HomeMy WebLinkAbout0546 BAY LANE - Health 546 Bay Lane
Centerville
A=
UPC 12534
2.13E 53LO
parr
II
LaE
JIVII
DATE a/4 os
PROPERTY ADDRESS 5
w Centerville
MA 02632
optic system at the address above was
On the above date, the
Inspected.SYSt n consists of the following:.This
1., 1-1000 gaiton ZePt.ic tank., •
2., 1-D.izta ikut.ion &OX.,
3., 1- Peach•.ing lie-id W 2ong
Based on inspectlon, l certify the following conditions:
4., 7h.iz- i,6 a 7.itie T.ive SeRt.ic -6y'3tem.+
5., The zept.ic Zy,6tem h in 12ao12e2 wo2k�ny o2de2 at the �2ehe2t t ime.Y
SIGNATURE
Name: Robert&Paolin -
Company: Qehh P• Macomber &Son Inc
Address: P. O. Boxes
Cente +lile. Mass 02 2
Phone: 6087776a=or 508-73�
•JOSEPH P. MACOMBER & SONV NQ,
Tsnks-Ceupooli-L.epchflelds
-'Pumpgd&:Instilled
TOM Sewer donne Alons
026,32_0066
p.0, Box 66 Centeiville� M
•7788 , 77.l9.6412
COMMONWEALTH OF MASSACHUSETTS
ExEcunw OFFICE of ENviRomAENrAL,FAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TEE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLU14TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
rAAT A
CERTIFICATION
PropwtgA 546 Ray Lane
C'PntPrvi 1 1p MA nu32
owneesNomr nnna 1 d McGoldrick
OwneesAddrem &a;m2
Date.of Ian: g.f a /n 5
Nam ofinspeetor:(pbasepr Robert A Paolini
ConqmwyN=wt J_P_Macomber & Son Inc.
Address Rnx 66
[Centerville MA 02632
'fade dwwNader 508-775-3338
CERTIFWATION STATEMENT
I certify that I have personalty inspected the sewage disposal system at this address and that the information reported
ted
below is true,accurate and complete as of the time of the inspection.The inspection was performed bad on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pur-suant to Section 1 -W of TUle 5(310 CMR M000). The system:
XXX Passes
Conditionally Passes
Neo Further Evaluation by the Local Approving.Audx*ty �
a
Iimpector's Sipatwe: Dale:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthor
DFP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10.,OOd
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
***w Sis report only descrRm conditions at the that of inspection and under the candid=of use at Ad.
am This Inspection does not address tow the system wi@ perform in the future under the same or different
candilionsolum
Title 5Inspection Form 6/1512000 page I
Page 2 of 11
OFFICIAL INSPECTION;FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM.INSPECTION FORiVI`
PART A
CERTIFICATION (continued)
Property Address: r;d r, Ra jr Tan e
Centerville MA 02632
Owner: nnna 1 d menal drink
Date of Inspection: A 14, o g;
Inspection Summa y .Check A,B,C,D or.EJ ALWAYS-complete all of Section;D
A. System Passes:Ye-3
ri 0 I have not found any information.which indieatesthif 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:
Septic zyhtem iz in 20 e2 W0akjn
�2eaen .cme.�
B. System Conditionally Passes:
n 0 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.
no The septic.tank is metal.and.over 20 years old*or the septictank(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:
n 0 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:
no 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 11
OFFICIAL•INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property Address: 546 Bay Lan
Centerville MA 02632
Owner:. Donald McGoldrick
Date of Inspection: 8/4/0 5
C. Further Evaluation is Required by the Board of Health:
no 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:
no Cesspool or privy is within 50 feet of a.surface water
n 0 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:
no The system has aseptic 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.
no The.system has a.septic tank and SAS and the•SAS is within a Zone 1 of a public water supply.
no The system has a septic tank and.SA&and the SAS is within 50 feet of a private water.supply well.
no The system has aseptic 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 . vi z u a-e
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
z
f
Page 4 of 11
OFFICIAL INSPECTION FORM-NOTYOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION(continued)
Property Address: 546 Bay Lane
rp-ntPryi11P MA 02632
Owner: Donald McGoldrick
Date of Inspection: 8/4/0 5
D. System Failure Criteria applicable to all systems:.
You must.indicate"yes".or"no".to each of the.following.for all inspections:
Yes No
_ X 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 tbaground or surface waters due to an overloaded or
X clogged SAS or cesspool
Static liquid level in the distribution box.above outlet invert due to an overloaded or clogged SAS or
cesspool
_ X Liquid depth in-cesspool is less than 6"below invert or available-volume is less than'/:•day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
X of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
T .Any portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface
water supply.
_ X Any portion of a cesspool or privy is within al Zone 1 of a:public well...
_ Any portion of a cesspool or privy is within.50 feet of a private water supply-well.
Any portion of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water _
supply well with no acceptable water quality analysis..,[This system.passes.if the well water.analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates..that the well is free from pollution.from.that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or.less than 5 ppm,provided that no other,failure criteria
are triggered:A copy of the analysis must be attached to this forip,]
no
(Yes/No)The system fails.I have determined that one or moreof.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 10,00.0 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
— _ the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade.the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional.office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 4 6 Uav, r:ary__
Centerville MA 02632
Owner: Donald McGoldrick
Date of Inspection: 8/4/0 5
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
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X — Were all system components,excluding the SAS,located on site?
X _ 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
— — Existing information.For example,a plan at.the Board of.Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J
Page 6 of I 1
OFFICIAL INSPECTION FORM•-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:I.
:SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION
Property Address: 546 Bay Lane
Centerville MA 02632
Owner: nnnal A Mc GrO rlrick
Date of Inspection: 8%4/0 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms.(actual) 3
DESIGN flow based on 310 CN1k 15.203(for example: 110 gpd x#of bedrooms): 3 3 0
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n 0
Is laundry on a separate sewage system(yes or.no):.n oo [if yes separate inspection required)
Laundry system inspected(yes or no): n 0
Seasonaluse- (yes orno): no 2003=138, 0.00ya.Ei n-6 GP D.=378.,08
Water meter readings,if available(last 2 years usage(gpd)):2 0 0 4 113, 0 0 0 ga 2i o n s G%D=3 0 9 5 8
Sump pump(yes or no): n 00
Last date of occupancy: R 2 e z e n t
COMMERCIAL/IUSTRIAL
Type of establlnt: N/,4
Design flow(basted on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sg8,etc.):.
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system-(yes or no):_
Water meter readings,if available:
Last date of occupancy/use: .
OTHER(describe):
GENERAL,INFORMATION
Pumping Records
Source of information:All
Was system pumped as part of the inspection(yes or no):_
If yes,volume.pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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:
Instaiied 10130185 Roge2 R - (Jun
Were sewage odors detected when arriving at the site(yes or no):n 0
' 6
Page 7 of 11
OFFICIAL INSPECTION FORM=NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'C
SYSTEM INFORMATION(continued)
Property Address: 5 d h Ra r-an e
Centerville MA 02632
Owner: Donald 14cGn1 crick
.Date of Inspection: 8/4/0 5
BUILDING SEWER(locate on site plan)
Depth below grade: 3 0"
Materials of construction:_cast iron X_40 PVC other(explain):
Distance from private water supply well or suction line: 10 f
Comments(on condition of joints,venting,evidence of leakage,etc.):
o.intz a1212,ealt tight no z.i n, 0 Qeak¢ e. .S zt em vent d
nough .hou3e vent.
SEPTIC TANK:y a h(locate on site.plan)10 0 0 ga-e i o n
Depth below grade: 2
Material of construction:_!I_concrete_metal fiberglass polyethylene
--other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—.(attach a copy of
certificate)
Dimensions: 8' 6"X5 ' 8"X4' !0"
Sludge depth: z a c e
Distance from top of sludge to bottom of outlet tee or baffle: t2 a c e
Scum thickness: t 2 a c e
Distance from top of scum to top of outlet tee or baffle: t a a c e
Distance from bottom of scum to bottom of outlet tee or baffle: c e
How were dimensions determined: m e a z u a e d
Comments(on pumping recommendations,inlet.and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
Ineet & outlet tees ace .in piace , Tank 1.6 .6Lfluc iarzUy A01Jnn'
no h.ignzs o f iaakage ,
GREASE TRAP:n o (locate on site plan)
Depth below grade:—
Material of construction:_concrete____Metal
metal fiberglass_polyethylene—other
(explain): —
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
raeaze t.¢aR .i s not R2ezent
L
Page 8 of I
OFFICIAL INSPECTION-.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 546 Rn y T.ani-
canfervillp MA ,02632
Owner: Donald McGoldrick
Date of Inspection: 8/4/0 5
TIGHT or HOLDING TANKit O (tank must be pumped at time of inspection)(locate on,site plan)
Depth below grade:.
Material of construction: concrete metal fiberglass - .:polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
Tight oa ho&ing t¢nkz ate not R/Zezen.t
DISTRIBUTION BOX:y e-3 (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.):
Box iz Box hays 2 Qate
02 ea age .in o2 out o-1 90x ,
PUMP CHAMBER:nO (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
C Pments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
l umI2 ehamPea is not R2eseat.,
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
— SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S 4 6 Ray La nP
rpntp Ville MA 02632
Owner:. nnna1 d Mrcoldrick
Date of Inspection: 8/4/0 5
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located see Rage �0
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
X leaching fields,number,dimensions:
overflow cesspool,number: .
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS:.n o (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
cea-312oo,e.6 a/te not 12 1Ln/,nnf -
PRIVY: no (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.):
2.ivy ./.s not 122e sehY -
9
Page 10 of 11
OFFICIAL INSPECTION FORM.-NOT.FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE`SEWAGEDISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)'
Property Address: 5 4 h Ra 3.. T.a n P
rP-n+-Aryi 1 1 P MA 02632
Owner: Dnnn 1 d Mprnl Brick
Date of Inspection: 8/.4/05
SKETCH OF SEWAGE DISPOSAL SYSTEM l
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100.feet.Locate where public water supply enters the building.
s t 9
G, F
.. $ GA1E
I i
I
,I
I1.
10
Page 11 of 11
OFFICIAL INSPECTION�FORM—NOT FOR VOLUNTARYINSPECTION
PTIO FORM ASSESSMENTS .
41:. SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART C ,
SYSTEM INFORMATION(continued)
Property Address:_4 6 na-Ar r.a n A
Ma 01632
Owner: Donal d McZo1 drick
Date of Inspection: 8.4445
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells.
z
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:
U a-5 Observed site(abutting property/observation hole within 150 feet of SAS)
U"Checked with local-Board of Health-explain:n s g.u.i.P.t tl alLd
n o Checked4ith local excavators,installers-(attach documentation)
l e_,3&Qessed 0SGS database=explain R: o n•'11 aknb t a b 2e.,ma.,u s
You must describe how you established the high ground water elevation:
1lsed : Cane Cod Comm•izion 1datea 7ag:2e Coritouab And 1 u&.t4-c Uatea Supp.2y
GJeii head aoteet•io•n azeab map., Se •t 9.995
GI¢te2 aesouace�s oice cane cod co-mm.ib•ion.,
Leaching
Pit Beet
Groundwater feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical•separation distance between the botl �(
of the leaching pit and the adjusted groundwater table is dJ
• feet. ���
n
• 11
a•rmnrn T—ts,rs'-:r,—Trnrmnmsssrs�Tnasrrrerarr.•s,+tes,rteTrrOeeen TfTITR`�iTTIa'Tq*pq,QTq
7•te•rv-r�.•rsrm-•�r-s-.r•.
TOWN OF BARNSTABLE _ BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D•- CERTIFICATION .
••7S•S^T•tS:T�T.1,7^ -T'T7RTT1'RiRT,T'i7l7TfT.TT:Tt.'i*'StfiflP7lmmRl� TTFOR�/lT011lltlRV7Q!'S ��
-TYPL 0 PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 546 Ray Laop
ASSESSORS MAP, BLOCK AND PARCEL # UeOr
OWNER' s NAME Donald. McGoldrick
PART U - CERTIFICATION
NAME OF INSPECTOR Ro&eat Paoiin4'
COMPANY NAME ;oseph P. flacomgez'* Son Inc
COMPANY ADDRESS Box 66 Cen.teay.i.2ie flazz 02632
Street Town or City State LiP
COMPANY TELEPHONE ( 508 ). 7:75 - 3338 FAX ( 508 )790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally. inspected the sewage disposa`1 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:
Systeui PASSED ,
The inspection which I have conducted has not found any information
which indicates that. the system fails to adequately protect public
health or the enviro.oment as defined in 310 CMR: 16.303, Any failure
criteria not evaluated . are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con\auet has found that the system fails to
Protect the j-,ublic health and the environment in accordance with Title
5 , 310 CMR 15 . 30.3, and as .s ecifically noted on PART C - FAILURE
CRITERIA of this inspecti fo
u,
Inspector Signature Date
)ne copy of this certification must -be provided to the OWNER, the. BUYER
where applicable) and the BOARD Or HEALTJI,
* If the inspection FAILED., the owner .or""operator shall u pgrade ' the system.
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 3.;10 CMR 16 . 305 ,
No.......�........ Fxs.... .:..—
THE COMMONWEALTH OF MASSACHUSETTS
U� BOARD OF HEALTH
..............oF.....
T" ............................
l Appliratiou for Uii uiial Works Tomitrurtiou 1hrutit
Application is hereby made for a Permit to Construct (7r Repair ( ) an Individual Sewage Disposal
System at:
... a.. h:.. ----- .............. . ..... ........................................� ....... ----
ocation-Address or Lot No.
Owner Address
W ��'111���111 �
Installer Address
d Type of Building Size ....Sq. feet
U Dwelling—No. of Bedrooms..............a.........................Expansion Attic ( ) Garbage Grinder ( )
~ Other—Type T e of Building ____________________________ No. of ersons_______._______.______....._ Showers —
p., yp g p ( ) Cafeteria ( )
Q' Other fixtures --------------- --------••------------ -
W Design Flow_________________.S ___._.__________gallons per person per day. Total daily flow........................330......gallons.
WSeptic Tank—Liquid"capacitygallons Length................ Width....... __.---- Diameter................ e th__
x Disposal Trench—No. ......_____________ Width........ ,__ tal Length....... ...... Total leaching area___ _ ____sq. ft.
Seepage Pit No...................--. iameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (✓) Dosing tank ( ) ,,;; 0.0
Percolation Test Results Performed by AAW,_�;____0. ..____._A__: �_ 6j $D 14 Z�
� -- �� - --- ate_•-------------• - --- -- --------
a Test Pit No. 1____ _____minutes per inch Depth of Test Pit______ Depth to ground water-..-- _______-
r%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•----------------•--•-•---•--------- ......
-------------•---•----...._... ------------------------
-----------------------
.._.
0 Description of Soil......................... ---
x
c, --------------------------------- t St�t��A - -
VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
-------------- ..................... •---------------------------•--•----------•------------------••-------------------------••-------•----------------•-- .........................................
Agre nt:
e undersi d grees to install the aforedescribed Individual Sewage Disposal System in accordance with
the ovisions o i?: of the State Sanitary Code—The undersigned further agrees not to place the system in
op tion u i Ce ificate Compliance has een •ssued the b rd of health.
• A
ed -------------------
Approved �/� ...
� / Date
A licat Ti B •-----•- _ C_�l-'_` .�'!r" /�
Date
Appli tion Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
................................................................................................................................-----------------------------------------•...--------------------------
Permit No.------- Date
' ................ Issued------------------------------•--------•--------------
Date
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ..0---W J"�--...........OF..... I tZfiI � -c ............................
Appliratinn for Uiipaiial Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct (zr Repair ( ) an Individual Sewage Disposal
System at: ,
................. _:RaqR--A=..... : r= - ....---------...........--------- ar_.. _.... --- -
S' _V xAddr}ss 1 or Lot No.
......................—..................................................... -- ---------------•-------------------.....-•----......-••---.........................._.....
Owner.+9� Address
Aw
Installer Address _
d Type of Building ��jj Size Lot .....Sq. feet
Dwelling—No. of Bedrooms..............`..._.__....____.---____-____Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixture
W Design Flow.................5.._...................gal lons per person per day. Total daily flow..-_.._...._.__.....__.....-!Q......gallons.
1:4 Septic Tank—Liquid capacity t7 ..gallons Length................ Width_____-_,___--_.- Diameter................ Depth,................
Disposal Trench—No. ......I............. Width......z..___._.. Total Length...... ----- Total leaching area____1.61------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.' !� ..'z_..�Jl ._...._.l:.-.._._��.�r'.__ G f �--f
- --�i ECD ...... ---
aTest Pit No. 1....z-.....minutes per inch Depth of Test Pit_____::- .. Depth to ground water------:__-.:a—__-_-_-.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-_-_--___-___---_____-
a ---••-----------------•----•---•---------•--••-•-----•---------.................•------•----•--••••.........................................................
P = -------------------------------------
Descri tton o 0
-----------------
(� --------------------f-a------ti-----------�a-----Eat{----_v �-��Il ........ .... ........I... 1 J ..........................................
W ----------------------------•--•-----------------------•-----------•--------------------------•--•----•-------•--------------------•••.....--------•--------•......------.............................
UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------............................
---------- -----------------•----- •••---••---•----•••-•-----•-------------•---•-----•••-------••••-•-•••-••-------------••-••••----••••-----------•-----•---------••-----•--------......_..........
Age ent:
e undersi ed_ grees to install the aforedescribed Individual Sewage Disposal System in accordance with
the rovisions o• i? of the State Sanitary Code—The undersigned further agrees not to place the system in
op ion u t' e tificate o Compliance has beenrissued y, the bgard of health.
2 i ned. l a: ,�rti ......------;'-------------••-•-----G------..... ------------------------........
Date
,
=�----------•--•---
APPlira Approved Y `.----------------•-----•--- Date
Application Disapproved for the following reasons-----------------------•------------------•--------------•----•----------------•------------.........----...._._
................................•-------....------...---•--••---------------------------....----••-------•-•-•-•--------••--••-• --------------------------------:----•-.......----••-••-•-....
J[�j Date
Permit No.........
_'__-A-`4---------------- Issue<L.......................................................
Date
n'
THE COMMONWEALTH OF MASSACHUSETTS
[ BOARD OF HEALTH
............ �..........OF........... a t`�t i�U,T, .'�'�. .....................
fit
%Drdifiratr of Tlaai ph anrr
THIS IS T CERTdF That the IndWue,,AW . isposal System constructed ( Llf"Or RepairedbY--------------------• -•
nstall
at............ ----•--•••-•-•--- •-•- �---�--------•-- ----•---
has been installed in accordance itit the provisions of TITIE j of The State Sanitary Co e a .described in the
application for Disposal Works Construction Permit No---- "`� ^' I0............ dated---..-� .._._ _. _y...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE6 AS A G NTE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... .. ......................✓�. ............ Inspector---------
1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w
..........OF............ : ......S'i 1`r��='�----....------......-----
NO.................." FEE........................
7Mi��n�aa� n�'� �n � Sinn frrnti#
Permission is hereby granted...............!j
n'anted-------------------1 .--------------------------•-------------•--••-•-......•............---------
to Construct ( or Repair ( ) apn Individual S wage Disposal System
at No. .: ..C..,.l.-`•.........CIA0 U-------------- --•--------•--....
-------------------------------------------------------------
Street r
as shown on the application for Disposal Works Constructionf\Td...-�' ` .:'�0 Dated.- 1...-._...
/ -- �''t - -----------------------------------------.
Board of health f
DATE......... o�.' ...........................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LOCATION SEWAGE PERMIT NO.
LDT 3 6aY t-auE # 54� SS- to
VILLAGE
Ga,�evtu.E �
,Q INSTA LLER'S NAME i ADDRESS
20 w Q. oute. Co t u c .
a
BUILDER OR OWNER
AWta fi SIWIA-
a
DATE PERMIT ISSUED 10 -
DATE COMPLIANCE ISSUED ®_ � _��
1 I� Z3 l 15 24' Za
94 6 4-.lE
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•iJn,X[�iiA �E.AN . • r H r
I � �
No.------L2
Q,,of�"erow� OFFICE OF THE BOARD OF HEALTH
OF THE
S BAMSTAn ' TOWN OF BARNSTABLE, MATS.
Maas. o�
O 39• r -
o Y�� ,, is 19
MA --=-->>._�:. ------—- ----------- . . .
4DISPS� PERM-ITG I A
ei1 rj ' '. A
Permis"ftn s rchted',t�r 6 ''` "'=`r - to construct tr r —,� : a"^ �f "0 ,
g r a, r ____ F__ _ __
Upon the Premise.- f .3 '"6r> , f fe y" 'a �•. -- `
- tjr 9 „• o ,�••��'` ,r� - s r � _ �,,y.. V'a"��£.s^ .tia.! � ��� .........e..�..: ..,.�,•,..�w.......:,_.,.......
I f
In the
100 or more feet from any source of water supply z
20 feet from .building
10 feet from property line
�� Health Oicer.