?e:1 t-"f"�`^'� Slopes(%) [" Surface stones Distances From: Open Water Body Ft Possible Wet Area ft Drinking Water Well ft Drainage Way /V" ft Property Line ! ft " Otller ft P SYMTCHS (Street name,dimensions of lot,exact locations of Zest holes&perc tests,locale wellands'ln pro!tinuly to holes) N ':1�5`t1, `a. J 4-4 -y f Parent material(geologic) Ain I Depth lit Bedruck Depth to Groundwater: Standing Water.in Hole: '�' "" = _ 'Weeping fro!!)Pit ROG I 07U Estimated Seasonal High Groundwater,. '`N��' ' r• 7 t} DETERAUNA7 ION FOR SEASONAL fill l WATER TABLE `+lYl'ethoil Used S %D"eplln Observed standing in obs.prole: _ Id. Depl111U 5011 ttl9[tICY; � _ lu, Dcpth to weeping from stde'oE6�ssholc; .�,l!L GrOtllr)WatBr Ad,Juslment„ate I'P. Index Well 1# t -3\Rcading Datc: Index Well level _ �„ Ali•fBLtht' „� At��•Cltt7UntlwuteY hk4el e s PERCOLATI.ON TEST Observation j�. ' �" Hole It OQ I Time.tit 9" 'r �_.. Depth of Pere _ Time at(i" 'A� V t •7a ' •• �' 1 Stan[Pre-soak Time @ Time(9"-6") � •�.' t f' End Pre-soak Rate Min./inch ! �.�Yvw`; fir. •`• Site Suitability Assessment: Site Passed_>— Site'-Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back--- -- ***It percolation testis to be conducted vvitillll 100' of Weiland,you nlllslt Urst UOtify HIC. Barnstable Conservation Division at least 011e (1) rweel5 prior to begTiuning, QASEPT10PERCFORM.DOC -----�5r -LOG Depth from H Hole # p Soil orizon Soil Text l Surface(in.) Soil Color• Soil— (USDA) Other .. (Munsell) Mottling (Structure,Stones;Boulders, Con istenc % r;'tve/q— I n✓ Depth from DREPOpSERVATIONHOL Soil Horizon ��®]C1# E LOG Surface(in.) Soil Texture r,S,oil Colo; .,,Soil (USDA) , Other (Mrinsell) Mottling' (Structure,Stones, Boulders. Consis enc %Gravel S AlYA $'' 6 C 'r- = z,s�y>/y Boa Depth from Soil Horizon Hole# Surface 4 LOG (in.)_ Soil Tex S (USDA)) oil Color Soil Other ' (Munsgll) Mottling (Structure,Stones,Boulders. /OI/n Co siste c t] vel /'-' / sL ,0 y�z / a ✓yam ez — aN< �S • 1 I I Depth from Soil HorizonHole# Surface(in.) Soil Texture Soil Color Boll (USDA) (Munsel)) Mottlin Other g (Slruclti�e,S('Qnes',Boulders, (� Z Consi ten a I L,S /a YIZ --� 7 Goes Flood r nsurance Rate M � n / Above 500 year flood boundary No Yes ee A�P Within 500 year boundary No (1 1 l Yes within 100 year flood boundary No Yes O Dep b of Naturally_ccnsrrinL,peiyious Material Does at least fotlr;fe©t of�tafurally occurring perviaus material exist in all areas observed throughout the area proposed forth esogl absorptionste sym? If not, what is the depth of naturally occurring pervious material? _. e Ce�tflcaflon Y :. r 4•.•- I certify that on UP (date)I Have passed the soil evaluator examination approved by the Department of nvironmeotection'and that the above analy;is,was performed•by,me consistent with the regitired training, expertise and experience described in 10 CMR 15.017; / '� (/{- �" Signature_ . Dakc I . Q\SEPTICTERCFORM.DOC TOWN OF ARNSTABLE° 'LOCATION SEWAGE # i 1 VILLAGER l , -� ASSESSOR'S P INSTALLER'S NAME & PHONE NO, > , „ � �os"e aal SEPTIC TANK CAPACITY LEACHING FACILITY:(type (size) "540. OF BEDROOMS_, PRIVATE WELL OR PUBLIC WATERkoZ&b BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLtI,ANCE ISSUED: ✓ 'mil'� - } VARIANCE GR-ANTED: Yes ` No �! �V f r-e- 0 r! ASSESSORS MAP NO: 0,5 PARCEL NO: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diiipniul Work,i Towitrnrtinn ramit Application is hereby i de for a I.3 mit o C on "uct ( ) or Repair ( ) an Individual Sewage Disposal System at --...................... / -- -- - -- Loc... ----- .. -- Lot No. �.._. .--•cc_. ........... ...................•_.... Owner W ....... ......-cc - -••-•-• ........................... ....... -- . -- -• ...... ...... ------- -•- - -••- - r In er Addre - , Type of Building Siz - ot............................Sq. feet Dwelling- No. of Bedrooms.____. ________________________________F�pansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/_� gallons Length.:/_-�� Width_�3 ._--.__, Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length......_............. Total leaching area....................sq. ft. 3 Seepage Pit No.�................ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( Dosing tank ( ) '"" Percolation Test Resultt'Performed by Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-_-............... 04 O ..................... .............--••--•--- .....}................................... Descriptionof Soil . ... •-•---• . -- . . -••--•••--•••••••••-............................................... W ••-..................................................................................................... --•- ---•- U Nature of Repairs or Alterations—Answer when applicable ..__._.. = v ......--• .......... 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 s ystem in operation until a Certificate of Compliance h ��eee�issued by t board of health. Signed ...............��t----- / Date Application Approved By ..... ........ ----- ------ . ...................................:................ ........ e -7 J Application Disapproved for the following yearonr: ..................... .. ........------......--- ...... ..................................................................................................... . ... ..... ............... ...................................................... .......................----------------- Dare Permit No. ....... Issued .................................................................... Date r,,: ....-.. .-�..-«-.�s•. :t.. � -..y,�,..t �:y+S:.J:T�{,:-;t-'..+':�r..o-.•�-.��„-ris:�.....F=,+wT'',-.3:,�,�--_-..�.•�r:>...,� .�...R,..,,,...�... ...,n.-J4...._.=a:rw,..-_.._,,..� „-.. ... v ...ate,a2,�LG�"4'� s �- o a ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirotion for Di ipoml Work.6 Tonotrnrtion rrmit Application is hereby made for a Pe mit to Cons ruct ( ) or Repair ( ) an Individual Sewage Disposal System at�� Z .................................. .......:�; e, Je..... r.. ......_ ......_.....•....-_.._ .................................... t _______ Location-:�d]r or Lot No. ,- _ Owner � 1 '� ess W tla3dr vIn )�er Addr es u U "Type of Building Size Lot.......... ..................Sq. feet .� Dwelling— No. of Bedrooms.___.__: --------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.-.-----__-_-__-___-----_._. Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------I--------------------------------- WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity, gallons Length__r.�_..__ Width._�-------- Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.�_._.----- ...... Diameter.................... Depth below inlet.................... Total leaching area......... ......sq. ft. Z Other Distribution box (�) Dosing tank( ) •-' Percolation Test Results Performed by........................................................................• Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit---:............:... Depth to ground water........................ LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ... /K..---••-•----•---.-•.........- -•-•--........... Description of Soil......= t�fir� - �:f ; J -�_ ��-'�1 -------------------- x U x •---....---••................•---•-------••--•••-•----••-------•--------•---------••-•..........•-------•--- /i Nature of Repairs or Alterations—Answer when a hcable__ ---- 1_ � ----- --. ' U P PP .1� .= ....._.. •----•--------------------------------------------------------------------------------•---•-•----•.---•- .... � --v1 ---•--- � J -------------- ............ 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-beenissued by the board of health. Signed ------------ / /! /7`— ., Dace Application Approved By ............. ....� ...0 L �.--. ..........................................-----------:...............- -- .. re Application Disapproved for the following r2ons: . ................ .... . ........................... . . ..........................---....................... ............................................ ......................... ..... . .................... . ................................... ... ...........---.............. .. ........................................ Date Permit No. .........1 �� ` I �J Issued .................... :.............................. ...... Date ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ce>r#ifiett#e of GamyiianrC THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by C�. .. ---------- __--------_... ... ..... .............................._.........._ ...... .............................. .. . / .....Gr.. j....-----ny..........`� -:T ' at ............ .. .... . ..... .......... has been installed in accordance with the provisions of TI' he State Environmental 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 ....r..........: ,.. ...-<.. .........�w,,:_s .�.———----————r.—.——————--—,————ter,,———....a..a d—-- ———.—--.--——r.—.—ti--——————t—————_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.._ FEE-3 Bispiial Workii Tonotrution Wrmit Permission is hereby granted-------------- ------ -�.y--�-'._._ •----------------------•------ to Construct ( ) or Repair ( an Individual Sewage Disposal System at No..... - � a ................................................ �- - Street p as shown on the application for Disposal Works Construction Permit ------------------•--•••-•-•••••-•.•-•--•-�- \ -------------- ---------•-----------•-- Bo rd of Health DATE.............. ( - l..•• --- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS .. ; • �. e. �� . •::3 y ..... y�^ .. ..� .—__ — 14 � ^ems ., �� a � ! _ l .. '' n l _' �- -- C ,�' _ _' __ .,i. _'___ ---�— — c � — --- � � —----_— __'___--,—' 7 ,p —__ _ �� r - _ l !': _ t^��_— _ _ _ _ r f _ __. - __ _ � T — �. __ _ __ _ --- - � s . . - _— �j' ♦ � . � w ... r � .. i - ..� .i - �. i w �1§ J� 1 - .w A _ .. i s y ,. _ .. 4 F. ', .. .. �r. - ��.: � i - � - ,. �773 :ATION SEWAGE PERMIT NO. VILLAGE "/tom A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER / x C xe DATE PERMIT ISSUED DATE COMPLIANCE ISSUED D X7 -'F No..84-)71 .x- - Fss. ....1 S.00 ....... THE COMMONWEALTH CC,FzFAASSACHUSETTS BOAR® OF HtALTH .........................Tow.n......O F..........Barns table.....-----------------.......--------.............- Appliration for Disposal orks C�nnitrnrtinn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: Lane Lot..#19_.-. qu d.ex. ab1s.,..MA....02630.......................................................................................... Location-Address or Lot No. Andrew_ S._&r ............................................................... SQ.udrlar_-Eane Barn table,._5/A.....Q26 D- ...... Owner Address aA & B Cesspool._Service,..Inc,................................ $..B�.s_hQps_.T�xxa��,..H,y�artis.,..NIf�.....Q26Q1...... Installer Address Pq UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......................3 ...................... Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..........-2.............. Showers ( ) — Cafeteria ( ) 04 Other fixtures --------------------•-----------•------.....--------...---...-•---------------------------------•-----•---------------------.....-•----•......._•---•• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. 1................minutes per inch Depth of Test Pit....--.............. Depth to ground water..................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -•-••----•-••--------•--•----•••-••••••---••-•••...-----••-••--•--•-------•-•--•.......................................................................... - ODescription of Soil....Sand........................................................................................................................................................... x U ......-••••••--•---•--•••-•--•----•••--•-----•--•---.....-••-•-•--•••---•••--.......-•••••---•-----•••-•••-•••-------•-•---•---••-•-••--•---•-•......----••......... ....................................w x ••---------•---------•--------•---•----------------••--•-------------••-•----•--•...•-•••---•-----••-------•----------•--•-•------••---•-------•--••••-••---•-••--••••-----••---•---•-•---......-•-•---- U Nature of Repairs or Alterations—Answer when applicable.._iU*:as a: Qm__- ..tank, d-box and a1OOOal. stoae-- - i, ... t...(oveIoWV Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT.U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bbee-peep-issue by the bo health. Datqq Application Approved By...........................--••--•---••••----------•-•..............................•--•--_••---- ----••-•---••-8/ 84 2�1-. Date Application Disapproved for the following reasons:.................................................................... ......................................... -----------------------------------------------------------•----------------------------....------....--••--•••••-•--••-••---•------••-------•----.................................................... Date Permit No..�:-.-------•----•-••-•............................. Issued_.... .-8129184 I - ................ FElk...1- ..�o....... .'r va F- THE COMMONWEALTH Q -MASSACHUSETTS BOARD OF H ALTH .........................Town.----..O F.........Pam stable..... ............ Applirution for Disposal Works Tuustrurtion Frrutif Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at: Lane 1 Lot #19_.-..Scudder.XR4Xt1. Barnstable.-MA -02.6 0-- l .....-••••••• -------••-••--•• •-•-•--•---••-•--••-•-•---•-.....-•----•- Location-Address or Lot No. Andrew S. Keck• - Scudder cane, Pam stable. ",'A 02630 ...... Owner Address aA & B Cesspool Seryice,� Inc. 128 Bishops Terrace, Hyannis,.._=�4__...02601.........._•-----__-•- .... ........ � Installer Address UType of Building Size Lot............................Sq. feet I—I Dwelling—No. of Bedrooms..................3.......................Expansion Attic ( ) Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . WDesign Flow............................................gallons per person per day. Total daily flow-------------------------------------------_gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date...........-............................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P; .. . O Description of Soil...SDILd................................................................................................................................................................................... U ......................................................................................_................................................................................................................. UW ••--•-•----•----------------------•-------------••••--•------------•----•--••--•-•---•...---•---•------•--•-•--------------------•------•---•-•--••-•---•------•---------••-...------•--••--•----•-••-- Nature of Repairs or Alterations—Answer when applicable_installation Of a 1,500 gal. Septic tank, d-box and a 1,000 gal. stone packed leach _pit 66v6' low�l_ ..•----•------------ -------- •------• . -- ••_---•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be��ejj_ issued byy h.,e bo health. __�.. f .•- ---__••--- .....�-�-/29/a4..._ ApplicationApproved BY.................................................................................................. -----------------/ / Date Application Disapproved for the following reasons------------------•--------------------------------------------------------------•----------••--•----..._•--•-- ---••.............•••--•---•--------•-•....--•-----...-•----....•-•-•-•---...•••-•-•-•-•---.....----••-•-'•-••-••-•...------•---•----•-----•-----•--•-•-------•----•-•------•---•----•-•------------•••-- Permit No.- ....._.. ._ Issued .a u... ................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................Town.........OF.........Barnsta.ble .............................................. Ar Hr IF vEntifiratr of Toutpliturr T1�-&SBrSC ssp oEoJT�e��Yrrrri�T That InC: iv� l s` i1 DlI'S°rsi e�;t 'ygnn g act ( okb T,Repaired (x ) byLn •---•-••---•------•----------------- ---•--••---•---•----- -----•----------------••---•-•--------•• ....•-- •-- e Lot #19 - Scudder XBF., Barnstable, *stalb2b30 - Andrew S. Keck at.................. has been installed in accordance with the provisions of W IE 5 of The State Sanitary W�lgr a�, escribed in the application for Disposal Works Construction Permit No......................................... dated_...____��__``_----__-_-_---__....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS I) AS A GUARANTEE THAT THE SYSTEM WILL U CTION SATISFACTORY. 84 DATE..................3� ... Inspecto ..• -•-•----••••--•-----•••-......--••--•--•.....................•-•---•-••--••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Totwn Barnstable - ...................OF..........................-•--............ 15.o0 No.........•••--. FEE........................ Diaposal Ifork.5 Tongtrttrtiutt rrutit A & .. Cesspool Service, ...Inc.------------------------------•------.....-------••-••...._........_•-•-•- Permissa.on is hereby granted.L. to Constr>cot( # 9or_Ij �aird�r)Lane;d i uaj ebwrla � I�A Uzod - Andrew S. Keck atNo................................••- ............................ ", 84 as shown on the application for Disposal Works Construction Permit Street No.._ - ated.......................................... pp�� ------•-•••--•-........ •---- -----------------------•-----•----••••___--•-•-•--••--- DATE s/3.. c.7W...--•............................•---..... Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON - - 4f l� r r• IV 1 I } 11 1 t � Io3 J I � 4 1 t � t'+,1/ 00 r I qj I `\ I /�laT2' - :�ll'V��-;-yv.,.': t`-?lr.:v_•:., .:,.✓ /`9Esr�.� ._3f xJ L��/6'G � 4 1 TOP OF F013NDATION r CONCRETE COVER CONCRETE COVERS 4' CAST IRON I2"MAX. I "MAX OR SCHEDULE 4d 4�SCHEDULE 40 PV.C.(ONLY) P.V.C. PIPE PIPE - MIN. _T LEACH PITCH 1/4"PER. PITCH 1/4"PER.FT PIT PRECAST ° LEACHING ' INVERT . PIT OR INVERT EL • . . � DISTSEPTIC TANK ' :INVE7RT w EQUIV. BOX INVERT " �� GAL . IN.VERT 34 TO IV 2• INVERT w EL EL./� T 7,4S a WASHED LL I, i.w STONE PROFI LE OF GROUND WATER TABLE i 6Z. 5,.9 5_ t SEWAGE DISPOSAL SYSTEM NO SCALE ..' 7?/9�• :',f:' -!^./ ?N C-'977CUAJ O/— SOIL LOG WITNESSED BY TIME �, i BOARD OF HEALTH r HOLE i TEST HOLE 2 fl�w�r !r`"eIG[I ENGINEER v YI..44� ELEV. l % < <Uq„ q DESIGN DATA _ EZ �7-•,f,, >Evj� NUMBER OF BEDROOMS j ...r 'n''/' TOTAL ESTIMATED FLOW ?.. . . . GALLONS/DAY BOTTOM LEACHING AREA SOFT. / PIT li, iye'v ? �."1_v SIDE LEACHING AREA �' SO. PIT���'� �•• P• P✓ t a ii 4 GARBAGE DISPOSAL I � C, . (50 % AREA INCREASE) Ito TOTAL LEACHING AREA SQ.FT LE'�s 77/.A- :w4 1 PERCOLATION RATE . . MIN/INCH LEACHING AREA PER PERCOLATION RATE ? SO.FT/C'"oo. WATER ENCOUNTERED w 1 R17- NUMBER OF LEACHING PITS . PROVED- . . . . . . BOARD OF HEALTH . 7 !/�f•7' lC t'�-' r�;� -`7:'��i _`." �•�`✓ .Fy !.� . IE AGENT. OR INSPECTOR SO HAL " LO7 )o�/ j .5 H . SANfTAm ;'E TITIONER Architect: HEHRIGH 40MTHolA IAl BT09 98 bLEW100D VBrJ= go GARB 1-516 MA OZlsq (�C FFh 617�SI6-ZMI ��� Z?-O' 15'-6• II'4" CAnSUh211tS: Str Mmi Engineer. 811158119-A590GIATE%W. " r-------------------------------------------------------------------------------------------- TH AVE O -----------------_-_--- 6B4`a; _ GOhl1�hFJ1LMA 02I39 tom' PFh6�171�4-161Z BEAM POCM TO.W LL TD.SH3F 1`O �o E>J 60tT�4 .. �91' Ti 8,61=T S✓6'WI-YINLTiTi TD.5H3FSW r--Tl --, B,6d 7 ' Ti Ti - ----------------------------------------------- _ --------------------- — -- ---7-------- TD.W41 B[AM POGI�T 4 Er by-T VY TD.VKL U.bOr N-7 5�4;tW!J° TD.SHiFV EL.67 7 V1'I TD.518.E I -------------- BEAM PIOOMT 'O III 1 .__ TO.WILL AJOf TO.SLAB AL V EL,67-1 w ELF WL2 V 1 II AJ01Ah TO.SHELF leiIs ,— u i L_____________________ _________________ O + I '.I ' I -� Colon �--,---T--------- da - o TD.WILL TD.5H3F , , I - E1,61t7 506 O O ~ IV FIV WALL 2W KID 41�t \ _V TO.PULL A - 16J,61�758" O , ' O IZ'-* i 11 1 i_' 1 2 O A3= AM ' 2bL6. JB O' 4'-6' L2L&L 4w 7 4' O; id I '—— TO.SHELF O% ga61'-0 5l6' ------------------ ---- ---------------- -- --------- ------ - - -- W41 TO 518E TD.5H3F Ta 5H3F O% TO.WILL TD. EL 60'-0" EL 60b' L EL,6Y-T V2' F Ba 6Z4 VY EL 60-0' 10•no K L g ;j Ta Irgli TD.WN L I Z-0'FTas f 1 BEAM FOLLY EL 61 4• H+61'�' F Owners: j LANE r -------' Eu bo�AL ZBIi�Rtl�a�TABLE,MA OWSO Bru�A �solxr EHFW t F k TO.WILL Q 5Cn1L6 I/4'I'-O' - - B,62 TD.YMLL Ta SLAB tY JF O I Z 4 6 I TD.WILL TD.W W_ 6'-O' B-W L---------- BJ 6H 4' EL,61q-4• BI TD.SHOP TD.5H3F DOOR G WITH W EXTENSIONB,60-0' -STAIR STR B+E g-0' No. Revision Date I FERMIT SET NOV.13,mil i i i I I --_ Issue: s Date: PruMn No. Drawin g Name: ' q'6' , SOW �' BASEMENT w PLAN � Sheet Number. 1 BASEMENT/FOUNDATION PLAN A Architect: HE RICH THOMPSON STUDIOS 00 35 6L@WOOD ANANX GAMFJRI 7M MA 02154 PA 6193I6-214I I.". II'-O' c inSUlt8ntS: '.'^�6 � T'* S SWcblal Engineer. 945SM ASSOVATM IHG. W4 GOM40NjVft-TH AVE. \ T7---- ------- NBITON GBtIRL'MA 0219q I PHA FA74 17-2M 6 611-24a612 �° I 1 -1792 —-----------—-----------� � I I DINING UOVERED NC I I PORCH •� I I I I I I •. I I ___= --------- DN 111 IQ a 6'"'7 I I KITCHEN PANTRY LIVING ® ® 2 w' III ------- •° F,ICOVERED PORCH II II LSA/EUTN R Y ® l1 9�—i KIDNIS ENTRY/ M� __��iIII1IHFiIII 1iI IIIIII1I i tP ON ATot CD BAH CAWERED PORCH SCREEN PORCH OFFICE WALK-IN 7 ry 4�1NQ40�� I I w I I I I COVERED OO i i AM Noz II PORCH ® � MASTER BEDROOM 0 Bp1-6 4 0' L 2-6' L ------�jto'-- -- 24' ay' ' I I o BATH I I -------- --- I I I I I I ❑ _— I I I I I I I I COVEREDPORCH II I I it I I I i '•;;? ,`° I I Owners: --------- ------------ ------ ---------- eA1:sAxA a per SrAVOM LANE BARW6ARA6E IrAaLE.MA o2wo =� HALL 01 2 4 e -= 2]i' # U UP 20�• 6-0' a ►' Y44 - -- STO. No. Revision Date — -- -- PERMIT SEr NOV.IS,2011 It y Issue: Y Date: �. Pmjecd No. T 7- 9-4•9' S'4' 4'-0' 9'-O' 2' 2 S}' Drawing Name: -r-V �O 6• FIRST FLOOR w PLAN t z aS Sheet Number. 1 FIRST FLOOR PLAN Architect: HE RIGH THOMP90N 9TLOM 99 61BW00D AVEK E GAMMDW-MA 02194 PH. 6n-676-21g1 Consultants: I Structural Engineer. 94MM A99O'GATES INC. 694 COMMONWEALTH AVE _____ ______ ______ ______ ______ ______}i L❑ HB �-2 C"W61 MA 02I5q T I FA74 617-2444792 II II ---------------------- II II II 11 II L1 II ti II II I II II II II II II II II III 4i II T tl -----�— �I I I I 4LV I? ---J I II L---- ---------- rI j �I II I BEDROOM 2 I I I _ I BEDROOM 3 fn tl y II '4 * I j 10 LI tr-----rr I Y I I 11 1 1 1 1 it Di ry CD pg HALL i BATH !I,�Ii Illfffllf i I 1 j f DOM I I j2 II II I II FIT N I I I I LJ I ❑ I I r T, II I I w I I l BATH t 50 ® 'm I Nn w'roz 1 I BEDROOM 4 ------ ® i 210�' 2 #' s-�}' s-* W-*' k s-* l l ' I I ' I r� L ------------- I l I I II L II t� II II II II II II I II II II II II II----------�------i- ------7 „ Owners: - -- ------ &AME ROOM---- -------- L BJMR A!6E6RYEHRET ---------------------- _ ® i ' 219GODDea � BARN9TABL.E,MA 02690 I I I I BATH --- -------I-------------------------------------------i—- - -- - -—E SCALE,Im_V-& i _ PORCH I Xi 0 1 2 4 6 � IL ® I I I IFLA FEE I I I I I I II II __ II No. Revision Data PERMT9ET NOV.19,2011 -- — -- — s �'�• s� s�' SLR' Mew Date: �No. DmAng Name: SECOND FLOOR w PLAN �R 1 2 � Sheet Number. 1 SECOND FLOOR PLAN Architect: H MC44 7HON4-10N STWW5 99 61.Er400D AVENUE GMIBRID6f,MA 02194 PPh 617�3 F6-2191 Consultants: Structural Englneer. 51EOM A980UATE%M. 654 GOM40NWEN.7H AVE. ------ ---------------------- -------T------ p 02154 II II II II jI II I L1 tT II II II II I II II II jl II I +i II II II II II II jl II II II }I II 0 — --- ----------- I1 1 -------�---- ---- ---------------- -------—— � -- — I r rt II I II ll I II I I II I II II I I I I I I II II I I I I I II II I I I }I I II II I I I t y II II I I I III II II I I I I J I T7 I ---- I E rii it-- ----- ---- 1 ---� rZ III I II I I I I I I I ri II I I I I I p II II II II II I II II I II 1i I I F! ii T ++ ra }1 Ll II ti II II II Not i t ;i i i I I I I I Atot II L1 rrl II II II ti I TI II II II II I II II II II I Ltt II II II 7 1 __-_—____ Tl I I ----- ----- ----- ---- � I f`�,`--- ,,..fir---------------------il +t I t+ _ II II TT v II II II; II II r _ ri }rLOT ____ I I I O Q II II ;; II I g II II II II I r ' 4 IIII ;i r< iT ii i (gyp II I�--------------f+-----L---- J Q ------ ----- ---- r]� n u W I I I II II I I I � I I I I I I I I I 0 rC71 � _ I I I II II I I I I I II II I � II TT T II i Q A II -r II i I I I II II Ir- 1r11 II ----- --------- !� I I TI II ii ii ; li � I t7 t s rT II r U►702 wwa r -- --------- I j il II I I I I II I I I I II I I I I II I I I I II I I LpJ }t II _ II I I r I ------ -------- r----- -------- I �____- ________-__________ -----+__ 1 + r r —--- -----n- --��-----h lI II II II I II I _ _TF____ II II L1 r - ---- - III I I ++ I I IIIµ - �I I I I I I LL___ L II II Ir_ J I j II VWII�+ I I I I I I I I �: __ _-____�JIM rr i t I I I I BARENRA<6REfiORY L4REr \ j EAW6TABLE,MA 02690 I I II }1 II II II II II 71 ii 0 1 2 4 6 II II II II II II II II II I I - � IT I ------- II II II II IIr ---_________ II I I II II I I I I II U I I I I I I II II I I I I I I II II I I rj11 I I I I Lam__--��----�]-____x� me I I No. Revision Date JI PERMT SET NOV.15,2011 II II II II II II II II II II II II r}.% Issue: Date: Proled No. Drawing Name: ROOF w PLAN 1 ROOF PLAN s Off Sheet Number. SCALE: 1/4" = w A103