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HomeMy WebLinkAbout0028 STURGIS LANE - Health r _ 29 Sturgis Lane 4 Barnstable P t A = 278 037 f e I� o � e M I o i f L COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTERWIflVED Aor, 202002 TOWN OFBAKNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C� 0 ~1 - rn f� l O U Owner's Name: c e, r fo Owner's Address: Date of Inspection: 2 �o as Name of Inspector: (please print) Company Name: L X1 V i U— Mailing Address: n /Z 5?,Y Telephone Number:`So3,3 S— 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: LI Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Y ,, i�-`5�.V Date: :;ACC 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 how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: / �f u✓ �� v Owner: .�l✓1 S o Date of Inspection: o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Anv failure criteria not evaluated are indicated below.' Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair.as approved by the Board of Health,will pass. Answer ves,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank a111 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 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: t Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Ar✓�I S.f'o "' Date of Inspection: v 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: _ 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: . Page 4 of 11 v OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 031 : 4L4 1_ 1S `4/ Owner: 14,-1 f. 4•, 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/ _ V ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 2 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow � _ _L/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Hof times pumped v�ny portion of the SAS,cesspool or privy is below high ground water elevation. u Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. 'any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) ves no _ the system is within 400 feet of a surface drinldng 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. Page 5 of 11 ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B JJ CHECKLIST Property'Address: Owner. Date of Inspection: Check if the following have been done.You must indicate`ves"or"no"as to each of the following: Yes o . Pumping information was provided by the owner. occupant,or Board of Health vWere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period ziiave 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) J 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 th es or tees.material of construction.dimensions.depth of liquid depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: . Yes no Existing information.For example.a plan at the Board of Health. [. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION Property Address: a 1 s �'� ; f Z`—It� ,r✓154.W G, Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): SSfl DESIGN flow based on 310 CMR 15.203(for example: 110 gpd z#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):14 0 Is laundry on a separate sewage system(yes or no):XV [if yes separate inspection required] Laundry system inspected(yes or no): al ll'�V Season use: (yes or no): Water meter readings,if available{last 2 years usage(gpd)) Sump pump(yes or no):/l/✓ Last date of occupancy: u;rPr COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sg8,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: %! ze s9�' U�✓� l" Was system pumped as part of the inspection(yes or no): If-yes,volume pumped: pllons—How was quantity pumped determined? Reason for pumping:, TYPSYSTEM _Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _-Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval, _Other(describe): Approximate age of all components,date installed(if known)and sou of information: Were sewage odors detected when arriving at the site(yes or no)/ (7 Page 7 of 11 AI - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 29/ S-TV /-/ff Owner. v Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_L,,6ast iron _L40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints.venting,evidence of leakage,etc.): SEPTIC TANK:(r locate on site plan) l/ Depth below grade: 3S � 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: Sludge depth: of ia' Distance from top of sludge to bottom of outlet tee or baffle: .3 az Scum thickness: ,. Distance from top of scum to top of outlet tee or baffle: F �i Distance from bottom of scum to botto f outlet tee r baffle: How were dimensions determined: f y�e �5 T-7 c Comments(on pumping recommendations.inlet and outlet tee or baffle condition. structural integrity. liquid levels as related to outlet invert, dence of lfaka e,etc.):1 / GREASE TRAP:eOocate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other . (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition. structural integrity. liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of l i w OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: /4r✓4 i v Date of Inspection: v © , TIGHT or HOLDING TANK:6�tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass=polyethylene other(explain): Dimensions: Capacity: gallons Design 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: U' (if present must be opened)(locate on'site plan) Depth of liquid level above outlet invert: 00,-P� Comments(note if box is level and distribution to outlets equal,anv evidence of solids carryover-any evidence of le 4age into or out of box,etc`): lS G'tA6, PUMP CHAMBER& (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM!INS/FORMATION(continued) Property Address: d9 54VI I' r'S L14 ter► D,1�6�-C Owner. 14r-" -o y Date of Inspection: o 4'f SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty1/ leaching pits,number: leaching chambers,number: — OO / 4� c, leaching galleries,number: tl leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation etc.): CA ✓'1:7 E r( 0 /1 4,c � CESSPOOLS:o�cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil. signs of hydraulic failure.level of ponding,condition of vegetation.etc.): t PRIVY: 0 to 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: )9 54k4'''1f Owner•/4-V',S /c�7 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM . Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. r, :I / �_A I _ It l -3� - i tt 'i 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: d 9 ,S)'", is 4111 Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3o 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 established the high,.gro and water elp,vatiop: . I-a eves t �'��� t o S iv J' Lt g7v vie j O!� TOWN OF BARNSTABLE LOCATION - L51'U if -5 "L A • SEWAGE# VILLAGE r NsT�C L .' ASSESSOR'S MAP & LOT 2 7 63 INSTALLER'S NAME&PHONE N0. /nAYl C"D M/3eA'f SOiV 77s'�3�� SEPTIC TANK CAPACITY LEACHING FACILITY:.(type). L''LOu�CNR M/�P�c's (size) Soo G R` ;~ NO.OF,BEDROOMS S s BUII:DER OR OWNER PERMITbATE: I "-.1 - 8 COMPLIANCE DATE: i Separation Distance Between the Maxiiitum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet ( oit site or within 200 feet of leaching facility) Edge:of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) . Furnished by i 0 �-- io TE'iWN CiF BARNSTABLE LOCATION Z J`S r.0 & f S L A SEWAGE # 10 AGE A NS rid C L°e ASSESSOR'S MAP & LOT7X-a37 INSTALLER'S NAME& PHONE NO. p�f/d C f� e.0 SON 7�S3S SEPTIC TANK CAPAC=TY n a O LEACHING FACILITY:(type) .f' A10WCA(A K,3? 'J (size) S00 NO.OF BEDROOMS BUILDER OR OWNER -ars=:io PERMTTDATE: I -7. ' 9 COMPLIANCE DATE: I V Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply We!1 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 leac=ung facility) - Feet Furnished by �U s� lf b4- io 014 No. Fee $ 5 0-0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Z /_ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYicatiou for 30igool *p!tem Cow5truction Vertu Application for a Permit to Construct( )Repair(X)o Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 29 Sturgis Lane Owner's Name,Address and Tel.No. Barnstable,Mass. 02630 Robert Armstrong Assessor'sMap/Parcel 29 Sturgis Lane Barnstable,Mass. Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Res, No. of Persons 5 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow -3 1 1 1 n gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S. sting ()ngPi: Description of Soil Clay to medium fine sand- Nature of Repairs or Alterations(Answer when applicable) f-500 gallon chambt=r_q Packed in of 1 '-2" stone with 2" cap of 3/8" stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by t 's ar f lth. Signed Date 1 2/2 4/9 7 Application Approved by Date 4L - - 9 Application Disapprove for the f wing reasons Permit No. Date Issued No. — ! Fee $ 5 0. 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �r Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Z(pprication for Migpogar *pgtem Construction Permit Application for a Permit to Construct( )Repair(XX Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 28 Sturgis Lane Owner's Name,Address and Tel.No. Barnstable,Mass. 02630 Robert Armstrong Assessor'sMap/Parcel 26 Sturgis Lange Barnstable,Mass. Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Res No. of Persons 5 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3'1 1 1 n gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S. Exi si-i nq 1000 pit Description of Soil Clay to medium fine safiii. =� Nature of Repairs or Alterations(Answer when applicable) *3-500 gallon chambers packed in ''i 3' of 1y ' stone with 21 cap of 3/8" stone. 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 th'e Environmental Code ad not to place the system in operation until a Certifi- . Cate of Compliance has been issued by'fh's and f lth. 01/ / / 1� ' .• •� Signed Date 12 2 4 97 Application Approved by - Date - Application Disapproved for the fo wing reasons Permit No. 1 _{ "5 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (XX) Upgraded( ) Abandoned( )by J.P.Macomber $ Son Inc. at 28 Sturgis Lane marnstable,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will fun��n as designed. Date �2 Inspector V No. - Fee $ 50 .0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Oigozaf *pgtem Con!tructton Permit Permission is hereby, ranted to Construct( )Repai4X�Upgrade( )Abandon( ) System located at 8 Sturgis Lane Barnstable,Mass 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. 4 Provided: Construction must be completed within three years of the date of this permit. �-� Date: _ �. " ! 0 Approved by �- 10/9/97 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 ENGINEERED PLANS) I, Joseph P.Macomber ,Tr_ , hereby certify that the application for disposal works construction permit signed by me dated 12/2 4/9 7 , concerning the property located at 28 Sturgis Lane Barnstable,Mass, meets all of the following criteria: 9"e"There are no wetlands located within 100 feet of the proposed leaching facility _ •- 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. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will 114.t be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) 20 , B)Observed Groundwater Table Elevation(according to Health Division well map) 7 SIGNED : DATE: LICENI Le 2EPTIC SYSTEM INSTALLER IN HE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). q:health folder:cert 4; G � Ax ` _Lys- � ;* L Q CA T 1N S E W-A-6-E PERMIT NO. � " " VILLAGE I N S T A LLER'S NAME i ADDRESS ZtHlVtllt--- OR OWNER (/ DATE PERMIT ISSUED --� - � DATE COMPLIANCE ISSUED I� THE COMMONWEALTH fDF MASSACHUSETTS BOARD OF HEALTH _ .............. aN.....OF........... _L AVV1.1ration for Disposal Works Tonstrurtinn rumit Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System �C/ 3 � iC , -- Loca'on-Ad ass _ or Lot No. -- a ,ner '. .. ...... ._= . ddr s r �> •• ........._ Installer Address Type of Buildin Size Lot..... 7 Sq. feet. �d, Dwellin X No. of Bedrooms............................................Ex anion At is Garbage Grinder ( . .-,No. of persons_-------��______________ Showers a .—Other—g Type of Building p P (2) g Cafeteria ( ) Other fixtures ------------- .----- -• •-•-....---••--•---------•----•--•-- - - - W Design Flow-.•-_-•________.•�.�___-�__ xlloiis per person per day. Total daily flow--- .�-l�____..._............gallons.' WSeptic Tank�Liquid capacity,____ galloris Length................ Width................ Diameter__-_____.______ Depth.......,__,___ x Disposal Trench—No_.................... Width....._. ........... Total Length.................... Total leaching a rea....................sq. ft. Seepage Pit No_____ _________ iameter.......... ___._._ Depth belo inlet___.__�i__._.___. Total leachin area_-o .....sq. ft. Z Other Distribution box (� Dosing t �n ) �, -- '4 Percolation Test Results Performed b L� --i-u.S�. '^=�.................... Date........................................ ,.tea Test Pit No. 1_.__17--___minutes per inch Depth of Test Pit____________________ Depth to ground water........................ µ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - ---------------• y Description o. Soil = �t'..... >` • " ( .......................................419rd .... Ae ....1j,,A,,4 -.6....:7.4...:n--- n...-i...... LL !/ f �- ...........................x --•- .- - U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ...-----•------------------------------------------•••••-••--•-•-•...-••-•----=•---•.............-•---•------•-••----•--•••••---•••-....••-------••--•••-•••---••••••-•••••-•--•-•----•---•-•........_. Agreement; The undersigned agrees to install the,'aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasbgew"TpuedoPf the board of h lth. ..... ..___. - ------------- Sign Date ApplicationApproved By........ •- ----------- -- ---- s......_.. ..._._...--------------------------•--- Date Application Disapproved for the following reasons: -------------------------------------••--------- ........................................ ....................•-----....._......__._....--•--•---------•-•----..._...-•-----........_..-----...-----••----•---•••-••••••••••------••--•----••••--•--•-••--•-•----•------••-----••-•••--•-......••- ..... 0-` _? Date PermitNo......................................................... Issued.._ ... .............SC......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Dispu A lVotks Tonotrnrtinn ramit Application is hereby made for a Permit to Construct (ra+'j or Repair ( ) an Individual Sewage Disposal System ate- t .......................................... Location-Address& e -•---or.. Lot No. W r Owner Address a .... ..{. J rfr .... + ! "1 .A-•----•- `_�*'-�: .... �+ *. ......... , a�'a�'.e "............... Installer Address c Type of Buildin Size Lot..... feet Dwelling No. of Bedrooms.-___ _________________________________Expansion Attic 4) Garbage Grinder CLI Other—Type of Building ............................ No. of persons_...._...-- ------ Showers (Z) — Cafeteria ( ) a' Other fixt res ................ ----------------------•------- ......... --- -- --------------------------------------- Design Flow. ............... ..� Ions per person per day. Total dailyflow................ loris: WSeptic an Liquiii capacity..__:: allons Length................ Width................ Diameter-, ------ Depth......:......... x Disposal Trench N ..... .. ....... Width------- _._......__ Total Length.................... Total leaching area...................sq. ft. . Total leaching area_."' O s ft.Seepage Pit No, Di meter ____..__ :_._... Depth below/inleti ._._.._ _.. g �/.._ q. Z Other Distribution box ( Dosing to d„ . �l� 9` , `~ Percolation Test Results Performed. by, ............. Date....................................... Test Pit No 1 _. r__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......................... - -- ,� �` O Description of 9d -'� .. ` sG `- .,. .!` `�� ... �"�` r . x --------- ----- ►_..............""` ' -----•-••------------------------------ ---•-•-- -------------••-••-� .....- ,t . --- . -------- ............. � - U Nature of Repairs or Alterations—Answer when applicable_----_-__ z ______________________________ 4 ...... t -----•-•----------•--•••--•-=.................................................................................. Agreement The undersigned agrees to install the aforedescrilied Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the.State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ued the board of h lth. Date Application Approved BY --------- ---- -- .... . - Date - Application Disapproved for the following reasons:........................ - --------------------•--------•----------•-----------------•-•----•--------------..._..---------•.......--•. Date Permit No......................................................... Issued.------�7=-�---�- -------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH 1 + .....OF.............. .........:t�. ........ ,... �ler'tifi.>'tt�le of f�u�t�li�n�r�e THIS IS TO CERTIFY, Thai the Individual S wygee Disposal System constructed ) or Repaired ( ) by , _ ra+' ----- ,. '' ,O* I,nstaller at........................... •----------- .0 ._..:4.-`�.'r,/__"-4. as 4n ---------e " " ' „ ` " . ' # '----•--••------------ has been installed in accordance with the provisions of TI �. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... _ _... _ dated---.---- ¢, � `}^ ._...... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT E� NSTRUED AS A GUAR AU THAT THE SYSTEM WILL FUNCTION TISFACTORY. 2 DATE._.................. Inspector ------.------------------.---------•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF. HEALTH l. ..... ..............OF.............. I................. No....._...... � G i FEE:. lghiposat nrki TV #r init amit Permission is hereby granted....._. _.._ " *'""::.............. - M - ..............•........... ...•--- to Construct ,,� or Repair )'`an 'v u ea a is osal'System atNo» . , .._..... ............. ........................................................... ree as shown on the on or D`p s ll Works Construction Permit No. ............... Date .: •,r -1 ..... .. .__._...._ .. .-- t1 J B of y/ „zri. 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