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Home My WebLink About0035 AUTUMN DRIVE - Health 35 Autumn Drive Centerville P A = 167. 002 if r� omrford. NO. 152113 ORA 100/0 DATE : 9/6/02 PROPERTY ADDRESS: 35 Autumn Drive -----------,-ff -------- Centerville,Mass. 02632 ------------------------ ------------------------ On the above date, I inspected the septic system at the above adea� This system consists of the following: 1 . 1 -6 ' X8 ' block cesspool. S E P 2 4 LU102 2. 1 -1 000 gallon precast leaching pit. 6 'X9 ' TOWN OF BARN STABLE Cesspool and pit are in series . STABLE HEALTH VEST. Based on my inspection, I certify the following conditions: -� 4 . This is not a title five septic syste, . I 5 . This is a sewage system. 6 . The sewage system is in proper working order at the present time. 7 . Both the cesspool and leaching pit were dry at time of inspection. 8 . The stain line in the pit is 54" below the invert pipe. i SIGNATUR Name : J . P . Macomber Jr . ---------------------- C0ripany : Jos ep P,_ Macomber & Son, Inc . A d d re s : ba__Q2632-0066 Phone :--508-775- 3338 ------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 -\ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 35 Autumn Drive Centervi e,Mass. Owner's Name:Anthony Azelis Owner's Address: Same Date of Inspection: 9 6 02 Name of Inspector: (please print)Joseph P.Macomber Jr. Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 Centerville,Mass. 02632 Telephone Number: F(1f3_77-i_3338 CERTIFICATION STATEMENT I certify that 1 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 app{oved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Z�sses _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4 Date: 5�—A-A The system inspector shall bmit 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. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:35 Autumn Drive Centervil e,Mass . Owner: AnthonyAzelis Date of Inspection: 9 6 0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: Ad have not found any information hich indicates that any of the failure criteria described in 310 CMR 15.303'or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The sewaae system is in proper working order at the nracant times r B, System Conditionally Passes: ,fW 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. a 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 existuig tank is replaced with a complying septic tank as approved by the Board of Health. `A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: . Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: '41� The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Add ress35 Autumn Drive Centerville,Mass . Owner:An bony Azel i s Date of Inspection: q 6 f o 2 C. Further Evaluation is Required by the Board of Health: k 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. I. 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: X-16 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. .4-6 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 0 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ,,0 The system has a septic tank and SAS and the SAS is less than 10 feet buy750 feet or more from a private water supply well". Method used to determine distance "This system passes ifthe 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: This is a sewage system The system consists of 1 -6 ' block cesspool. 1 -1000 gallon precast acts as an overflow from the cesspool. The cesspool acts as a septic tank.Solids , are contained in place and the effluent passes to the leaching pit. 3 I • Paee 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem Address:35 Autumn Drive Centerville,Mass. Owner: Ant-hrin)z A7,pl i s Date of Inspection: q/( 2 D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no" to each of the following for all inspections: Yes No ackup 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 th distribution box bove 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 'A day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number _ Lof times pumped _JL'� . Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. /Any portion of a cesspool or privy is within a Zone 1 of a public well. < portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply — /tdhe system is within 200 feet of a tributary to a surface drinking water supply '`the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered -ves" 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. 1 4 Page 5 of I I OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 35 Autumn Drive Centervi e,Mass. Owner: Anthony Azelis Date of lospection: 9/6/02 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 ere any of the system components pumped out in the previous two weeks ? 2Has the system received normal flows in the previous two week period ? J Have large volumes of water been introduced to the system recently or as pan of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note iA _ 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,.�uding the SAS, located on site ? Were the e tic 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: Yes no J�Existing information. For example, a plan at the Board of Health. G� Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 35 Autumn Drive Centerville,Mass. Owner:Anthony Azelis Date of Inspection: 9/6/0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): k:57 Number of bedrooms(actual):_ 1� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedroomsjX), J'/� �d Number of current residents: .2 Does residence have a garbage grinder(yes or no): .(� Is laundry on a separate sewage system (yes or no):.Wa (if yes separate inspection required) Laundry system inspected yes or no):, Seasonal use: (yes or no): S Water meter readings, if available (last 2 years usage(gpd)):2000-22, 000 gallons=60 . 28 GPD Sump pump(yes or no): .C1'3 2001 —1 8, 000 gallons=49 . 32 GPD Last date of occupancy: COMM ERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 4,14 gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): " Industrial waste holding tank present (yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):" Water meter readings, if available: /Q Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no)• 6� If yes, volume pumped: /� gallons -- How was quantity pumped determined? Reason for pumping: T}',PE OF SYSTEM il/f Septic tank, distribution box, soil absorption system / Single cesspool Overflowx4&&peol/AV d Privy ti0 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 objained from syste owner) _Tight tank Attach a copy of the DEP approval 4 Other(describe): I-e)d Ap oximate as of all AompOnents, date installedhif known) and source of inf rmation: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Autumn Drive CentervillefMass. Owner:Anthony Azelis Date of Inspection: 9[6/02 BUILDING SEWER (locate on site plan) 4" orangeberg pipe from the Depth below grade: Mouse to the cesspool. s� Materials of construction: cast iron _40 PVC �ther(explain : Distance from private water supply well or suction line: ,d rA' Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.The system is vented through the house vents. SEPTIC TANKdJ&r,(locate on site plan) Depth below grade: Material of construction:,d�iconcrete,4/Ametal�tl�fiberglass�l/I�olyethylene yl�other(explain) N,q If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):�(attach a copy of certificate) Dimensions: �Iq Sludge depth: �JA Distance from top of sludge to bottom of outlet tee or baffle: _y Scum thickness: Ar9 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ,e,.�9 How.were dimensions determined: sllS+9 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is not present. The cesspool acts a septic tank. The cesspool should be pumped every 2 years. GREASE TRAAC�v%L4locate on site plan) Depth below grader Material of construction;4y coneretcSkmetal-! fiberglass 4polyethylene�Wother (explain): iU/9 Dimensions: /ly Scum thickness: Distance from top of scum to top of outlet tee or baffle: ,�fJ Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 4_ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present. 7 Page 8 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property' Address35 Autumn Drive Centervi e,Mass. Owner: Anthony Azelis Date of lospectioo: 9/6/02 TIGHT or HOLDING TANK46&Lfe(tank must be pumped at time of inspection)(locate on site plan) Depth below glade: AM Material of consrrtruc : AVA concrete AM metal 414 fiberglass r-/4 AolyethyleneAl,4 other(explain): AIIQ Dimensions 4/19 Capacity: A)A gallons Desien Flow: gallons/day Alarm present (yes or no): // Alarm level: OVA Alarm in working order(yes or no):>A111 Date of last pumping: X14 Comments (condition of alarm and float switches, etc.): Tight or holding tanKs are not present. DISTRIBUTION BOXt (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: XA 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 not present. PUMP CHAMBEw,r,C►X/60ocate on site plan) Pumps to working order(yes or no): Alarms in working order(yes or no): y Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pumlp chamber is not present 8 Page 9 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 Autumn Drive Centerville,Mass. Owner:Anthony Azelis Date of Inspection: 9/6/0 2 SOIL ABSORPTION SYSTEM (SAS): Zocate on site plan, excavation not required) 1 -6 'X8 ' block cesspool & 1 -1000 gallon precast leaching pit as an overflow. If SAS not located explain why: Located: See page 10 Type/ leaching pits. number: X7 leaching chambers, number: O leaching galleries, number: ,?AL leaching trenches, number, length: Q A/, leaching fields, number, dimensions: Q overflow cesspool, number: innovative/altemative system Type/name of technology:te, j' ?� �,o Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _Loamy sand to boney medium sand to fine sand.No signs of hydraulic failure or ponding Soils are dry. Vegetation is normal. Waste water isnot present in the cesspool or pit. cROdbSStt 9lT- n th� pit 54" below the invert pipe. L �i�cesspoo m st be pumped as part of inspection)(locate on site plan) Number and configuration: ILI Depth —top of liquid to inlet invert: Depth of solids layer: Depth of scum laver: Dimensions of cesspool: 1%' Materials of construction: A&-" Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Same as above- YPRIV (locate on site plan) Materials of construction: /lam Dimensions: yA Depth of solids: � Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Priy; is no present _ I 9 PaV 10 0( 1I OFFICLA- fNSPECTION FORM - NOT FOR VOLUNTARY ASSESSME.tiT, SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM fNFORMATION (conlinvcd) ofl<� A00fcl,:35 Autumn Drive c ntPryil e Mass . O-orr:Anthon Azellas 011( 91 Inlpcclioo:9 6 SYCITCH OF SCWACC DISPOSAL SYSTEM Plo. oc I lkrlch of the l (Ill lih* ll lyllcm Inclvd(ng Ilcl to al Iteal two permancnl rcrcrcncc ItAcm,rx, otncr�nvk, l0tlit 111 .<Ill �;�1in 100 (ttl. Locilc whtrc pvbllc wilt! IVpply tnlcrl the Dviloin; i I �> Cp I iooq I 10 f - Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem, Address:35 Autumn Drive Centerville,Mass . Owner: Anthony Azelis Date of lnspection:g16/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: No Obtained from system design plans on record • if checked, date of design plan reviewed: NA y ,SObserved site (abutting property/observation hole within 150 feet of SAS) NSL Checked with local Board of Health-explain: yFSChecked with local excavators, installers- (anach documentation) _FSAccessed USGS database-explain: httA: // town, barnstable.MA.US. You must describe how you established the higgh ground water elevation: Ised: Gahrety & Miller Model 12/16/94 Ground water elevations above sea level Ised: USG-: Ohs _rva ion well data June 1992 Ised: US letin 92-000-1 Pale #2 Annual ranges of to run — ground water elevations. Leaching Pit rounowater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is f� feet. 11 ^'... .. }TL�,Tj TTII4.'TCT.IT. -.. .. .TST'TTT .�...�•.-�...F rT'iT.—n'fi�-TT�1.'lT�Jrr'I.TTlra'T.T..`TT.TT:.Tr'TT:'1'a"trtll TOWN OF Barnstable BOARD OF HEALTH - T T-- --SIJi)SURFACF 9EWAGF DISPOSAL ,SY�BTF;M INSPECTION FORM - PART D^- CERTIFICATION-TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 35 Autumn Drive Centerville,Mass. 02632 ASSESSORS MAP , DLOCK AND PARCEL # 167-002 OWNER' s NAME Anthony Azelig: PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAMEJ.P.Macomber & Son Inc:' ' COMPANY ADDRESSBox 66 Centerville,Mass. 02632 Street Town or CSty State LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX (508 ) 790 -1578 .. A CERTIFICATION STATEMENT 0I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection «hich I have conducted has not found any information which indicates that the system fails to adequately protect public hea1Lh or, Lhe. environment as defined in 310 CMR 15 - 303 . Any faililre criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection wilicil I have con acted has found that the system fails to Protect the j)ublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signat Date 94- copy of certification must be provided to the OWNER, the BUYERane where applicable ) and the BOARD OF HEALI'1l. * If the inspection FAILED, the owner or.j.operator shall u pgrade ' the aystem within one year of tl)e date of the inspection , unless allowed or required otherwise as provided in 3.10 Ch1R 16 , 305 . partd .doc No. �— THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTtl 1.0Win.............OF... � �_L ....................... Appliration for Biupuuttl Works Tomitrurtion Vanfit Application is hereby made fora Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at _•... ------------------------------------------ Location-Add s ), or N. caner - Add ress W ----..... � . - 1� ,.' 'J' ;� ......... / ht"'1�� - - -- --------------------------------- Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -----•-------•-•----•-••-•-•--•. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____________________• Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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 Soil---------------------- CK. ......- l `......----------------------.-------------.----.-.....------. W V -•-•-------------------•--- ---------------------------------------- ------------------------------------------------- •--------------------------------------- •---------------- •-------------- ------------------------------------------------------------------------------------------------------------------ J, ... ......------------�--------.----------.--- 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 iITI,E 5 of the State Sanitary Code—The undersigned further agrees n t to place the system in operation until a Certificate of Compliance has bee issued by the board health. ne g . .. .. � � . at ApplicationApproved By ------ -•-• . -•---•••....----•---•--------•..........-•-••--••-••............. -•---•• ... �. ---- ....... ate Application Disapprove fort e following reasons:---------•--------------------------------------- ------------•-------------------------------------•-•-----•--- -------------------•-------...•-•--•-•••...-----------•-••-...-----------....--•--•------•...•-•----•----•------•-----------••••--••-•••••-••••-•-•-------•••-•--•--••••-•-----•----•---•••----......... Date PermitNo......................................................... Issued_....................................................... Date No. ....• ....... THE COMMONWEALTH OF MASSACHUSETTS BOARQ...-OF HEALTH 1 ............. .)...............OF...... ...... ......................... . . Appliration for Dwpatial Works Tontitrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ................................................................................................. ...... ...................... ............ ....... Location-Addregs or Lot No. . JIL ......................................................6;:.4........... ....... ------------—-- Owner 7 Address I.LZ... ................. . ....7............. ------------- ------------------------------- InstYiler Z�d'r'e"s*s Type of Building Size Lot............................S4. feet Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons____-_-__.__-_:-:___-__-___- Showers Cafeteria ( ) a4Other fixtures ......................................................................................................... ........................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width.._............_ Diameter._.._-_......... Depth................ ' Disposal Trench—No..................... Width_......-_........... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No..--._._--_-------- Diameter.................... Depth below inlet....-__.._......._.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ 1_4 Test Pit No. 1................minutes per inch Depth of Test Pit._...........__..... Depth to ground water.--_.._................. Test Pit No. 2................minutes per inch Depth of Test Pit_................_.. Depth to ground water...-_--_.__.__..--_-_--. ---------------------------------------------------------------------------------------------------------------------------------------- 0 Description of Soil.......................... e� Z 1- J . ................................ ..................................................... U ......................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable----------- ................... ..I............................. ................................................................................................... .................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance 4'ith the provisions of T I T 1E 5 of the State Sanitary Code— The undersigned further agrees not to place.the system in operation until a Certificate of Compliance has bee5e,issued by the board of-health. . .........6,!..... gr ate Application Approved By. .................................................................. ........ ---E-a-be--------------- Application Disapprove or Ite following reasons:.................................................................................I............................. -------------------------7.......................................................................................................................................................................... Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .....OF. ...:.'r !�.......................................... (Irdifiratr of Tong hear THIS—IS TO CERTIFY, That the:Individual Sewage Disposal.-,System constructed or Repaired _-.by................ .......................................... ...................... t................................................................... Installer at.............. . ...... ...... ........................... ....... ............. ......................... .... --- ---�c---�e has been installed in accordance with the provisions'of TIT13 5of The State Sanitary Co m i d in the 'ell application for Disposal Works Construction Permit -------------- dated. .. ......./r-------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 'a DATE.....................................................�'. -V.. Inspector............................. ................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7"................ ..........OF......... ........................ ' .......NOA.!�.................. FEE.......::. .. Biapoaat lVorkp 05onotriv,tion rrrmit Permission is hereby granted..... to Construct, or Repair,( an Individual Sewage Disposal System '72. - .. .1 1 -1 4-- , j;-! j - i ........... at No.---- . .....-a,.;,z- . ..... ......... ..................... Street .m Works Construction .Permit as shown on the application for Disposal Dated--............ ...... ............................. ............. ...... .................................... .......................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN F BARNSTABLE J 1 1°OCATION SEWAGE # VILLAGE �.f�?i�/ 6, / ASSESSOR'S MAP & LOT 9 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) A-;b4W e�/Xq/ (size) /4®I NO. OF BEDROOMS BUILDER OR OWNER --- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility I 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 d L hing acility ( any wetlands exist within 3 ee of e facility) Feet Furnishe by I \cr ' 3 �� .7�lZ, � � ��-.Gas - _ --_�lii��e' - - �-_--- - ---- - /��9 c ofr?T'�2 �_. , . ;�.;,: ,.-. , I � r/9 ,. / `C b �� L?�- CI � , C �'� ,�. ;�;