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HomeMy WebLinkAbout0035 CAP'N CROSBY ROAD - Health 35'Cap'n Crosby Road,Centerville A=194-030 i I �.7//1►/I/lelllG UPC 12534 No.2_ 1� qar HASTINGS, MN I ter Town of Barnstable Barnstable Board of Health j o'`2 n`�$ 200 Main Street, Hyannis MA 02601 I 639. `� 2007 f0 MA'S A Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff, D.M.D. Junichi Sawayanagi I I CERTIFIED MAIL #7012 1010 0000 2843 1884 February 13, 2013 Mr. Michael W. Goode 35 Cap'n Crosby Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5. . The septic system located at 35 Cap'n Crosby Road, Centerville, MA was last inspected on 1/12/13, 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. ti • System needs to have PVC outlet tee 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 within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO. Agent of the Board of Health Q:ISEPTICIconditionally passed135 Capn'Crosby Rd Jan 1013.doc v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn' Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this forma Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information � `""tttllllllt///"S � on the computer, ��`` N OF �'1,,� use only the tab 14 f�s3 .°� �" MAS key to move your 1. Inspector: •••off, cursor-do not James D.Sears JAMES m= use the return Name of Inspector c�; („ key. Capewide Enterprises LLc •• o : c Company Name �'�.VQ ,' ;�� .� 153 Commercial St. INSPtEG�p�`p Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority jz� 1-12-13 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The.original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. c 3 t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 v i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '<a 35 n Cap Y R'Cro sb d Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ahaays complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): , t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Need to replace line tank to pit and replace old baffle w/pvc tee ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 3 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owners Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth irusemped is less than 6" below invert or available volume is less than Y2 day flow ooOl-7 t5ins•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 1.5.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal precast tank and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-37,000Gals g ( y g (gp ))' 2012-33,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn' Crosby Rd ,p — Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn' Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Around 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ❑40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Line tank to pit orange burge, Line need's to be replaced. Septic Tank(locate on site plan): Depth below grade: hilt et Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal precast Sludge depth: 2., t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Past ReportSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and covers at 11" below grade w/inand outlet baffle's. Tank atworking level. No sign of leakage or over loading outlet baffle in bad shape, need to replace w/pvc tee. Grease Trap(locate on site plan). Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '^ 35 Capn' Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form_-Not for Voluntary Assessments yt 35 Capn'Crosby Rd Property Address Michael W. Goode Owner owner's Name information is required for every Centerville MA 02632 1-12-13 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one 1000 Gal precast pit. Pit and cover at 23" below grade, Level in pit at 20"below inlet line, No higer stain line, NO sign of over loading or solid carry over, Pit is working pit is 30+ years old. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn'Crosby Rd lug - Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn' Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A �R a ti-T Q -9 =21 6 O (3- / oO t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Capn' Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated t depth gh ground water: 10+ p hi feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: . Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Past Report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Past Report 10+' No G.W. A butting area drop's off, site high Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Capn'Crosby Rd Property Address Michael W. Goode Owner Owner's Name information is required for every Centerville MA 02632 1-12-13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Health Master Detail http://issgl2/intranetihealthMaster/HealthMasterDetail.aspx?ID=006033 Logged In As: TOWN\Flynnj Health Master Detail Monday,February 4 2013 Application Center Parcel Lookup Selection Items Reports Parcel l Septic Perc I Well I Fuel Tank Parcel: 006-033 Location: 309 PINE RIDGE ROAD,COTUIT Owner: BARGER,JAMES C&LANE E Septic 1 Ne p I w Septic Permit number Permit type Select Complete system f- Issue date T Complete date Septic tank size: Type/Size of SAS Installer: Select Installer f Card on file: F I/A service type Select service r7l';-� Innovative/Alternative Technology type: Select IA type Variance date: Abandon complete date p Abandon permit number.� I Repair deadline date: Repair notification date :�- Keyword: Comments: •created for septic inspection Delete Septic Inspection 1/19/2013 New Inspection... Number Inspection Date Inspector Result 7670 1/19/2013 j McElroy,Shawn UPPER CAPE SEPTIC SERVICES -- i F(Fail) li I — - — --- The following condition(s)are occurring: C discharge or ponding of effluent to the surface of the ground I Ci pumping more than 4 times during the last year NOT due to clogged or obstructed pipe r. backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool r static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool F, any portion of the SAS,cesspool,or privy below high groundwater elevation i i (-i any portion of the cesspool within a Zone 1 to a public well j G any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis Received Date Comments 1/25/2013 Perc Test-2/14/13- Delete Inspection" :I ----- - ---- - _ ... I h rvSave Septic Changes r7Return to Lookup— a( I http://issgl2/intranetihealthMaster/HealthMasterDetail.aspx?ID=006033 2/4/2013 . Health Master Detail http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=148025 • Logged In As: TOWN\flynni Health Master Detail Monday,February 4 2013 Application Center Parcel Lookup Selection Items Reports Parcel ( Septic Perc I Well I Fuel Tank Parcel: 148-025 Location:427 NOTTINGHAM DRIVE,CENTERVILLE Owner: OBRIEN,KELLY A Septic 1,12/18/2012 1 New Septic... Permit number: 2012-401 Permit type: Complete system: E. Issue date: 12/18/2012 Complete date 01/29/2013 Septic tank size: x1000 Type/Size of SAS 2 500 gal leac h chambers w/3'stone Installer: Brown,Douglas A.,D.A.Brown Card on file: F. I/A service type:fSelect service' Innovative/Alternative Technology type: Select IA type ,i- Variance date : Abandon complete date : Abandon permit number: Repair deadline date : 12/03/2012 1 Repair notification date : 10/03/2012 I M Keyword: Comments: 3 BR !' !Delete Septic °I .— ....... _... ........._... _ --- Inspection 09/05/2012 Inspection 01/05/2006 New Inspection... Number Inspection Date Inspector Result 7159 09/05/2 112 Brown,Douglas A. [,J— I F/R(Fail/Repaired) The following condition(s)are occurring: G discharge or ponding of effluent to the surface of the ground (i pumping more than 4 times during the last year NOT due to clogged or obstructed pipe r backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool G static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool r any portion of the SAS,cesspool,or privy below high groundwater elevation C any portion of the cesspool within a Zone 1 to a public well any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis Received Date Comments 10/01/2012 I A Itouse sold-_1 1/2/2012-system failed 9/5/12Perc Test 11/13/12 �� Delete Inspection Save Septic Ctianges I �,:Return to Lookup 'I http://issgl2/intranet/healthMaster/HealthMasterDetaii.aspx?ID=148025 2/4/2013 TOWN OF BARNSTABLE LOCATION 11 SEWAGE # VILLAGES'lJn�e/[�z��i� ASSESS 'S MAP &LOT,,gn �S@E3Rs NAME&PHONE NO ��O at SEPTIC TANK CAPACITY 160 Q Q0 LEACHING FACILITY: (type)�i ��� (size) /O©Q NO.OF BEDR C / � `` %� BUILDE OR OWNE �ara/7 17ZC-17,_ _)"1,9 c tS PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist 1,,.d- within 300 et of a hifaci ' ) /V Feet Furnished by j r � / V) 6 V 5-1 0 •t� No. C 5 Fee 6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS applitation for Misposaf 6pBtem Construttion Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System [,Individual Components Location Address or Lot No.31 C4P ij C,RoS 01 Rn Owner's Name,Address,and Tel.No. dC Assessor's Map/Parcel j 0j p-_3 0 Pt x 1 r' tom' y L3 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Gl A0 6-,e>cc0 E 6 0A 5S LA-0-. F Type of Building: Dwelling No.of Bedrooms Lot Size t 3,5 4CA-1i5a. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures -Design Flow(min.required) gpd Design flow provided 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) 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 I& Signe Date Application Approved by Date t Application Disapproved by Date for the following reasons Permit No. P j 3 Date Issued Z7 No. �C J Fee 6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for aisposaf *pstrmi Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No.3 33- CAP°sj 0_iZ OS D1j Rn Owner's Name,Address,and Tel.No. Assessor's Map/Parcel OC+ p 3 a �`ENTr:72v i '� 57 4��Q Po C. [1 Al Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. � cua(.c S ✓bv Type of Building: Dwelling No.of Bedrooms Lot Size i 35 -s Garbage Grinder( ) Other Type of Building IZ_1K04AJ-ThIVA _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r, Nature of Repairs or Alterations(Answer when applicable) L I 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_ (�Sig�nedl\ i�` DateApplication Approved by .-_ Date ' Application Disapproved by Date for the following reasons Permit No. Date Issued 7 --------------------------------------------------------------------------------------------------------------------------------------- Th E COMMONWEALTH OF MASSACHUSETTS L BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by I:AFL'i IM— E?JT1EQ_P XE~S (..LcL at 3 S 4:!Ap°�ZOSaq RI) °�� LLL:rhas been constructed in accordance with the provisions of Title 5 and the for Disposal System pp Construction Permit No. D C13 La "'dated 1 7 Installer 0APERAJA bc— �LcSri Designer #bedrooms Approved design flow gpd The issuance of this permit shall`not be construed as a guarantee that the system will function as d se igned. Date t `1 � � Inspector -----------------------------------------------------------------------------------------------------------------------J---------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal bpstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade(� ,)ems Abandon( ) System located at —? (�2A-p f 6AUSig V P() t✓° of l(.1►�-� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be/com7pleted within three years of the date of this permit. Date / I �/ /l Approved b\y, BORTOLOTTI CONSTRUCTION, INC :9 tf. =, ry.;..... ...,. � , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop 0Q r Date of Inspsc} p �S— MAP p;/ arFe � Own PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND 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 COLUMES 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 N/A. THE FACILI O'R DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK=UP. E SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. AUG OD cfIVE� 1 4—ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. 2 8 199 THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TAN S INS�� FOR.CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQU FI OF E, DEPTH OF SCUM. !--THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORM A Fj; rf APPROXIMATED BY NON—INTRUSIVE METHODS. FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL No of Bedrooms No of Current Residents Garbage Grinder Laundry Connected to System Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: Pump' g Records an GALLONS Source of Information: n�— SYSTEM PUMPED AS PART OF INSPECTION? O IF YES,VOLUME PUMPED = GALS F ping:TEM: Septic.tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool PrivyShared system'(if yes,attaStkrevious inspe9tion records, N any) Other_Okplain) /aove 4.hd S. S Approximate ape of all comments Date installed.0 known. Source of information. k .. n ut ' , s� SEWAGE ODORS DE[ECTID WHEN ARRIVING AT THE �'`...:.A',: r y,: #r',+T a- �k�4e . ��'�7,:�ft+„a' '' r t�.rv'�'',�� tit 4. ,k t �'� , M W: a,S"r ;,�•', � 3^ £!:. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM rPART B SYSTEM INFORMATIONf(Continued) x mot, x ...:,-=.:4 .a. r.A,s. .5*fyr�ld-ay.'Z ,�.t,�3,a..,. f'xr.. .x`r[e_:. .dz�',X;: y`w`4'�" ?a«, "< ,'�r.'+*.w.wsdc'i!'w.:.`�`:�?fie '= •tt- ', '` {� Y. 1 `� w 'eT+'4 s.h`a+i b-•.5 ,�' CsF �fl > - DAN epth below grade �}�� t 2r� 1i: C . VL ..K 2 t '+•`+3 Dime lions �, A ;' I '. _ f Materiel of construcfbn ` Concrete g Me11ef FRP t Otl�r} `..tj e Depth T � y {rif8���y /� Distance from top of sludgy to bottom of outlet tee or baffle Scum Thickness D ofk Scum top of outlet tee or baffle y / isteme from Top Distance from bottom of Scum to bottom of outlet tee or baflie iw . r y _ 9 Commerrls K D `' I TRI UTI N BOX -. .•._. �° DEPTH OF UQUID LEVEL VE OUTLET INVERT ° PUMP.CHAMBER: Pum s in working order? Comments: SOIL ABSORPTION SYSTEM SAS : IF NOT PRESENT,EXPLAIN: TYPE: — oL Comments: CESSPOOLS: Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension-of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials df construction Dimensions Depth of solids Comments: r '' � aN'�'i'W+ ,v.�n1k � ��"F'.s Fa 1�. �=���,..,,+�) 't✓y�''� Ef's r�. �.��-_.,�7 su.•s ,�,�= ,F zw rx a .�-F' S -�`. -'c- s1-)y •i �.;v -'e 'lzj-•, - } 1,�F` :.�cdinz.-•..! �,•; �Q, .iK•�•sk> g.> g.,-`.�'i kYr F r ' �'r { i. "•; xsa,�+pss7 twat L `� �-.` :� 5" x s r•#.,.: v fir; .W 6,, My, �' 5-�t n 2 ;4 r o •�.� q, xt ,�} � �r t k i� •� ry� � � � � N� •tPSa G° �,`.� y •k `-'`, a e sr �,,� t 7 k,''7�,,aM1a �r �` yi.,�, .x ,,,3 (. r ..e . r. . .+ Z,,s�a� nzut F x � rSrSs vx r,4 6 KSUBSURFACEkSEWAGE DISPOSAL SYSTEM INSPECTION FORM �x'xJk tS�''��K ` Ft v4r f � y PART B y S�fSTEM INFORMATION (Continued) A �K - Ik 4 8KETCH V8EWAGE-DISPOSAL SYSTEM 1 INCLUDE TIES TKO fL LEASTxTWiD PEAIU�WENT REFERENCES.LANDMARKS OR BENCHMARKS. LOCATE ALL WELAVVIMN{1 k � FIRy x' AN— as t O DEPTH TO C31ROUNDW 20DEPTH TO GROUNDWATER METHODQFQ ��INA�O�►�PPi��5O� XIMATtON: .d. rE ssF s o ... �3 * ,_;: ,, ' y� f:Y.3S �#',r`�iF .t A +✓ .t"a ��, a..t "'+�,e. n t '1�,�` �4�d�'� � a'S. Ck;,' 8 P# 5- n "�r�-s�—$'ar' t4.,7 f`�'-.., '� 3G�;ir�.0�'��.,� 1v��'-a- �;,� x^ e'Sriti '�.�n�r.� x '�,e,i."xt'"4.t sY.� A.sg•..z� +�s�.x4''�� �' S s,�.� t '�f�" �+'',�,,. 7 F.t �s#' Ee�"� `'k.•�'. .�*'t,' 'l�.^S.'i�yt'�'�"*�tl�� .s:>.�i,���'i°f'�'yE`a�:j-� 6:.;m�i'..._ar "ti - fv Y"v •d.^ 5 xs .x9'r y as..3 •_'"5x s�hry �.t� 4!: = '�h�` v.a;v,'-.fit?"' ` ,P "S°4,, .'. i ,:5 .3.:Y -s•'�`�1 -.�,r^...,, +Ye<n s. `.',�..ic;�E S's.,� '..� � �:^,`4�r�`...r�Y e _.. �":.±i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM x �^ y s M x ti.-ir.,� 'k�'.. ,C •�Skst,Sr°`�"s— n� ' j 3 .t` t�.si. k k � i k .,ifi..�� i CRITE 1-1 .46z .r <.: v h ',`+3ay,.sn '3;,xc vaP•'' i,.£tf ;4 d'.-C `. .•-?Fu'n ..j»ti' € }t�-'�'3;• t y, c .w Er 7 r �aK't!s."rK t sx� per r ti ,, � PARTxC FAILtiE RII� '' ,� ,� "'r: r• x s•, .a ,.{- tEA'r�` -L x+,:r Hids"• ,, Y ; i a � ;s �:4 ' . u,J„:2t � a`'3,2rr aatr{ ': r 059,v Y es �10 ,q dot d tnsd O cribs b dabe�m ion M't+at a. ,ir;ed t +w �aSAW e U 6 66, ,.+�- o gf- •t 3 ''- � i's 'x. ^, 7 �rK.g 3 l�roSl ty Dlscfiarge or ponding of efflugent to the surface of the ground o�surface waters "Y 3taUc�llquld level in the dlstncuUon box above outlet invert? � 5 11/ Vquld depth In cesspool, 6'below invert or available volume, 1/2 day flovl/� . R;eau red41 s um In 4 time or more m the last year's Number of times pumped P P 9 eP k is`- ft ,cracked structurallyunsound�substantial infiltration?substantial exfiltratfon? j�'kT7anK:iiUr@ m @ant? z '� i f, r t rig 'r r €�` i�� � � �. � z '"°�w43 Y7�7�M �` x' F .,µyy i�. :y t ,rr, �'k}• r�,C ' s x ���. ,` by s an.1port ion f theicesspool or pnvy,below the high groundwater elevafionI f� a•e, ��IVIthln 50 feet of a Surface water' a Within 100 feet of a surface water supply or tributary to a surface water supply? �t015111111 'S?-'' a � aA3ry' ."�L..,�a f _ - lA r" fillVithm a Zone I of a pubbc well ` r7,".'"':.r13` - FWitthin 50 feet of a private water supply well? Vlthin 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? i Y Less than 160 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. � I PART D — CERTIFICATION INSPECTOR:' ROBERT J. BORTOLOTTI'- ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508)771-9399 CERTIFICATION STATEMENT x I CERTIFYTHAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MYTRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE-FAILURE CRITERIA'SECTION OF THIS FORM. I HAVE D&ERMiNED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE.'FAILURE CRITERIA'SECTION OF THIS FORM.': _ INSPECTOR'S SIGNATURE DATE w,� ORIGINAL TO SYSTEM.OWNER,COPIES BYER U Qf -pip ic6io) APPROVING AUTHORITY �° g4azr«w i w.c +'fr s.+ kt ^,�?,.a�r rt'.c,y s u v _' �k' E" r'�uv!.a'�a ;,e°d'�1' t'>a ✓ `•E` y , -_.4�°��k - �4.�,rt".S�" '��� � .. r. ."r�..4"^z`"'�'f��"`•�� fr•° a, a�� z- max. w Y' 'i t37 skt'�'•• � �r 3 �. a:. _�1^�%�� .ir c � I •x s f�i � � ,,$3r �43 y:.f Y� 3'Lx,1 k �=s.A�,��#�?'i .., ,YSt -t£�Y���'J.yty.: �xt^i� s•.w ..& ..'ma's nfA `�j `�,v t M ��at„�' �'.-. �� �.y� ate.. THE COMMONWEALTH OF MASSACHUSETTS �v *,L3S F H ALTH , cl 3 -D ,,,,,BOARD ...............OF.......�..... 1...... . . ------ ................... ,� s lirttt�oa� -for orko Tooitrortioo Peroiit Application is hereby made for a Permit to Construct (") or Repair ) an I dividual Sewage Disposal Syst t: c� . :_.. ---- o - or Lot No. _ __ , W er Address !.. . ... - Installer Address d Type of Buildings Size Lot----------------------------Sq. feet U Dwelling V No. of Bedrooms--------- ---------- -- -Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------- W g ............. _-, Mons per person per day. Total daily flow........__ gallons. Design Flow.. .. . . ------ CI'�-------- -------- WSeptic T.tnk/--Liquid capacity{jf-__gallons Length---------------- Width................ Diameter------..-------- Depth---------------. x Disposal Trench—No- -------------------- Width--------- ___ _ otal h_.._. Iotal leaching area--------------------sq. ft. Seepage Pit No..../.............. Diameter_/ ___� ow i le __.. ____.. ..... Total le Ching area._...____.___.._sq. it. 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...-_-..-_---.----.-__.. �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water._._.-.--_-----.-__--._. tx ---------------------------------------•--------------- -- -- ----------•-------- -•---•---•-------.------ O Description of Soil------------------------------------------------------- 2` 'j .-`------- x W ---•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article NI 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. igned--------- /f ---•--------------•-- ......_.....Da ............... te Application Approved By-----_ C /� - Application Disapproved for the following reasons:---•---•---•-----••---------------------•--.....--••---•--•-----•-•-•-•-•-•-••----•-------••--•----------------- ...............••---••--------------------------------------------•-------•------••-----•--•------._..........-••----•------•----......------....•----------••••.._._..._.......-----•------------------. Date N ' Permit No. = -;� . ':; Issued:: 4 Date No.....!tj --- FE�.. ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF H A_ LT H \J... ..f 1. Lj. OF..... ...................... Applirtttion -fur Bi-qVuotti Works Tonfitrurtiou Vrrutit Application is hereby made for a Permit to Construct_ ('"') or Repair ) an I dividual Sewage Disposal SWtat � . .................. .............. . ................q------- - -- ---- -­----­---- ..... .............. f ---------------- o or Lot No. __ ___ ........................ _._________ _ ___.._ _ __.___________._.._____________._._______________.._..___. er '. ` Address W •••••----.` •----- • ................. ....................................................... ristaller Address UType of Buildings Size Lot.................... q. feet Dwelling No. of Bedrooms________ --------------------------------Expansion- Attic ( ) Garbage Grinder ( ) pa,, Other—Type-of Building ____________________________ No. of persons..-___-_-_:__-___---___---_ Showers ( ) — Cafeteria ( ) d0.4 Other-fixtures ---------=---------------- - = ::;:. •----------------------- t W Design Flow__ ________________________��___�____-illons per person per day. Total daily flow_::__,_ __�I�-____-_.-.._....gallons. WSeptic Tank,-•Liquid capacity{�allons Length---------------- Width......._:.__--- Diameter-----....------- Depth------.___.-_--- ; x Disposal Trench—No- __ ���tdth__ :_ __ of 1 h_-_-_ Total leaching area..__ .-. -..._--_sq. ft. E Seepage'Pit No Diameter./ .w` e _.. Total leaching area ..-_s(. It. z Other Distribution box ( ) Dosing tank ( ) "- '0Vr.04 ~" Percolation Test Results Performed b _____________________________ Date_-________-__-__'-_-_ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._-. -.--.--__.-__ 1:14 Test Pit No. 2................minutes.per inch Depth_.of-Test Pit_._......_.__._.____ Depth to ground water.....------------------- Ix 1. DA� Description of Soil------------------- ,,�„�,' 1 4 ...-__•______________________ ___ ___ _ ._..l1lZ_R-__- ••�" 4 � F z.��. / + .__________________•-_-______-_._-.--..__-____-_______-.--___--_____________________________________-________________________________-_-___.______.___,--_______-___-__--.__-__--_____________-__----__... WM r' 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 Article NI 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. -µ igned •--•--• •-- •--- '•-----•--._.--•--•-----•.._._ --------- ----------••---•------•------•-- Date Application Approved B . +� PP PP Y = ,1. r *dam. /rDa.: Dat Application Disapproved for the following reasons: ••-•----------------------------••••••-•-•----------------•-----------•--••••-••-•--...--------- :_.. _._-•-----•--------------------•-------------•-------------._..----------•--------------------•--------•---•--••-._-..._••-•----•-•--•-------.._...------------•--•-------•---'.......... Date :. . Permit No....................................................:.... Issued...................... -----=---------------•---•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFAHEALTH ` 1 .:..........OF......... . ... .... ............. S }. (Irrtifirttte of Bout Iitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal At constructed (Joror Repaired ( ) t by.......... r ° Installer --� at= � �'' / ---- --------- llas been installed in accor an with the,provisions Article+ of'The .State Sanitary Code as described in the Z_ application for Disposal Works Construction Permit No--- ______ _ ____ __ _ ' ____..'* dated..--_ THE ISSUANCE OF THIS CERTIFICATE SFIALL NOT BE CONSTRUED AS A GUARANTEE THAT'THE SYSTEM WILL FUNCTION SATISFACTORY.: a..,.. DATE................-----------------------=;,-.................................... Inspector,-----------=----------- -'-----..................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARDI'OF HEALTH ... FEE. No...pll....... - .---•----•-•-• err i Tu rurt' n Prrmit Permission 's hereby granted•__.. _ t ------------------ to Construc '( . ) o e�a-, ( an I ' +'d zal Sew g Dispos 1 y r • re as shovvn,.orf=the application for Dlspo.saI Works Construction r t N . . ___._ Dated-_f:2.. .__/.Z/—_`f__,X______ ................. !!! Board of Health �. . `_....DATE --------------------•••- 4J FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ti �pQ TH F pO�y• � � ' TOWN OF BAI3NST:`Al Ca s BARHSTUILE, o' \,� '03MASS.9 \ob (— Bog-�.rd of Health OOA o MA(Ar' FROM THE OFFICE OF f t 6"` k r N 00 4 1� V ice ® �- �--0 t1b