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0266 BUCKSKIN PATH - Health
266 Buckskin Path,Centerville A= I llll UPC 12534 No. 2-153LOR ,w HASTINGS, MN r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21pplitation for Misposal 6pBtrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A.4o O M45KIN PAW<!V(LLE Owner's Name,Address,and Tel.No VO, Uc.4 ,-ot D Assessor's Map/Parcel C EX)T-. Installer's Name,Address,and Tel.No. ✓`wF3y cF��- y 7 Designer's Name,Address,and Tel.No. C;4A�6�1U� �► .cS� Lt.� c Type of Building: f', .C� Dwelling No.of Bedrooms Lot Size +.3 `1' s�,-ft. Garbage Grinder( ) Other Type of Building _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided /y gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) & C—' 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 of He . Signed Date Application Approved by Date ad t 2— Application Disapproved by t Date for the following reasons Permit No. o1'C) I2 ' I Date Issued �— .f No. �U I ' Fee a I yy= THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE; MASSACHUSETTS Rpplication for Misposal 6pstem Construction Permit I Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. d4G OUC45KIIJ ji(< `v iLLE Owner's Name,Address,and Tel.No. ' JJ IJ6EUC� sr(R.1C�iko(-A.� N Assessor's Map/Parcel 9 gLue, AS' t Q Installer's Name,Address,and Tel.No. 3'CE-4.7)-W 7 7 Designer's Name,Address,and Tel.No. C;aA93 ux"DG Ees�4tv-th (see r Type of Building: Dwelling No.of Bedrooms 3 Lot Size •3 4 sq t. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) t r gpd ` Design flow provided �/ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. i Description of Soil i i Nature of Repairs or Alterations(Answer when applicable) N, � �Grs Date last inspected: 3{ 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 of He Signed Date t Application Approved by, Date Application Disapproved by Date i for the following reasons n % Permit No. 9 t) I 1 — r 13 Date Issued 2' �— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by CAV&q-�(m (�1 9155 (i4.1c— at 2421, (bx)GIC S toc lLJ PAN 48&TQW(U►.6 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 07 U 1.7--It3 dated S^ l �- Installer I �(.}�i IL(� rTt°{ GL Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wilff inction as designed. Dates l 4 Inspector. - � K -....ate.._.... I _____________________________________________________________________.___-__-_-_____________________.___-__--_-______________--______-___ No. 2 t 13 Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposaf *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( & Upgrade( ) Abandon( ) System located at �(� (3(,GCS ICf�„) ��-�( C t3L -SX)e/L1�s 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. v�— Provided:Construction must be completed within three years of the date of this permit. Date 1 Approved by i i r r w Town of Barnstable Barnstable SHE Tti Regulatory Services Department e"aC y I IIA LE,r.MASS., Ok public Health Division m 9Q NASS 0o a639. rf0 007 µAt" 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #701 1 0470 0001 4525 6775 April 30, 2012 Mr. &Mrs. Richard Brown 266 Buckskin Path Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 266 Buckskin Path, Centerville, MA,was last inspected on 4/17/2012 by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Inlet line from pool 1 to pool 2 needs to be replaced You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system with in the deadline period will result in future enforcement action. r; RDER OF THE BOA OF HEALTH omas McKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Eval\266 Buckskin Path,Cent..doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13445 V� Jam Logged In As: Parcel Detail Wednesday,April 25 2012 Parcel Lookup Parcellnfo Parcel ID 191-121 I Developer LOT 40 Lot Location 266 BUCKSKIN PATH Pri Frontage 106 Sec Road I Sec Frontage village CENTERVILLE I Fire District C-O-MM Town sewer exists at this address No I Road Index 0192 Interactive Map - Owner Info owner BROWN, NANCY W& RICHARD M I Co-Owner Streets 266 BUCKSKIN PATH I Street2 City CENTERVILLE I State MA zip 02632 Country Land Info Acres 0.34 use Single Fam MDL-01 I zoning RC Nghbd 0105 Topography Level ( Road Paved utilities Public Water,Gas,Septic Location - Construction Info Building 1 of 1 Year Roof Ext Built 1972 Struct Gable/Hip Wall Wood Shingle Living 1524 I Roof As h/F GIs/Cm I ac None 7BIM: Area Cover P pTypeInt Bed .6 WDK Style Ranch I Wall Drywall Rooms 3 Bedrooms 1' 15 12 Model Residential ( Int Carpet I Bath 2 Full I 24 w 11 Floor Rooms 2 Grade Average I Heat Hot Water I Total 6 Rooms I eAs Type -- Rooms :6= BMT 3 GAR , Stories 1 Story I Heat Gas I Found- Poured Conc. I 1 d Fuel ation 48. 14 Gross 3320 Area Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=13445 4/25/2012 C 1��- CoMmooweafth of Massachusetts Title 5 Official Inspection Form SullOwfac a Sewage Msposal System loran-Not for V-duntary dents 28S Budmkin Path Pr Nancy Wm" information IsCenterville MA 02632 4-17-12 Pap- Chylrown State Zip Cade., Date of loan Inspection results must be submitted on this form.Inspection forms may not be a[tered in any way.Please see completeness checklist st at the end of the form. tmpoowf When i ow#ctor A. Genera! Information 't on the computer, use only the tab 1 Inspector. key to move your James D.Sears =��:' JA M ES use the return k"- Name of Inspector = SEARS Capewide Enterprises, LLCCompany Name e �T 153 Commercial St. %'/i,F 5 INS? CompsnyAddress ►nnnnm►� Mashpee MA 02649 sty Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected ft sewage del system at tht address arW t -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©EP moved system inspector pursuant to motion 15.340 of Title 5(310 CRHR 15.000).The system: j a Passes Conditionally Passes D Fail 0 Needs Further Evaluation by the L=4 Approving At cm'ty C 4-18-12 ! �n S SignatlRE Date 7 The system inspector shall submit a copy of this inspection report to the Approving Athorityoard of HeaM or UEP)wi#tin 30 days of completing this inspection. If the system is a shartd)syst- or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit, report to the appropriate regional office of the DEP. The original should be sent to the s�►s�'tem owner ` and copies sent to ft buyer',d applicable,and the approvirq at#wity. *"*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inslon does not address how the system will perform in the future under the same or different conditions of use. LA! WW..k qlV�JUJ'� t5fns•11110 Me 5 offi-- she Sewage System•psQe 1 of 17 s Commmmeafth of HIMsachusefs Title 5 Official Inspection Form & tsurfme&Wa"Diisposal System form-Wt for Voluntary Assessments 2W Buckskin Path PropeiV Address Nancy Brown OW1W OWMWGNBM irdonnaitDn Centerville AAA 02632 4-17--12 pae. Uyrrom state Z10 code Date of Umpedlon B. Cel teation (corn.) Inspection Stanmary: Cheat A,B,C,Q or E 1 ahtrays complete aft of Section Q A) System Passm Q 1 have not found arry information which indicates that any of the failurecritemdesatbed in 310 CAAR 15.303 or in 310 CAAR 15.304 exist Any failure criteria not evaluated are indicated below. Cements: 8) system Passes. One or mom system oomponents as described m theTAmdftionaf Bass'section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of HeaW will pass. Check the box for W,"no"to 4not determine"(Y,K MD)for the following statements If Onot 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 exftltration or tank failure is 1mrninent.System wig pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Ham• A metal sew tank will pass insertion 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. 0 Y C1 N ❑ ND(Explain below): t •NNl) Tine 5 Official Inspection Form:StbsuRace Sewage Disposal System-t ge 2 of t7 ytA Commonweafth of Massachusetts Title 5 Official Inspection Form Subsur[aw Sowge Diis System For -Not for Voluntary Assessments 2W min Path Propaty Address Nancy Down t �� Centerville Ma 02632 4-17-12 t►age. cnyrrom State Z!P cD& Data of knpedion B. Cer nn (om) B) System condition y Parsses.( ): ❑ Observation of sewage Crackup or break out or high static water level in the distribution box due to broken or obstructed p#*s)or clue to a broken,settled or uneven distribution box System will pass inspection if(with approval of Board of Hearth): ® broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed Q Y ❑ N ❑ ND(Explath belowy ❑ distribution box is leveled or replaced ❑ Y ON ❑ ND(Explain mowr Orange Burge Pipe W/Roots From Pool 9 to Pool 2 Need To Replace Line ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass laspechon if(vdth approval of the Board of Heafth). ❑ broken pipe(s)are-replaced ❑ Y ❑ N ❑ ND(EA below): obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is ftegtured by the Board of Heald: ❑ Conditions exist which require further evaluation by the Board of Health in order to detennine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordamm with 310 CMR 15.MXI)(b)that the eye#em Is not functioning In a manner whit h wilt prohxg putt heat, safety and the environment: Q Cesspool or privy is within 50 fee of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh tins-11119 Title 5 offiaal 6isperwon Form:Subviftee Sewage Disposal System•Wage 3 of 17 coMMOnweafth of MassachuSaft Title 5 Official Inspection Form Subsurface SewW Disposal System Fom -Na for Voluntary Assessments ouck-skin Path Nancy Broom �is emy Centerville MA 02632 4-17-42 page. C41frown state zip Code Date of trispecdon R. Ceffificalion (coat) 2. System will faM unless the Board of Health{and Public Supplier=if any) determines that the system is functioning in a manner that protects the pubic health, safety and emvironmeft ❑ The systern has a septic tank and sod absorption system(SAS)and the SAS is 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 putft water supply- 0 The system has a septic tank and SAS and ffm SAS is within 50 feet of a private water supply we(l. 0 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. I *'This system passes d the well water analysis,performed at a DEP certified laboratory,for ftcal cohform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no otlte€failure criteria are triggered.A copy of the anatisis,must be attached to this form. 3. Odw. f1) System Failure Criteria Applicable to All System& You must indicate"Yee or"Now to each of the following fatal,ins: Yes No Q §g 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 60 below invert or available volume Is less than%day flow. t%W•11/10 Title 5 Official fnspeaion Form:&b&gfaoe Sewage Disposal System•Pap 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subwrfam Sewage Disppsal System Fon -Not for Voluntary moments 2M Buckskin Path Pmpft Address Nancy Brown OMM era rnformatior►is Centerville MA 02632 4-17-12 tom, ckyrrown state Zip Code Date of Irmpecdon B: Ceifion (tom.) Yes No o o Required pumping more than 4 times in the fast year MOTdue to dogged or obstructed pipe(s). Number of times pumped: 0 0 Any portion of the SAS,cesspool or privy is below high ground water elevation. Z Any potion of cesspool or privy is within 100 feet of a surfer water supply or tributary to a sum water sul". D 0 Any portion of a cesspool or privy is within a.Zone 1 of a WjW wed. 0 0 Any portion of a cesspool or ivy r.within 50 fed of a prime water supply well. 0 N Any portion of a cesspW or privy is less than 100 fit but greater than 50 feet ftwn a pry water supply well with no acceptablew quality ands. system passes if the well homer analysis,perfonned at a DEP cerfifiW laboratory,for fecal coMam bacteria indicates apt and*9 presence of ammonia rilb" n 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 cry must be atlached to this form l The system is a cesspool Ong a facility with a design fir of 20009pd- 10,000gpd. ❑ ® The system fas.I have determined#hat one or more of the above lure criteria exist as desk in 310 CMR 15-303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary 10 corm the fallure. E) Large Systems: To be considered a LvW 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 foifowing,in addition to the questions in Section D. Yes No Q © the.system is within 400 fee of a surface drinkmg'water supply 0 0 the system is within 200 feet of a tributary to a surface ddnking water supply 0 0 the systehn is located in a nitrogen sensitive area(h t im Wei Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered°yesn 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 Sin E or faded 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 tsfts•ttno stbaftum se DWPWW systm-Pap 5Oftt Coln of Massachuseft Title 5 Official Inspection Form Subsurface SeiiiffW aWOW System FMM Not fore Awessrrierits 2W Eluckskin Path Property Address Nancy Brown ownff ownersNaTris {niomration is� Centerville AAA ft2832 4-97-92 Paw- Mytrom state Z0 Code Date of irispection C. Checklist Check ff the following have been tom.YOU mUSt Indicate u s or-W SS W each of the Wkmng+: Yes No 0 0 Pumping information was provided by the owner,occupaK or Board of 0 0 Were any of the stern cots pumped out in the previous two ems? 0 0 Has the received nonnal flows in the pmviota two week mod? 0 N Have large volumes of per been mtroduoed to the system recently iva,part of this inspection? 0 0 Were as built plans of the system obtained and examined?(ff they were not available note as N/A) 0 0 Was the facility or dwelling inspected for signs of sewage back up? JR 0 Was the site umpected for sqns of Weak� 0 0 Were all syst txmVoneals,excluding the SAS,located on site's 9 0 Vvere the - -'mates ur ,opened,and In �_ ktspected the condition `or tees,nuterial of corAUw dimensions,depth of quid,aeW of edge and depth ofscum? 0 Q Was the facility owner(and occupants if different from owner)provided with infon€riatfon on the proper maintenance of subsurface sewage disposal sue? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 0 0 Fang information.For exarrtpie,a phi at the Board of _ D g Determined in the field(if any of the failure criteria related to Pad C is at issue approximation of distance is unacceptable)1310 CAAR 15.302(5)] D. System Information Restdendal Flow Gamut , Number of bedrooms(design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CHAR 15.203(for example: 110 gpd x#of bedrooms): 3 30 •��no Tide 5 of el inspedon Form:Sub wfaoe Sawage Disposal System-Page 6 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsorfaw Sewage MsposM System Form-Nat fcx Vol faeykssessments. M Ruch"Path PrW tit Address Nancy Brown tA�ner 0WrAWe NMM ink � Centerville AAA 02632 4-17-12 page- CWTown State Zip Code Date of ftwpuftn D. SJstm Infer lion Des ption: The system is two cpols and one pit Number of current residents: B Does residence have a garbage grinder? Q Yes 0 No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry aye inspected? 0 Yes 0 I Seasonal use? 0 fifes 0 No Water meter readings,if available(Iasi 2 years usage(gpo)?: �#tl t� 2011-33,000 Dew - sump pump? Yes 0 No Last date of occupancy: t ConinlerciWindustrial Flow Conditions.- Type of EstablishmenL Design few(based on 310 CMR 15.203Y Gaftm per day(9pd) Sa`siS c#4esip {seatsdperson.$dsq-ft.,etc. : C3rease trap present? 0 Yes 0 I Industrial waste hog tank Ott? 0 Yes 0 NO Mon-sarftq waste discharged to the Title 5 system? 0 Yes 0 No Water meter readings,if available: t5im-t t110 r10 5 F*M Sum S-rAM MPOSW 5ystwn•Pap 7 of V Commonwealth of Masc Title 5 Official Inspection Form Subsurft"Sewa"DispwMSyAmFw -Not fdr fur" 2W min Pat Nancy Mom fewj redfo esf�f . Centerville MA 02632 4-17-12 i� Pap. CWTOWn state zip Code Date of limpection D. Systm In#aliaboln (cont.) Last date of occupancyluse: Othw(desedbebelowy Genera!11dormsfion Purnpjag Rw"ds: Source of Won on: NA Was system lug as part of the moo? 0 yes 0 No If yes,volume pump: Aar Howl was quantity pumped determined? Reason for pumping.- Type of SysISto: 0 Sept tank.distribution box,soil absorption system cesspool S Overflow cesspool 0 Privy 0 Shared system(yes or no)(if yes,attach previous inspectim records.if any) 0 InnovativWAlternative h0mology.Attach a copy of the cuffent operation and maintenance contrad(to be obtained from system ova)riot a topy of Wad inspection of the YA system by system operator under c ontt ❑ Tight tank.Attach a copy of the DEP approval. other(describe). t5irts•11110 Title 5 O(fidaf htspect-Farm:Sub-ft-Sewage DWPosai System-Page 8 of 17 VOMM-Onweaft of massachuseft Title 5 Official Inspection Form Subsuffk a S"vage Disposal Sysbm Fat -Not for Volun"Ass�srrrents M&Wkskin Path Property Address Nancy Srown OWW_ ir`s is fewikedforemy Centerville MA 02632 4-17-12 page. Cityrrown state Tip Code Date of hopectbn D. System Information (cont.) Appmmate age of all mTgonerft date wvsWled(if tom}and sourm of Vic : Were sewage odors detected when awing at the site? 0 Yes 0 No B Bng Sew{lam on site plank: Depth below grade: 2T fmt Material of construction: 0 cast iron 40 PVC o (win) Distarm from private war stay well or scion Ise: Cormnents Jon condition of puft venting,evidence of leakW, ): Inlet line 4"sch 40 pvc line p2LA 1 to pool 2 orange Burge w/roots need to Leplace fine Sew Tank{locate on site p1w* Depth below$radar Material of censh'uction: 0concrete Omew 0 11bergim 0polyeth 0 other twin) If tank is metal,list age: YMS Is age conf ned by a Certificate of CompTance?tam a copy of ) 0 Yes 0 No Dimensions: Sludge depth: t5ft•11110 Ti to 5 Oft21 tnspecbon form:Subs ftm Sewage Dispasat System•Page 9 of 17 C-OnU got fth of MaMachuSOMS Title 5 Official Inspection Form UvStburface SewW Qs"sal SysUm Fwm-Not for 16oluntaq Assessments ZW Buckskin Patti Property Addrm Nancy t3 OM fhwer Owrnsr'e Narrro Centerville MA 02632 4-17-12 page. CWTown State Tip Cocle Data of kin D. System Information (cont) SepdC Tanks(cDnt) Distance from top of she to bottom of oust tee or baffle Scum thickness Distance from top of scam to top of outlet tee or bafflee Distance€torn bottom of scum to bottom of outlet tee or baffle How were detennfned7 C mments{on pumping ,inlet and outlet tea or bale condition,sbuctural,integnty, levels as m4at+ed to outlet invert,evidence of leakage,etc.): Grease Trap Gate on site plan;: D"M below grade: feet Alert of corshuc n: 0 concrete Q metal o fogless 0 t*W MM 0 00M Dimensions: Scum thickness Distance from top of scum to top of outer free or baffle Distance from bottom of scum to bottom of outlet tee or baft Date of last pumping: Ehft t5h s•11110 TWO 5 OMCN t MsPeCU 1 Fomr.&bsurtaoe Sewage System•Page 10 of 17 caMl n-NO8ft t of Massadwseft Title 5 Official Inspection Form &*Su faee Sev W Disposal Sys form-Not for Wfurdary Assessment �l3cskin Patf► Nancy Brown tr 0wwftNww fWevWy Centerville MA 42632 417-42 Pap- CRylTown state Zip Code Date or broection D. System Infomation (c onL) Comments.{on 13umpmg recomnwmdations,inlet and outlet tee or baft tonditm sirtutuggi ute"> liquid levels as related to outlet invert,evidence of Vie,etc.}: rkjht or bolding Tank(tank must be pumped at time of inspection)(lam on site ply). Depth below made: Material of constuctiM 0 concrete 0 Metal fbMilass 0 Polyethylene 0 obw( Dimensionw. Capacity, gaOns Design Fes: gaftm Perday Alarm p 0 Yes 0 No Alarm level: Alarm in vying order 0 Yes 0 No Date of last pumping: Date Comments{widition of alarm and mat switches,etc.}: Attach copy of current pumping contract(required).is copy attached? 0 Yes 0 No t5ft•t Wo TNO 5 OKieial fispeew Farm.&ftwfwe&WIsge ofspow System•PW it Of 17 Cote MOMNea of Massachuseft Title 5 {official Inspection Farm Subsurfmw&wwage Disposal Sys Fwm-f40t f br Voluntaq Assessrrrents 2W BUCI Skin Pit Property Address Nancy Brown thwwes Nanne Mformation mqwfw�"M Gentervft RA 02632 4-17-12 Pap. Cttyrrown State Zip Cade Date of Inspection D. Sys ton Infornwfion (court.) Distr%utlon Box{if present must be qw-sed3{locate on site p1my Depth Of Uquld level move outlet Invert Comments{note if box is level and dis#ibution to outlets equal,any evidence of so s carryover,any evidence of leakage into or out of box,etc.}: Pump Chamber(kx2te on site plan): Pumps in working off 0 Yes ONO Alarms in workft order: 0 Yes 0 to Comments{note c ondihon of pump chin ,cx ndition of Wrips and appurtenances,etc.): Soil Absorption System(SAS)(bmte on site putt,excavates most requited). If SAS not lot:�,explain why: I t5frta•11110 Tf b 5 OMW i WOCOorr Form:SUbsta[aoe Sewage DiSPOW System•Pap 12 of 17 COMMOnweafth of Massachuw is Title 5 Official Inspection Form &Awftee Sage DapoW System Farm-NCA€or Vdw-&" rnents M Buck"Path ftWeftAftm Nancy Brown r feww oc t;>�esy�s Gentenrille MA 02632 4-17-12 rec�uiced page. Ckyf town Stme Zo Cade Date of hopecoon D. system ln#on mwm (cons.) Type: leaching Pits number 1 a teaching chambers amber; 0 leaching galleries number 0 leachirig try number.iengfir 0 leaching fads number,dimensions: 0 overflow cesspool number 0 tnnovativefaftemative system Typeiname of technology: Comments(note edition of sod,signs of hydraulic failure:level of ponding,damp soil.condition of vegetation,etc.): Leaching is one Itom?Gat Precast Pit, Pft at 4 C Below Grade w "cement coiner at 18", Pit is dry watts clean like new Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Pa®L'rl Number and configuration 4" Depth- ti of id to M invert Dry 3Depth of solids�r Dry Depth of scum layer i Dimensions of cesspool Ir lory tUtalen'ials of construction Block Block Indication of groundwater inflow 0 Yes 0 No t5irts•11110 Title 5 OtfbW Mopaction Form:StbanfaM SGWDW Dispose(System•Pape 13 of 17 I Conmxmweafth of Massachusetts Title 5 Official Inspection Form Ubsurhm Swr.W Daposal syst m Fwm-Nmt for Vduntafy Assewrients M&Mk-1 lM Path Property Address Nancy Bromm Owner Owner's Nmw Iff W Aattan is re Centerville MA 02632 4-17-12 Pap- for every Centerville State Zip Code Date of hmpertton D. System information (cont.) Comments{cote coition of soil,signs of hydtautic faun level of ponding,wnMon of vegetation, etc.): Pool one BlocK V water No in or out Tee 3(r cerrw%t Cow at 21" Pool tiq ice,dry, No in Tee, Outlet pvc Tee, 32"Cement Cover at 16' Privy(locate on site plan): Materials of construction: ObTlensions Depth of sokis Conmients(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ft•ttno Title 5 Offidai Inspection Form:subsuftm Sewage t)WposW systwn•Page 14 Of 17 Title 5 Official Inspection Form S allot f&VdwWy W"ft wed Im mew MA 02M - : Iry Coft . Sy,Sysum Infamu6m Ste.Of Sewage DISPMW Sys PMVWa a vow of Me: at least two permanent mkw4ce bndrm�or Wxh�Locate ag weRs wMib 100 feet Locate 144 —4- i - ..S ..,,.«.� :...w..w....-w:.aif.-F...�.ve....:a....,.»M-�1...e... .. T...,-x" .e_�.... J L'. F COM- mom of an Title 5 Official Inspection Form Sutmurfmm Sewage Disposal system,Fw,,v -Not for Vdturtary Assesstrerfts 2W sucksicin Path Prw"Ad tew Nancy Brown OWMft MITMMM is Centerville MA 02632 4-17-12 Pe. Cayrrown state Zip Code Date of k wecUon M Syslam Infonn"on (cent,) Site ExaRL Check Slope 0 Surface water 0 Cheat cellar 0 Shallow wed Estimated depth to high ground water: 20+1 feet P3ease vide all methos used to determine the high ground water elevation. 0 Obtained from system design Runs on record If wed,date of design plan reviewed- Date 0 Observed site(abuffing pi up e, hole within 150 ted of SAS) Checked with teal Board of Health-explairt; 0 Checked wth local excavators,installers,-faltach + ton) 0 Accessed USGS database-aptaW. You must desk low you established the high ground water elewation. Per asbudt no water at 20{' Bottom of Plt at 19 Below C3rade Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5&t•11110 TMO 5 Qffmat bwspectla Fort:Surface Sewage Disposal System•page 16 M 17 Commonweam of----. . Title 5 Official Inspection For Sabsur€ac*Sewage Mpcsaf System f -Not for Voluntary Aueuments 2W&K*"to Property Address Nancy Brown owneft Ma" trtrormat�on a Centerville AAA 02632 4-17-12 wed�r every Pap. C8ylrmn State Tap Code Date of lnspedion E. Report Completeness Checklist 0 Wspection S vmary:A,B,C,13,or E cheeked p Inspection Summary C{System Ea#ure Cr#te W ApptiwMe to All Systems}cmwmed 0 System Information—Estimated depth to high groundwater Sketch of Sewage Ural System,et w drawn on page 15 or attached in separate Me t5fits•11110 TO 5 Offid MspeMm Form:Substufaoe Sewage Disposal System•Page 17 of 17 J , a 9 _ l0 CONI-mo. l'E.kLTH OF NLNSSACHI:SETTS EhECLT_k'E OFFICE OF E\ \''VIRONNIET. FF. .S6 r - - 1 DEPARTMENT OF ENVIRONMENTAL P CTIlaO r, ONE nAINTER STREE BOSTOX NL4 02108 1617J SEP 17 1999 N TOWNOFBAtUJStAAI,E S HFJILIN DEPT iR'li D1' COX Secretar ARGEO PALL CELLliCCI ' ID AVID B. STRLH Governor Fe Commiss:one i� n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM U_`ITaY — PART t O T r CERTIFICATION Property Address: a.�(Q .�.5 yJ u►1 Name of Owner IN 6 %t Address of Owner: Q Date of Inspection: mInspector; Nae of Ins. or:(PI ase Tint Q� 1 am a DEP approved system inspector pursuant to Section 15.340 of ride 5(310 CMR 15.000) Company Name: r^�+er L4 j%S e- k' 'u MaTing Address:—'ea , L z�C�-- HAS NPfit= I�'/'� aZ6,4-cl Telephone Number: CERTIFICATION STATEMENT 1 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 inspection. The inspection was performed based on my training and experiepce in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs F her v u he Local Approving Authority _ Fits Inspector's Signatur Date: —� The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised '9/2/98 PigeI•of11 ii Primed on Recycled Paper { 1A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) %iroperty Address:al(efQ BMXS 6 VI) Jwner: Date of Inspection: INSPECTION'SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfittration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corttirwed) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to deter ' e if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE TH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland r a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND P UC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC LTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption s stem.(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 soil absorptio system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorpti system and the SAS is within 50 feet of a private water supply well... _ The system has a septic tank and soil absorp ' n system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well wat analysis for eoliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine di ance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 3 0 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine at will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available olume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT d to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or rivy is below the high groundwater elevation. Any.portion of a cesspool or privy is within 100 fee of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zo e I of a public well. Any portion of a cesspool or privy is within 5 feet of a private water supply well. Any portion of a cesspool or privy is less- an 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If th well has been analyzed to be acceptable, attach copy of well water analysis for •coliform bacteria, volatile organic cc ounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each o the following: The following criteria apply to large sy ems in addition to the criteria above: The system serves a facility with a esign flow of 10,000 gpd or greater(Large System) and the system is a significant threat to publi health and safety and the environ ent because one or more of the following conditions exist: Yes No the system is wit n 400 feet of a surface drinking water supply the system is thin 200 feet of a tributary to a surface drinking water supply the system i located In a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water sup p .well) The owner or operator of a such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department f further information. revised 9/2/98 page 4orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 0,p�! t -�l s tI{,1j i Owner: Date of Inspection: Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NJA. y _ The facility or dwelling was inspected for signs of sewage back-up. CYO _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: PJA-- Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at.issue,approximation of distance is unacceptable) (I5.302(3)(b)] The facility owner(and occupants,if different from owner)were provided with information on the propermaintanan"-of SubSurface Disposal Systems. revised 9/2./96 P#gcsar•u s •. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C Q, SYSTEM INFORMATION 'roperty Address: �ECoS�G� Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:630 g.p.d./bedroom. Number of bedrooms Idesign):C-'43 Number of bedrooms (actual):03 Total DESIGN flow_ Number of current residents:A2?A Garbage grinder(yes or no):_j,,) Laundry(separate system) es or no): 0; If yes, separate inspection required Laundry system inspected ye or no) Seasonal use (yes or no): Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no):—.&) Last date of occupancy:'` COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: apd 1 Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as�part of inspection: (yes or no)LIi. O S If yes, volume pumped: I QOts gallons Reason for pumping: pZT1h;\ir 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other u APPROXIMATE AGE of all components, date installed(if known) and source of information: �j L 1 QL4 O(n�S Sewage odors detected when arriving at the site: (yes or no),6& revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) +roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete_,metal_Fiberglass _Polyethylene other explain) . If tank is metal,list age_ Is age confirmed by Certificate of Complian e_(Yes/No) Dimensions- Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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 baff How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and ou et tees or baffles, depth of liquid(suet In relation to outlet invert.structural integrity, evidence of leakage,etc.) GREASE TRAP: (locate on site plan) Depth below grade: P Material of construction:_concrete_me I_Fiiberglass _Polyethylene_other(explain) Dimensions Scum thickness: Distance from top of scum to top of o let tee or baffle: Distance from bottom of scum to bo om of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, ndition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) I revised; 9/2/98 Page 7or11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Iroperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _con ate_metal_Fiberglass_Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working rder: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and loot switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryo er, evidence of leakage into or out of box, etc.) - PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition:of pump chamber,•condition of pumps and appurtenances,etc.) revised 9/2/98 rage 8ortt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection. SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:A'L,(. leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: 1"tpxt� Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,c nditi n of vegetation, etc.) TILS -WIG I CESSPOOLS: S (locate on site pl n) Number and configuration: Depth-top of liquid to inlet inver 9epth of solids layer: l cl )epth of scum layer: AC' Dimensions of cesspool: Sbi P, S r b r` � cTt y-e_._ Materials of construction: Gti,)rYL=s'C VPv r— Indication of groundwater: N� Inflow(cesspool must be pumped as part of inspection) Sao q tRi�S Comments: l (no a condition of soil,signs of hydraulic failure, level of ponding, condi n pf veg ati , etc.) t S PRIVY:461.3 (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.) revised 9/2/98 Page.9ofII t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'broperty Address: ;te(Q i3vc h Jwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) � � P Z to to 3 1 tj AA revised 9/2/98 . pyge.tooru 1 I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: 'n-L Owner: Date of Inspection: NRCS Report name - — --- Soil Type_ — -- Typical depth to grounddwatter__ __ USGS Date website visited V`V Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope (`lU Surface water f-)0 • Check Cellar Dg.kj Shallow wells 64:) Estimated Depth to Groundwater t Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you estabtisshed the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11 of 11 e � TOWN OF BA;LNSTkBLE Li Ck17Or�' �C����.1 �� SEWAGE # _ `.'B_LAGE n �-���� 0� _ASSESSOR'S MAP & LOT I_ t1`1STALLER'S NANM&PHONE N0. SEPTIC TANK CAPACITY 1P 0® \ LEACHING FACILITY: (type) figCs kw 1 (size) 1 wm5vN1 NO.OF BEDROOMS BUILDER OR OWNER l __ IDATE: M�.� COMPLIANCE DATE: —— -- Separation Distance Between the: Maximum Adjusted Groundwater Table,� F'� ��T ���'� `r... :r,�, �Fc_ Private Water Supply Well and Leaching Facility (If any wets exist 1� on site or within 200 feet of]caching facility) V* c ' Edge of Wetland and Leaching Facility(If any wetlands exist I within 300 feet of leaching facility) Furnished by__ _ j.� y 2-L Lo { 3c° boa k? — :;S' g2--)�y a F�$.......20.�_00._ No.- •- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------ . Town.................OF...........Barns.table-----------------------....................... Allp irution for Uhipati al Wuxku Towitrurtinu Prruti# Application is hereby made for a Permit to Construct ( ) or Repair�XX) an Individual Sewage Disposal System at: f • ....266 _Bucksknl?.? kt .-------- f .... S^ _----— Location-Address or Lot No. ti .&a rz_.J_osque..........--•------------------------------••--•------..._ ..........--------....----•-•--...-----------.........-------------- = z------.-------------- Owner Address a .........d_.P..._Macomhar....................................................... .-•---...........---......--------------•-•••---------•---.......•----------•.........._....--•--- Installer Address Type of Building Size Lot............................Sq. feet Y DwellingXX No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ............. No. of persons._......_.................._ Showers — Cafeteria Otherfixtures -------------------------------------------------------------------------------------- ------------------------------------------------------------ • W 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. 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_-____-_-_-__._-_----. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------------------------------------------------•-------•---......--•-------...-•--------------.._..----- ...... ODescription of Soil.....................................................Sand...&..LrravaL........................................... V ----------------------------------•---...----------•---•-------------------------------------------.....------------------•----------------------------•......'.... --------------•-----------•---- _._ W -----------------------------------------------------------------------------------------------------------------------------------------------------------------------............................... UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ------------------------------ -----•--------------------------------------------------------------------------------..1.-.1 QD 0_..q llox •------------.....-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 'THE -� the provisions of'THE 5 of the State Sanitary Code—The undersigned further agre s not to place the system in operation until a Certificate of Compliance has b en issue by e boa d of health. Signe ...._ _ n M . . ........... ........... ........ Date Application Approved By...................------- ---- ------� - .--------------.--••-- -----------7 Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------............... . ,T �a Date PermitNo.........&A----- -------------------- Issued.................. ----------•----.....------. .� . . il;:te $ 20.00 No.... ....: . � Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...-----... own .............OF...........B.. .r.ns. . J.?.........-------------........................ ApplirFatiun for Diopug al Works Tontrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair X�XX) an Individual Sewage Disposal System at: 266 Buckzs'rinpat:h Centerville •. -- ..............................................•-•--................••-- ....--••--••••---•-•••--••-•-••-•-•--....--•--•--...•-•-•---••-••••-••--•••--•-----•-••--•-------- Location_Address or Lot '.No. ....................Barry .Ad tu --------------------------•------•------------...---------- ..............................................................................................•... Owner Address aJ.P.Macomber ................... Installer Address QType of Building Size Lot............................Sq. feet Dwelling?LK No. of Bedrooms.._.........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------•---•---------•---•. . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity...._.......gallons Length................ Width................ Diameter................ Depth................ w Disposal Trench—No. .._.......•......... Width.................... Total Length Total leaching area__-----_---....----.s . ft. x P g g q 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-.___-__-____--_____--_ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-___-_--•--------_____ -•---------•----------------•-•-------•---•-----------•------•----......................................................................................... O Description of Soil....................................................Sand & '"ravel x U ----•••--•-•---•----•------••--•-------•----•------------------•----------••-...--••-•-•••--.._.........••-•-------------------•-----------•---••----•------------•-------------••.....---•-----------•- w ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable________________________________________________________________________________•------•----•-. 1_-1000 r allon nit. -•--••-------------••---•--------------------•------------•-•-----•--••---•--------•...•-•-•--•----. - -- .................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f`1T('1'�.i.^ the provisions of i l i! 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Signed ,/ kJ 1� ,f/YYt!1 2--: ��_:. ... g/2 2/-g 8- f Date Application Approved By................... " - ----- -•------ Jl 9- Date 1 Application Disapproved for the following reasons____________________________________________________________________________________•---.....................__.. ..............•--------------------•-----.....--•---------------•--------•-•-----•---------•-------......•-----------•--•-----•--•---------------------•-•---------------•-----•--•--•----•--••••------- Date PermitNo........ - c �--�---< �--------------------- Issued--...----•--------------•--•-••-•---------•--••-•--•--- • -•-•--- Da--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............TOwn...............OF.....MasilNnn......................................................... Trrtifiratr of Toutplianr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedX((X) by... . P.Macorn e Y__._____ .-•----------------------------------------•-------------....---•--...------------.....------•-----•--•----------------...--------------•------- 266 Bu:' CsicinJati1 Centerville Installer at . ..............................................................................been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....@&_=--- ----!g-/.......... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC ON SATISFACTORY. DATE............................ .� - -�ls. ........................ Inspector..............---- =- .............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ........................................... FEE............. OF..................................................................................... 20 .00 � � .......... Disposal Workii TWonntrttrtion rrntit J.P.Macomber Permissionis hereby granted...............................................••--•---•-•-••••-•-•-•-•....-----•-•-•--•--------.....•-•••--•---.......••....._......-•-...... to Construct ( ) or Repaie (`�'f an Individual Sewage Disposal System 266 Bucksxinaatb. Centerville atNo..........................................=....---•-------••----•-------•-•-------_.._. Street as shown on the application for Disposal Works Construction Permit Nc&.—I`�/_.....• Dated.......................................... ---........-••--•-------•-•-•----V �------------------------------------------------- _ DATE_ .............................. Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE LOCATION,.- � fsp/� a SEWAGE # �j� S� t _ VILLAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO,�✓ j4 4,,jAl i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER _ DATE PERMIT ISSUED:. DATE COMPLIANCE ISSUED;'' VARIANCE GRANTED: Yes No �_- O /A i I �; Ae