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0018 TALLY HO ROAD - Health (2)
18 TALLY CIO ROAD Barnstable A = 298 — 070 TOWN OF BARNSTABLE LOCATION J'p y /16P `Re SEWAGE# c� o -;La/q VILLAGE dF-fa,1 ,7XeZC'oo ASSESSOR'S MAP.&PARCEL e:2 19cp INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) <-O.-ea Are CAW4 Size) NO.OF BEDROOMS PERMIT DATE: > o�'=�y COMPLIANCE DATE: Separation Distance Between the: 1-60-4f�A 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) d,�Feet FURNISHED BY _ U � feat f 3l 6 Building Sketch of 18 Tally Ho Road, Barnstable, MA 0A. Property Owner: Steven Marchessault Basement53---------- ------------ -------------------------------------------------Apt Sq Ft= 760.5 Utility = 413 110' Deck 12' 1 Kitchen Family Bath Bedroom / Den 11.5' 6 co/S 623' __ S mh ---------- S = Smoke'detector - 8' 13' Utility mh = Mini Horn H GEJ ------ co = Carbon Monixde detector S ---------------------_ G = Gas detector 14' Electrical Clos 1---------------------------------------- ------~ H = Heat detector -3 F 2' x 5' 5Y Y Building Sketch of 18 Tally Ho Road, Barnstable, MA Property Owner: Steven Marchessault 1st Floor l st Fl Sq Ft= 1173.5 53 ---------------------------- ---------- -----------------------------------------------* 1 1 , 1 1 16' 1 - 1 24' 12' Deck ' 1 Mud Kitchen Dining Bath . 1 Garage Room co/S 24' 24'' S mh S 23' H- H Porch Imh ct Bedroom E 13' Living Rm 14' S 11.5f --------=--------------------a --------------------- ---- 24' ; S'= Smoke detector 8' 45' mh = Mini Horn co = Carbon Monixde detector H = Heat detector ' Building Sketch of 18 Tally Ho Road, Barnstable, MA Property Owner: Steven Marchessault 2nd Floor: 2nd Fl Sq Ft = 1081.5 . 45 ___ (includes storage) 14' ct Bath ct 16' 6 S mh Bedroom :14' Bedroom co/S S mh S = Smoke detector 8.5 12' 1 Ict I storage _ 10.5'- mh = Mini Horn storage ------ ---------------------_ co =°Carbon Monixde detector 14' •---------------------31------------------------ } Building Sketch of 18 Tally Ho Road, Barnstable, MA Property Owner: Steven Marchessault 2nd Floor: 45' 14' ct. Bath . ct 16'` Bedroom 14' Bedroom 12' ct storage storage . 17' 28 1st Floor 16 . 12' Deck 24' 53' Mud Kitchen Dining Bath Garage 24' Room 24' 8' 24 Porch ct Bedroom 13' Living Rm 24' 31.' 14' -Basement 10, Deck 12' 53' Kitchen.' itchen Family Bath Bedroom/ Den 12.5' 14' 24' 8' Office 13' Utility 12' i 31. 14 Building Sketch of 18 Tally Ho Road, Barnstable, MA Property Owner: Steven Marchessault 45' ........:..... ................................................................................... .......... .............................L 2nd Floor: 2nd FL Sq Ft = 1126.5 14 ct Bath ct (includes storage) 16' 16' S mh Bedroom 14' Bedroom co/S S rmh ........... S = Smoke 9.5' 12' ct storage :10' mh = Mini Horn storage ........... ..........................................r co = carbon monixde detecter 14' ........................................................................................................ 31' Building Sketch of 18 Tally Ho Road, Barnstable, MA Property Owner: Steven Marchessault 1st Floor 1st FL Sq Ft = 1226.5 53' . 16'. 24 12' Deck .....: ..........., Mud Kitchen Dining Bath Garage Room co/S _ 24' 24' S m h S 24' H H Porch E mh ct Bedroom 13' Living Rm _ - 14' .............1.5' ...........................:......................... . .................:.................... .............� 24' = ...........................�.......................... .. ............................................. ..................................... . ........................¢.. S Smoke . mh = Mini Horn H = Heat ; co = carbon monixde detecter Building Sketch of 18 Tally Ho Road, Barnstable, MA Property Owner: Steven Marchessault Basement 53' ................................................................................................................. ..................................................... .4 Apt Sq Ft = 662.5 Utility & Office = 564 10' Deck 12' 12.5 Kitchen Family Bath Bedroom / Den S mh 12.5' co/S 14' 24' S = Smoke Office mh = Mini 'Horn 8' 13' Utility 12' H = Heat H co = carbon monixde detecter S ............... .................. ..¢............., ...................................... ..............45 ........... .................... No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co user: PUBLIC HEALTH DIVISION :.TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for Misposal 6pstpm ConstCuttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot 0 P?'Q Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 9 00 -;,, Z> Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building !r—p No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,✓ Design Flow(min.require ) gpd Design flow provided ��J gpd Plan Date Number of sheets I-le Revision Date Title Size of Septic Tank 40' Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: . Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board th. n Date 1> Application Approved by ,flDate Application Disapproved by Date for the following reasons Permit No. Date Issued �I No. / k Fee f� VYes THE COMMONWEALTH OF MASSACHUSETTS- Entered inconpnter: PUBLIC HEALTH DIVISION.-TOWN OF BARNSTABLE, MASSACHUSETTS ; ftprication for bis o '—6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon;( ) ❑Complete System ❑Individual Components Location Address or Lot No�� /1O p?® Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ;L p dP — ,7 ra Innsst}all-ler's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. d Type of Building: I Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildina�z qr. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided �/�,loll" gpd Plan Date!/ Number of sheets / Revision Date Title �~ s Size of Septic Tank p �/©OO Type of S.A.S. Description of Soil- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: �- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of N Compliance has been issued by this Board o th. �? Jg'ned i ('.� .1�'J_.. Date Application Approved by / ; f �_ Date AApplication Disapproved b vV V v V Date / for the following reasons Permit No. / O Date Issued TH E COMMONWEALTH OF MASSACHUSETTS f BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by.C ©C`!.i/t' at �p ��/�/T ��� Ff, has been constructed ir accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ( �AM dated Installer`,/i,,��/����,yt' Designal//�j � f b y #bedrooms Approved desi n flow S" / r gpd The issuance of this •ermit shall not be c6nstrued as a guarantee that the system fun,tio;A74 �designed. Date / Inspector - - -f_ - ------------ _ - - --. _ _ _. - .._ _ -<-------------------- ------------ gel No. / Fee �•/"_' HE COMMONWEALTH OF MASSACHUSETTS " PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal 6pstem Construction hermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction,Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constr c on mu t e co leted within three years of the date of this permit. Date P/1� Approved by,. 1UL/23/2014/WED 08:42 AM FAX No, P. 001 Town of Barnstable Rc -alatory Services a Richard V. Scal,Imterim Director Public Health Division Thomas McKzp,Di"etor 200 Main Strezt Eyannis,TMA 02601 office: 508-862-464- Fax: 508-790-6304 hstaller&Designer Cerdfication Forma Date: - ZO, Sewage Pexmit.� Assessor's maplParcel t Designer: Znstalder� 1 �. Address: ✓ a _ Address: On /s1 � was issued a permit to install a t (date) (i�astaller) septic system at b sed on a design drawly by duress) 1 � - �� dated (designer) I cent that the septic system referenced above.was installed substantially according to �Y � y —" the design, which may include minor approved changes such as lateral relocation Of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (Le. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision Or eez'tified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co ance with the terms of the 11A approval letters (if applicable) �Ss�ip�tn) IAAp�dS$n*�Itl�� §0N(I1as ,1 ls T S (De (Affix Desia � p Here) PLEASE RETUIC TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED Ui TIL BOTH THIS FORM AND AS- BYTILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC ERALTE DIVISION. TEAK YOU. Q;1Sgtic Desiper Certification Form Rcv 6-14-13.doe r Town of Barnstable P# '. Department of Regulatory Services n,er rA s Public Health DivisionMAM Date n�3q 200,Main Street,Hyannis MA 0260d +-•> . L Date Scheduled_ Time Fee,Pd: Soo `uitac`biiity As ,esSmentfdr Se e Performed By:_Tk) `Witnessed By: g LOCATION& GENERAL INFORMATION Location Address / g. T�.ezy. f�® �® Owner's Name ,S'.�l-d 6qGG � Address Assessor's Map/Parcel: O 9/ Engineer's Name /��✓rf' �� NEW CONSTRUCTION REPAIR Telephone# 6a Land Use. Slopes(96) Surface Stories a Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other. ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,I ate wetlands fin proximity to holes) 73� t Parent material(geologic) Depth to Bedrock 7. Depth to Groundwater. Standing Watei in Hole: Weeping from Pit FpCe Estimated Seasonal High Groundwater -- - -_- DETER NATI.ONFOR SEASONAL-HIGH-WA-'TET) 'I'ALLr -_ Method Used: Depth Observed standing in ohs:hole: in, Depth to soil mottles: In. Depth to weeping from side of obs.hole: __ in, Groundwater Adjustment ft. Index Well# Reading Date: . . Index Well level. �,.Adj.factor m 4 Adj.Groundwater Level, PERCQLATION TESL' Observation Hole# Time at 9" 1 . t/ Depth of Pero Time at 6" Start Pre-soak Time @ Z r 1�� 'rime(9"-6") End Pre-soak pp n F Rate Min./Inch ' 1 L✓ �' r4° . Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Heath Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders. o isistency.%Gravel) 0 L.t-5 > l 7 4 ,�7V� DEEP 013SERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ra .DEEP OBSEIIVk ON HOLE LOG ]EYole# Depth from Soil Horizon Soil Texture1 Soil Color Soil Other Surface(in.) (USDA). . (Munsell) Mottling (Structure,Stones,Boulders. P Con i to O i DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. �D:� In jW t >� IF,lood Insurance Rate Man: Above 500 year flood boundary No Yes ._ Within 500 year boundary No Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious majerial�exist in all areas observed throughout the area proposed for the soil abs tion system? If not,what is the depth of nat rally occurring perv' us in terial? Certification { I certify that on ` (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performe by me consistent with . the r9quired training,expertise and experience described in 310 CMR 15.017. Signatur Date Q:WEPTiCkPERCPORM.DOC r, Crocker, Sharon From: Crocker, Sharon Sent: Wednesday, August 07„ 2013 2:42 PM To: Dabkowski, Cindy Subject: Denied - 18 Tally Ho Rd, Barnstable " 14 2013 08 07 14 40 _40.pdf(357 K... The fax did not go through,so I am sending this way. Sharon ,xq ... 1 Town of Batnstable health Inspector FIRE Tp Regulatory Services Office HOW'S�p p wti b 8:30-9:30 Thomas F. Geiler,Director 3:30—4:30 BARNMOLE, Public Health Division 9 MASS. 039. A� `,Chomas ilkl.cKean,,Director ArFD MAy 200 plain Sheet, Ilyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTI®NNAIR]E Date:Tune 26,2013 1. General Information: Size of Property: 1.12 acre Address: IS Tally Flo Road Barnstable, MA 02630 Mal)/Parcel: 298/070 Name:Steven M:Marchessault Phone a': 617-240-91.00 2a. How many bedrooms exist at your property now? 4 2b. Are you planning to add ariy bedrooms?NO If yes, how,many? 0 2c. Flow many bedrooms total are proposed at this property(including the amnesty Unit)?4 (2 bedrooms in:klain House and I bedroom in accessory apartment) 2d. Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed anuiesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to I.nrblic sewer? 1V0 If thedwelling is connected to public sewer, skip questions#4 throueh 49 below. 4. Location of dwelling is Orric' a Saltwater:Cstuary Protection Zone? 5 . Location of dwelling is Ocri,.ricer a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an PUBLIC fVATER? c 7. Is a disposal works construction permit oil file? JYES or NO s S. If yes;how many bedrooms were approved.according to this permit? Bedrooms. t 9. \here any building permits obtained for construction of additional bedrooms? YES or iV 10. Is there an engineered septic system plan on file at the Health Division? YES or: NO 11 Flas the septic system been inspected by a DBP certified inspector within the last two years? YES, or NO - -- --- ------- — ---------- = --------- ------ -- ---- _-- ----- ------- - -- ---------- ---- _.. FOR OFFICE USIA ONLY bP �t �e I?t�Ulic Heat Dtvtsron has no objection t0 bedrooms at this property, Special Conditions: Date: Jj I a ' McKean, Thomas From: McKean, Thomas Sent: Thursday, July 18, 2013 4:03 PM To: Dabkowski,Cindy Subject: 18 Tally Ho Road-DISAPPROVED Good afternoon, I reviewed the septic system information for 18 Tally Ho Road. The existing septic system is too small for this proposal of four bedrooms. The only option would be to have the homeowner upgrade the septic system to sufficient size to accommodate four bedrooms. a, T.McKean � v i r . Town of Barnstable Health Inspector pF114E rqk, Regulatory Services Office Hours .l, 8:30-9:30 �.� Thomas F.Geiler,Director 3:30—4:30 MRNSTABM MASS, Public Health Division 9 039. ��� � � Thomas McKean Director ArFD MA'I A 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 _ _ Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE, Date:June 26,2013 1. General Information: Size of Property: 1.12 acre Address: 18 Tally Ho Road Barnstable,MA 02630 Map/Parcel: 298/070 Name: Steven M.Marchessault Phone#: 617-240-9100 2a. How many bedrooms exist at your property now?4 2b. Are you planning to add any bedrooms?NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?4 (2 bedrooms in Main House and 1 bedroom in accessory apartment) 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is Out ' a Saltwater Estuary Protection Zone? 5 . Location of dwelling is Out a a Zone of Contribution to public supply wells? ✓ F 6. Is the dwelling connected to an PUBLIC WATER? '. ru; OES 7. Is a disposal works construction permit on file? or NO ' .> -73 8. If yes,how many bedrooms were approved according to this permit? Bedro°bms. ti 9. Were any building permits obtained for construction of additional bedrooms? YES o N(� 10. Is there an engineered septic system plan on file at the Health Division? YES or nNO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ---- - -- -------------------------- ------------------------- ----=----------------- - — FOR OFFICE USE ONLY e P -ublic He-a IVlsion has no objection to bedrooms at this property. i Special Conditions: Signed: R Date: McKean, Thomas k From: McKean, Thomas Sent: Wednesday, October 02, 2013 4:28 PM To: Dabkowski, Cindy Subject: RE: 18 Tally Ho Rd Yes, if a DWCP permit is obtained before requesting approval from the Health Division for a building permit. -----Original Message----- From: Dabkowski,Cindy Sent: Monday,September 30, 2013 11:55 AM To: McKean,Thomas Subject: 18 Tally Ho Rd Hello Mr. McKean Mr. Marchessault of 18 Tally Ho Rd Barnstable has agreed to upgrade the current septic system to accommodate the AAAP bedroom. Will you be able to sign off on the Accessory Affordable Apartment Program Questionnaire- contingent upon the septic upgrade? There is CDBG funds available to assist the homeowner in the cost of the septic upgrade however that is contingent upon Mr Marchessault receiving a comprehensive permit. I will assure you that the comprehensive permit will have a condition pertaining to the septic upgrade. Cindy Dabkowski Affordable Accessory Apartment Coordinator Growth Management Department 367 Main St Hyannis, MA 02601 508-862-4743 1 McKean, Thomas From: McKean, Thomas Sent: Thursday, July 18, 2013 4:03 PM To: Dabkowski, Cindy Subject: 18 Tally Ho Road -DISAPPROVED Good afternoon, I reviewed the septic system information for 18 Tally Ho Road. The existing septic system is too small for this proposal of four bedrooms. The only option would be to have the homeowner upgrade the septic system to sufficient size to accommodate four bedrooms. T.McKean i McKean, Thomas From: McKean, Thomas Sent: Wednesday, October 02, 2013 4:28 PM To: Dabkowski, Cindy Subject: RE: 18 Tally Ho Rd Yes, if a DWCP permit is obtained before requesting approval from the Health Division for a building permit. -----Original Message----- From: Dabkowski,Cindy Sent: Monday,September 30, 2013 11:55 AM To: McKean,Thomas Subject: 18 Tally Ho Rd Hello Mr. McKean Mr. Marchessault of 18 Tally Ho Rd Barnstable has agreed to upgrade the current septic system to accommodate the AAAP bedroom. Will you be able to sign off on the Accessory Affordable Apartment Program Questionnaire- contingent upon the septic upgrade? There is CDBG funds available to assist the homeowner in the cost of the septic upgrade however that is contingent upon Mr Marchessault receiving a comprehensive permit. I will assure you that the comprehensive permit will have a condition pertaining to the septic upgrade. Cindy Dabkowski Affordable Accessory Apartment Coordinator Growth Management Department 367 Main St Hyannis, MA 02601 508-862-4743 1 „< Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments yf 18 Tally Ho Road _ Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information � forms on the computer, use 1. Inspector: only the tab key �� to move your Brad J White cursor-do not Name of Inspector use the return key. Wind River Environmental Company Name y V"Rr� lR0. Box 85 Company Address . North Carver MA 02355 City/Town State Zip Code 508-962-0728 Telephone Number License Number B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority (A jj�� 10/04/07 Inspector's Signatur Date The system ins ector 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. k-J ****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 P Y the same or different conditions of use. 16tallybordbarnstable•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 1 of 11 +,.1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets pass criteria. Recommend annual service and installation of effluent filter on outlet. 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 yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(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 will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ' 18tallyhordbarnslable•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts F - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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: ® ❑ 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(5)] 18tallyhordbarnstable-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 57.53 gpd Sump pump? ❑ Yes ® No Last date of occupancy: Approx 9 1/2 months Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped after inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,000 gallonsgallons How was quantity pumped determined? Sight tube on truck Reason for pumping: Check tanks structural integrity Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System was upgraded in 1998 per as built plan of the septic system. Septic system was original Were sewage odors detected when arriving at the site? ❑ Yes ® No 18tallyhordbarnstable-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is Barnstable MA 02630 10/4/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 19" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition.No evidence of leakage in or out of piping. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5'-7" x 6' x 8'-6" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Measured 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees are in good condition. No evidence of leakage in or out of tank. Tank appears to be structurally sound. Recommend annual servicing and the use of an effluent filter. Grease Trap(locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons , Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is level with no evidence of leakage in or out of box. Box is down approx 24" below grade and only has one outlet. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Tally Ho Road M Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil is dry. No signs of hydraulic failure. Vegetation is normal. No evidence of pondin . 18tallyhordbarnstable-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 a> Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,'t '< 18 Tally Ho Road j i Property Address •,� Chris Bade Owner Owner's Name . information is � . required for Barnstable MA 02630 10/4/07 � every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) k Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or ben hmarks. Locate all wells within.100 feet. ` Locate where public water supply enters the buildin ' Rcplt f y ��, f I $ . 4 ,2 ` ,,�181allyhordbamstable 0$/08+ Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 �' I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Tally Ho Road Property Address Chris Bade Owner Owner's Name information is required for Barnstable MA 02630 10/4/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 7+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1998 Date ❑ 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 ground water elevation: Taken from as built plan of septic system. No indication with a slope off to the side of the property as well within T of surface. Bottom of s.a.s. at no more than 5'-6" below grade. As built plan indicates no indication of groundwater@ 9'+. System is above estimated seasonal high groundwater, 18tallyhordbarnstable•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 _ TOWN OF BARNSTABLE,., LOCATION /7 ll 6 VC1 SEWAGE # �� VILLAGE , O 4 / ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � �0- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 0 '0 (size)NO.OF BEDROOMS BUILDER OR OWNERA,�&A 4 ,9 U PERMTTDATE: /. COMPLIANCE DATE: L V Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � � � ��-_� - � �� � `.. � � _ ,, �- r - �- •_ r No. !! 7 Fee$5 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migozar *pMem Construction i3ermit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 3 6 2—9 41 8 18 Tally-Ho Rd, Barnstable,MA Donald Murray 18 Tally-Ho Rd Assessor's Map cel �7� Barnstable,MA Installer's Name,Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No. WM E Robinson Sr Septic Sry PO Box 1089, Centerville, MA 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( np Other Type of Building No.of Persons Showers() ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of a new D—Box, new TeeWye, and three H-20 infiltrators 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 issued by this oaz cf Health. f Signed � Date/�� c�� Application Approved by — rep Date Application Disapproved for the following reasons Permit No. �/' Date Issued "' _ TOWN OF BARNSTABLE LOCATiON'''�g / SEWAGE# VILLA "' AJ'°A *- f lydb��' � ASSESSOR'S MAP&LOT � INSTAUtit'.S NAME&PHONE NO. d b i SEPTIcIANK CAPACITY . LEACHRjrj FACILrrY: (type) 3/'�a �' (size) NO.OF H bROOMS _ BUILDEt O t`OWNE c� PERMIT'iATE: COMPLIANCE DATE: /-/,;t Separatfon Distance Between the: Maximum;Atljusted Groundwater Table and Bottom of Leaching Facility Feet Private VWate 'Supply Well and Leaching Facility (If any wells east on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within300 feet of leaching facility) Furnished�y:> #. ,y'��J! .. . ! .. ' ... -..»e«- ....�-..-... ...w--... .. ..i..�........ ...r v. r .... ..9.y.ri.rar.w+... w..«..w....._. qw../ r# � F No. / CJ-:r Fee $rJ 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS xv 0(ppYication for Migpozat *patent Cori.5truction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑IiidiWual FCC ponepft§ Location Address or Lot No. Owner's Name,Address and Tel.No. 3 6 2—9 2 1 8 18 Tally-Ho Rd, Barnstable,MA Donald Murryry 18 Tally-Ho Rd Assessor'sMap/MCM Z1,7— 0700 Barnstable,MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. WM E Robinson Sr Septic Sry PO Box 1089, Centerville, MA 02632 Type of Building: - 7 , :��.A u� Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( n)O Other Type of Building No. of Persons Shcwers( ) Cafeteria( ) Other Fixtures Design Flow gallons per da/C46culaCed daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of a new D-Box, new TeeWye, and three H-20 infiltrators Date last inspected: Agreement: , The undersigned agrees to ensure the construction and maintenance of the afore described on-s to 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 issued by this oar f Health. J Signed $-_ Date Application Approved by Date Application Disapproved for the following reasons Permit No. 7 Date Issued --------------------------..----_------- THE COMMONWEALTH OF MASSACHUSETTSi' BAR STABLE, MASSACHUSETTS Murray / f ., - ' . ✓` � �ic�te o�'`c�ont�Yiar�ce �`� THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( x)Upgraded( ) Abandoned( )by at 18 Tally—Ho Rd, , Barnstable has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9417' y dated /r Installer Wm E RobinsonbSr Septic Sery Designer The issuance of this permit shall not b construed as a guarantee that the system ill-fun\tion as designed, Date Inspector � . --------------------------------------- No. ,f Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Murray Miopooar OpMem Con!6truction Permit Permission is hereby granted to Construct( )Repair(xx)Upgrade( )Abandon( ) System located at 18 Tally—Ho Rd Barnsta the, MA Installer: Wm E Robinson Sr Sej3tic Service and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this p r Q Date: /� Approved by t 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, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated��'^� concerning the property located at 18 Tally-Ho Road, Barnstable, MA, meets all of the ` following criteria: * There are no wetlands 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 with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) r— B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: a� G DATE 7` LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). F 6d' j® z— z6 C� THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA _.... ...........OF............... .. ................... Appliratinn -for Uhipaoal Worku C omitrurtion Perutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 3,q ................. .....0.0 Loc ti n-Address or Lot No. Owner Address a ..............f l--a=-•--••-....-•----•-•---............-•--------•--•••••......--•.... ----•-----.......----------•----•--...... ........----•-••--•----•------•------------ Installer Address UType of Building Size Lot----'i�A.®�0-........Sq. feet Dwelling=No. of Bedrooms------------- ___________________________Expansion Attic (P-j' Garbage Grinder (A14 `4a4 Other—Type of Building ............................ No. of persons...___ ------•-•---••---• Showers (4 ) — Cafeteria ( ) G4 Other fixtures ------------------------------ - W Design Flow-------jP........•....:..............gallons per person per day. Total daily flow.............%3-®P------------------gallons. WSeptic Tank rLiquid capacitv/00.0...gallons Length................ Width...... Diameter................ Depth_---.---_---.--- x Disposal Trench—No- -------------------- Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No.....�............. Diameter..../odQ.0 Depth below 'nlet...._.___....._..... Total leaching area.---..-___ _____sq. ft. z Other Distribution box ( ) Dosing tank ( ) tl,�'— Al- 3 v — 76 P. aPercolation Test Results Performed by---------------------------------------------- --------------------------- Date--------------------------------------- a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water...---.-_---..-.--.----- rXq Test Pit No. 2----------------minutes per inch Depth of 'Pest Pit--__-_-_--_--______- Depth to ground water---------------.-___-.-. R, �---- ---------•---•. a 0 Description of Soil ' :_. .`�... _ � 'y = UW -------- ---••. ./ ------ --- 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 Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued a board of Signd- .. -- .... -• •...................................... •------------ --- Date Application Approved BY---------------- --- ---------- ..-..�!.-.71,P------ Date Application Disapproved for the following reasons----------------------------- ---------------- --------•------------------...•--••--•-----•••••--------------... ...----•--------------------------------------------------------------------------------------------•--•-•----•--------•-•-----...--•-•••-------••-•------------------------.......--------------------- Date Permit No......................................................... issued jQ � ------ Date No.----.....`��-_3. Fizim ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA H -+.----------OF............ e. ... ... ... Appliration -for Bhipwial luorkii Cnnni#rurtinn Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: !Q.. f••�/1......-- D---- F�€�aJSTAF�I=:...............•--. ...........R-C).................................................... Locati n-Address or Lot No. `RR�IV E_--..../-�xliyn/uN '!J--..._GC1�2�1� �,Awl Owner Address a ...............fi-�-13...............••-.------•--------•---•--•-------••--•---•-•--•---- ................. - ....----•--•-•-------•--------•------------ Installer Address Type of Building, Size Lot_--__:y�_p.�_..._._Sq. feet �-, Dwelling—No. of Bedrooms-------------3--------------------.------Expansion Attic Garbage Grinder Other a —Type of Building ----------------•----------- No. of persons------ //11-................. Showers (a) — Cafeteria ( ) Otherfixtures _--•----•---------------------------------•---------------------•--•-•--------•-------- W Design Flow...........5_~d...........................gallons per person per day. Total daily flow._____..____.�0!-_______-__-__-__gallons. WSeptic Tank—Liquid capacityJ00--gallons Length________________ Width................ Diameter--.............. Depth_-_-__---_--- x Disposal Trench—No- ____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No------/............ Diameter____- SP Depth below inlet____________________ Total leaching area-------...........sq. ft. z Other Distribution box ( ) Dosing tank ( ) 640'— `V v - 76 �Xj Percolation Test Results Performed bY.......................................................................... Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---____--_____--_-__---- fX, Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water----------------------- - . Description of Soil_____ --d.rl� 7/ 2 U fW ----- ------------------- — t/Lr = (,(_L ......1 rt UNature of Repairs or Alterations-Answer when applicable________________________________________--_-____-_______________-____--._-._----__--_-______---. --•--------------------•---•--•-•---•-•----------•----..._.--•---•----•------•--------•-------•----•------•• --•----•------------------------•-••••-------------------------------- ------•-• --•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued e board ,{of�health. ZZ __ �`-1� Date Application Approved BY !`#�'�'J -//-Dal -�-•-•-- -_------ --- '`✓ Application Disapproved for the following reasons______________________________________________ -•--------------____....._._________.______________..-_- --...----•---------------•-...-•-•---•---•--•-----------•-•----------_...._---------•----_ ..............----------••-------•---------------------•--------•-----------------••-•-----------•-----_----- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O, HEALTH �; i --,' .- �1.........OF...... 1� . ............ �rrtifiratr of T"amplidnrr .— TH, S IS O CERTIFY, That the/fndividual Sewage Disposal System constructed. ( ) or Repaired ( ) by...-..7 �- - �L-�'- ., ter - -----------=- t - ' �j staller at.-_ -_ _ !�'c--_yl•-�•,-: �r� vYr?+5..._.__ / r` of-C�'t_ / �. 9t/t L i has been installed in accordance with the provisions of Ar ' X,of Tl tate Sanitary Code as describe in the application for Disposal Works Construction Permit No.... ___._v __ _____________ dated-_-___ --"___-___--.____--'_,/ .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F NCTION SATISFACTORY. v DATE , ------------------------- --- -----•-- Inspectors . •............................ i THE COMMONWEALTH OF MASSA ETTS BOARD OF HEALT No FEE__ ", Di.svalittl' arkfi Trrn 11r�tr14m. Vrr n1 Permission 's eby granted_________ -____ } �; - 1 to Constr t (/) or Repair ( ) n I, dividual Sewv Dis o al S st at No. ; 1 `('f -' ;;�` 1 - ....... ... .-.:. treet as shown on the application for Disposal Works Construction P'rr��iit No. __-.:.__1 ated_____ __fit 7 ✓' DATE-----------^--------------------(�-•----------------------- ................. Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS C LOT A C_U? C� sit i n 4/ r7.,' f 7-o NE. S/LL LLL✓______ FAT 480✓e LaOAD PI-Or PL. A IV LOCAT/ON: SCALD— / a �4�ZIAT& PI-AA1 2EFE.LEn/CZ : BC--IIVG Lo-r B& AS S//Ok//v /&V P4AA1 Sool< 9C' - �� w n I NE26eY CEVr/,r 7;�•/A 7- Tye EX'IS`7-- y y CAS T f-R�4p� /NG F'OUn/DA r/OA/ LOCAT/p.V /S OUZZ6 4 SURv -I 45 T.�-/E $U/GD/N� �ETf3.4C�Q�QI�ie�M�iC/1 OF TiyE TOWN OF G�.o�� Lis� • e w/c c o�.�,/sr y.4 :yo n ,fir,M4 .. i ! ASSESSORS MAP : TEST HOLE LOGS PARCEL: 1) The installation shall con►i.,, with Title V a►�d Town of�„�ypn I3uard o1. Ilealth Regulations. FLOOD ZONE: �d J l �G SOIL EVALUATOR : c/— e, *M �cS� g WITNESS : r�jOc✓kl /D to/�Z.S 2) The installer shall verify the location of utiht►es, sewer inverts ,nd septic REFERENCE: --7'-- V / DATE: �!�►�L Zv e-o ! components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per loot. The first �v _ '� 22�0� 6 PERCOLAT ION RATE: .-c z N,( two feet out of the d-box to the leaching shall be level. �✓ �� �CJL� - I `' � t �tk 4) This plan is not to be utilized for property line determination nor any other 74 TH I w I TH-2 ?j H AM. � � purpose other than the proposed system installation. A0 t yj y� L ® �� ����} 5) All septic components must meet Title V specifications. l•`�/ ��' l ►L i � I 6) Parking shall not be constructed over II10 septic components. LEI { 6 A d t/ �� 1 7) The property is bounded by property corners and property lines. .10 %,!� �t, ti� 8) The property owner shall review design considerations to approve of total LOCATION MAP — U' � ` �1�1) �5 �� �� design flow and number of bedrooms to be considered for design. Receipt t w of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material 5 {L� '�✓' per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per J 4-) Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the ' w water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The tine is to be sleeved as aforementioned and maintained in place. SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the 1 ? q owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. �� ;t I 13)The installer shall verify thelocation, quantity and elevation of the sewer C�� ��:� /BEDR001WS /.T �� 'GAL/DAY/BEDROOM GAL/DAY lines exiting the dwell►ng'pr►or to the installation. t FOlfi}yry}�lS�4 � �'v ,1 5 14)` + This plan is representative only that a system can fit on a property meeting� t , '273,DO r SEPTIC TANK Title V requirements. i 86 #-,Q-GAL/DAY x 2 DA �S - eD GAL i I " / � .j USE IWO GALLON SEPT I C TAN �Xl ltq J / CIE A( i�j SO IAA SOP I 0 SYSfiEM _ �A D SIDE AREA: v�3�5 -t- I2, XJ7J' u,, T r,, ;• d /� BOTTOM AREA: I i x ) �ro . osGIST �o VC �--� 77.� E-PT 1 C SYSTEM SECT I ON g� IDS � ----- I , VIM-_ \_17' U, 1�) 1 ' GAL p-7 _ - fog !- '—`�., SEPTIC C T NK __ ��� � � ► �- 7,91 SITE AND SEWAGE PLAN LOCAT I ON : I - Ol� PREPARED ` FOR M I�, ►M►� 04 , -- - SCALE z o o i � DAV I D B . MASON ,P�S DATE: 0 11 O DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA DATE I HEALTH AGENT 508 ) 833- 2 177 M �v. -7 1,ry lzolq I l40Ly t4 qv per';7elbr