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HomeMy WebLinkAbout0022 CAP'N LIJAH'S ROAD - Health 22 CAP'N LIJAH'S RD., CENTERVILLE T A= 192 186 `r I Si_ _ o UPC 12534 ° No.2�153LOR HASTINGS.MN Wix �Iq y �- BORI'OLOTTI CONSTRUCTION,IN .:` 1998 . 765 WAKEBY ROAD,MARSTONS MILLS,MA 02448 1508-771-9399 509-428-8926 FAX: 508-428-93 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI 'NFORM , PART A �= CERTIFICATION Property Address:t., Date of Inspection:S/ Ins ct is Name: - er' Name and Address: i V CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at tkiis addswss and that the informa- tion mWited below is true,accurate and complete as of the time of inspecd0,n.'11AZ inspection was per- formed based on my training and experience in the proper function and ini;inter ante of on-site sewage disposal Vtems. The System: Passes " Conditionally Passes 7,Needs Further Ev tion Dy t i ucal Aproving Authority M i Fails ; Inspector's Signature: Date: <4� The System Inspector shall submit a copy of this inspection report to the Apprce4rig authority within thir- ty(30)days of completing this inspection. If the system is a shared system or h is a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report io the appropriate regional office of the Department of Envirompentai Protection. The original should b�.�':w it to the system owner and copies sent to the buyer,if applicable and the approving authority. ry ' INSPECTION SUMMARY: A)SYS1 PASSES: I have not found any information which indicates that the sysicin v ika'ates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria ilot ;inWated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of d.termi.r.ation in all instances. If "not determined",explain why not. i`i�The septie.tank is metal,cracked,structurally unsound,shows substiutial infiltration or Wiltration,or tank failure is ittuninent. The system will pass in.p*Aion if the existing sep- tic tank is replaced with a conforming septic tank as approved t►y "he Board of Health. Sewage backk-up or breakcut or high static water level observed in t'r,e distribution box is due to broken or obstructed piper or due to a broken,settled vi uricv, a distribution box. The system will pass inspection if(with approval of The Board J.JeA i i): - 1 - r i a " SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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): Br(ken,pipe(s)are replaced Obstruction,is removed 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 the public health,safety and the environment. 1)SYSTEM�WH.L PASS UNLESS BOARD OF HEALTH DETERMINES THAT+THEY SYSTEM,IS NOTTUNCTIONING IN A MANNER WHICH WILL PROTECT-THE,.,,. PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or.a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLICWATER SUPPLIER,II!APPROPRIATE)DETERMINES THAT THE SYSTEM ISTUNCTION- INiG IN A•MA_NNERITHAT PROTECT.THE PUBLIC HEALTH AND SAFETY ANWTHE ENVIRONMENT: The system has a septic tank and soil absorption system and is within'100 Feet to a surface ,• watersupply or tributary to a surface water supply. i -The,system has aseptic tank and soil absorption system and is with a Zone If a public.+°4 water supply well. The system has a septic tank and soil absorption system and is within 50 Feet ofa private, water supply well. The system has a septic tank and soil absorption system and is less than`100 Feet'but'S0 y'+ Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from ! the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less 5'ppm - , D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below.'`The'Board of Health should be contacted to determine what will be necessary to correct the failure. ` Backup of sewage into facility or system component due to an overloaded or clogged SAS or,cesspool. Discharge or ponding of efiuent to the surface of the ground or surface waters due to an,,..' overloaded or clogged SAS or cesspool, :Static pid level.in the distribution box,# ye.outlet invert due to an overloaded or clog- gedASAS:orcesspool. rLiquid depth in cesspool is.less than;6";•below invert of available volumeis less than 1/2 . . : day flow: - :,Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tin=_es pumped -2- `"`.w x #1 { �*' � iy+l ,r�}�'e s" 2 :�:�%�T i t•, /.� kai ,.�, fix, 72•, i i! Y SS 1 0. ,. i t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is glow the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 Fcet 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliforn►bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FALLS: The following criteria apply to a large system in addition to.the criteria above: F" The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant' threaf to public health and safety and the environment because one or more of the following{t.icy., `` conditions exist: The system is within 400 Feet of a surface drinking water e;upply I +kgri The system is within 200 Feet of a tributary to a surface drinking;vjater,supply J :," The system is located in a nitrogen sensitive area Interim Wellhead Protection Area Y r>�Aa t 4, (IWPA)or a mapped Zone 1.1 of a public water supply well• :.y� ► Alt;. �+tt' ";tail t�`camr! The owner or operator of any,such system shall bring the system and facility iwo i'ull,eompliance,with•* groundwater treatment program requirements of 314 CIVIR-5.00 and 6.00• Pleasc,consult the'local.. ari ? regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ja.W _ftio"� Check the following have been done: Pumping information was requested of the owner,occupant,and.Eloa d of-77' Health t ,, None of the system components have been pumped for atleast two we ks and the;systeniiw,,isv I. been receiving normal flow rates during that period. Large voilumo,;of water.havemot 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 facility or dwelling was inspected for signs of sewage back-up. The system does not receive'non-sanitary or industrial waste flow. 'r Th&site was inspected for signs of breakout. ? All system-components,excluding the Soil Absorption System,have been located on site 'The septic tank manholes were uncovered,opened,and the hatmor of rhe,sepd tankmas�ia y� spected for condition of baTies or-tees,material of construciida;dirue.•tsions,depth.;of�gwd, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated byi.non-intrusive methods. -3- r-� SUBSURFACE SEWAGE DISPOSAL,SYSTEM;INSPECTION FORM PART B + CHECKLIST(continued) The facility:owner(and occupants,if different from owner)were provided with information on the.proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C - - '"SYSTEM INFORMATION FLOW CONDITIONS 70aiplow lions Number of Bedrooms: l Nu r of Current Residents: Grinder: Laundry Connected To System: �" Seasonal Use Water`MeterReadings,if ail able::. Last Date'of Occupancy - 67 F. .� 'C,OMM RCLAIlINDUST iAL;. r� r,.,. ♦ I `r:t t�n rd�ly, i Design Flow .- •>� aallondday �Grease Trap Present:(yes or no) -` -Industrial Waste Holding Tank Present:. System:V t W e TDischa Discharged To The Title S s n- ani ast Y{No S �rY g , Water Meter Rea dings,yIf Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: !i GENERAL INFORMATION PUMPING RECORDS and source of information4e V --— System Pumped as part of inspection:_ If yes;volunw ptanaped: �aRons .Reason`for:pumptng TYPE OF,SYSTEM: + l%leptic`Tank/Distribution,Box/Soil'Absorption System Single Cesspool oviinow Cesspool_. , Privy Shared System(If yes,attach previous inspection records,if any), Other(explain) ROXIMAT `"AGE of all componen ,date installed(if known)and.source of:information: y ge odors det6de&hen arriving at th ite:LA.2 FS;r}' �3 "°#1 4 h� '"+(N',•h'.� a, ._?t. 4 ' ,; w • m,�r �d` d t �4 �7 �.r.���j t � i, �f��7,+a',,. !h j'S,Rhj�t�N•>a,.y f t, )Yi�. �yt f`. � i'A %.y+�'7 ' _ • •�q ' � y.lr ..,h P k _ .. 1 fi:.S-i 4 " �r tt b+ 1 r,. 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (confiatied) SEPTIC TANK: Depth below grade: ' Material of Construction: ✓concrete metal . FRP Other: Dimisions: 'XCo' S' Sludge Depth: �� Scum Thickness �'� Distance from top of sludge to bottom of outlet tee or baffle: _� Distance from bottom of scum to bottom of outlet tee or baffle: '7 Comments:{recommendation for- pumping,condition of inlet and outlet tees or baffles,depth of li wd level in relation outlet invert,structural integri evidence of I ge,etc.) x °/, All • i G ASEZs_a-�j Depth Below Grade: Material of Construction:—concrete—metal— FRP Other (explain) Dimensions: Scum Thickness: . Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping;condition of inlet and outlet wes*.r baffles,depth ofliqui¢ level in'relation to.outlet:invert,structural.integrity,evidence of leakage,etc.)___ TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete—mcl.al—FRP_Other(explain) Dimensions: Capacity: Gallons Design Flow:_ _ �allons/day Alarm Level: _ °"r t Comments:(condition of inlet tee,condition of alarm and float switches,etc.) r DISTRIBUTION BOX: ✓ Depth of liquid level above outlet invert: b ital,zx Comments:(note if 1 el and distribution is equ ,evide of solids carryover,evidence of leakage into or out of box,etc)X� 't � k l a2Q Q d f�l h° .� A04d a—v PUMP CHAMBERS - Pump is in working'order: Comments: (note.condition of pump chamber,condition of pumps and appur!.c.nances,etc.)- - SUBStJ!lt"itE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): 1� (Locate on site plan,if possible;excavation not required;but may be approximated by non-intrusWer methods) ; If not determined to be present,explain: Type: Leaching pits,number: t Leaching chambers,number: Leaching galleries,number. 'Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool, number: Co nts:(note condition of soil,signs f by ulic failure level o ponding,conditi n of vege o 'etc ' pry ii ,,;CESSPO.OIS: 6 Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: r` ''Depth of scum layer: _ Dimensions of-Cesspool:- Materials of construction:s '. Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding;,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of.Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) ,j t i -6 4 SUBSURFACE SEWAGE-DISP..OSAL SYS'1'LrM.lNSPEC'FION FORM PA WF C SYSTEM INFORMATION (coW micd) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references, landmarks or benchmarkk. Locate all wells within 100 Feet. DEPTH TO GROUNDWATER: Depth to groundwater; f S Feet > a Meth Dete 'nation or A ro ma Ti: n: /¢ 1b�i{'/ �Y��' a®� 8 4!^pp L _.__.._ ig -7- ° No..--Y �� Fr�s..........�.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Bi-tipwial Wnrkii Tnnitrnrtinn Frrutit Application is hereby.made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ..... .. _...---- -------L=�'�'9-.... 5----------------------- ........................................................ ........................................ a-i or Lot No ryds •� .................. •-••••-•--`-------------L.a,��. C ------------------------ -•-•--••... .... . ---•-•----•-----•.....................__ . .....................••• --•-•• ...A............ ................... Installer ddress Type of Building Size Lot............... feet U Dwelling—No. of Bedrooms.___.__.____ -----------------________Expansion Attic ( ) Garbage Grinder ( O9)0 Other—T e of Building No. of persons---------------------------- Showers — Cafeteria a' Other fixtures ... ...._.. W Design Flow.................... _.____.__..gallons per person per day. Total daily flow-------------------_.��� gallons. WSeptic Tank—Liquid capacity,!_M---gallons Length----------------- Width----.----------- Diameter_------------- Depth................ x Disposal Trench—No. ---.-_---•--..---_-- Width-------------------- Total Length-------------t------ Total leaching area----------_.........sq. ft. Seepage Pit No...--------/----- Diameter.......lQ_-..... Depth below inlet......6.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_--__.-.--._---__-_-_.-. G%, Test Pit No. 2................minutes per inch Depth of Test Pit-_--.-__-...__-__-_- Depth to ground water........................ ----------------------------------------------•----------------------------------------------------.......................................................... 0 Description of Soil........................................................................................................................................................................ x U •--•-•-•-------------------------------••-••---•---•-•--------------•-••------•---------••--••--------------------------•-•-----•-------•-••----•------•-------------•-••••-•••••------•--•••-•-•---••-- W -----•-------------------------------------•----•-------------------------------------------------------------------------------------------••--------....-------•-----•-------•--•-------..._..-----••. UNature of Repairs or Alterations—Answer when applicable._._./�`s-sT�'r^___.,........./Q>713. .._... .. �y ......�_r-'----...-- �------XT)-------- ..-----�-� ' t f`��...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha ee issu d b the and of health. — � 2 Signed ............. ............... . .. .. ........ .............................................. .........--- --------------------- -ems,,. Date Application Approved By ...........`J J...�...+ --- ------------------------------ .-- Da te to q Application Disapproved for the following reasons: ....................................................................................................................................... ------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- --------------- ........................................ to Permit No. ...... Y �.............. Issued ..----------i------------------- ----- ------ Daze f y �1,F( ' No3-Li-=•-�D�, 1 Fps..��r::................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for UhnVoml Wnrlw Tomitrnrtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal System at: Local n-Address or Lot No.. 6 Zy �I �e�L � L��is `tr j� C Owner r Add t� ,J J %w��i,J '' ress/ Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............. ...............:..........Expansion Attic ( ) Garbage Grinder O�C� aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------•---------------......._..---•--------.........-•------------...----------.----•----------•------•-•--------••-••--•-............••-•••. W Design Flow----------------------. ------------gallons per person per day. Total daily flow._____._.___._. �U..._____.__...gallons. WSeptic Tank—Liquid capa6ty.`2Pf!__gallons Length---------------- Width---------------- Diameter_............. Depth-_..________---- x Disposal Trench—No. .................... Width.................... Total Length............._..... Total leaching area....................sq. ft. Seepage Pit No............ ------ Diameter.___--_rO I..... Depth below inlet......'.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------ ............................................................. Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Gil Test Pit No. 2..............:.minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --•------•-•--------------------••-----••-------•--•----•••---•-•••----••-•-••......•--......_•--•••......................................................... ODescription of Soil........................................................................................................................................................................ W ...............................................................---••••----•--------•--•-••••••----•--•---••----•----------•---•----------•-••--•••----------•-•••-••-----•-......----•-•---••......•••. W --...................-------------------------------------------------------------------------------------------------................................................................................ U Nature of Repairs or Alterations—Answer when ..-� applicable J 'a/'1r ".0! _•.•._ -. f r �"� . Z ':�` 4 k..._,�1. �' -- +--- - ...... : ..... :<._.. , .. . 15 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has,-b°een issu d by1 the ebboard of health. Signed-----.--------- 1 ---1/-................................................... ? ... Dare ApplicationApproved BY --------.. -... '... ._=.,a..:. . i --7- 1. ....�.4—..._....._.... _----"---------'---------....---......-------'---------- Dare Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................ Dare Permit No. ---- = - y��h _- Issued .................................................................... Dare ---------------------------------------------------------------- -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�e>rtiftrate of 0-lomplian e THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( > 1 by ..................................................../ U2�-`[v-lam------- _-`- 1`.,,.1 s i`%"C.--/C-------i. ------------_------------------------------------------------- . Installer at - - --- -------C�{�'-r`-`---------G-(S�-�S-------------- ..... C.---------------- s-ll vi has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _ 2--�i: ....:..... dated -------__--------------------__-...__... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUEI��AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ - ' ............... _,`..... -.... .-... Inspector -------------------�- .-_ ---- :---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... ...... . I FEE.... Uispgal Morkii Tonotrurtion rrrnnit Permission is hereby granted•-------------------���u�(C-(�. �,�`J ` '/ jAjL (,-j to Construct ( ) or Repair (� an Individual Sewage Disposal System atNo................................................ , Street ry� ��� as shown on the application for Disposal Works Construction Permit No._-J.�.-__ . Dated-___-.�.:__�--�...a�_.��...... _ C� Board of Health DATE--------- �' --------L ..........................-............ ` FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS TOWN OF BARNSTABLE IOCATION - C40Al U1,7-44.s SEWAGE # �'� eft VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.��ytTwi,,7 SEPTIC TANK CAPACITY / Od0 LEACHING FACILITY:(type) T/'T L (size) NO. OF BEDROOMS-PRIVATE WELL O PUBLIC WATER BUILDER OR WNE Ste` G DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No� _� �� ��©y/T i r > � ' ;7 3y �s xx' �y, �� 0 �� TOWN OF BARNSTABLE 1 LOC-ATION2.� G 4 G 1'A lea, SEWAGE # XVILLAGE �' I ASSESSOR'S .MAP & LOTI#9/04� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER A,4/1'c- BUILDER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No l PO u5 e t , Lei y p � J !' l r � P . 4 No........... FEu....�...... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ... ----OF..... .. ..... •r9�1.����//... .. Application -fur ]i,ipuutt1 Works Tonutrnrtiun Prrntit Application is herebymade for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System t ........................: � ,,.�� / ........................ ..... ............................................ Location ess �/ or Lot No. /•_ l��q_C ..................�._..� _.._...----• Owner � Address , Wo d �.` ................ ......... Installer Address Q Type of Building Size Lot,/ _�q........Sq. feet U Dwelling—No. of Bedrooms.............. ._...._. _Expansion Attic (,+tom Garbage Grinder (.U pwq Other—Type of Building ____________________________ No. of persons.-----------4------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ __ W Design Flow---------------- Mons per person per day. Total daily flow........._.....---.... � gallons. g g P P P Y Y g W Septic Tank—Liquid capacity/A-P-.��..gallons Length---------------- Width................ Diameter................ Depth---------------- ^_._- x Disposal Trench--,No..................... Width___--__-_____--.-_-- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...../-_____-____ Diameter-----�X6__ Depth below inlet.................... Total leaching area---_.__----_-____sq. it. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------.... a Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..._---_-.----.---_._... (Xq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--.--.__--_--___-___. 9 -----------------------------------------•-----------------'--------•-•-•....--•-••......'-"-'-•--.......................................................... G Description of Soil------------- S/uG�•----------••--•--•------ -------- ---- --- - - ----- W �7 -----------•--------------------------------------•-----•-----------1X---:, -------.----- �� E........f Tfl L.(� -•-•---••--------•------•---------------- x ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 a rees not to place the system in operation until a Certificate of Compliance has been issu he board of h Signed------ _ G •'-- �' 6 v Date Application Approved By.___.. ._ ./� (/ = ---------• •-•-•--•-•--•----•--------------------------- Date Application Disapproved for �IT.e following reasons: -------------------------------------------------------------------------------- --------------'------------------------------------------------------------------- ------------------ / Date PermitNo.--------s2l i� ...............----................ Issued......................................................... Date No........................ ...`..... ..... THE COMMONWEALTH OF MASSACHUSETTS .- BOARD OF HEALTH ,cr.............OF..... ...._o. .�?f2 /tom'/.-�...1121.. f...:........----- Appliration -for 4%ipwial Works Tonotrnrtion Prrntit Application is hereby made for a Permit to Construct (``)or Repair ( ) an Individual Sewage Disposal System,at: .. ' a ` Location-•Address ✓ or Lot No. � r � Address Installer Address Q Type of Building Size Lot_,Zl_O_°_�±--------Sq. feet U Dwelling—No. of Bedrooms-___--_-.._. ____________________Expansion Attic Garbage Grinder per, Other—Type of Building ............................ No. of persons............!............... Showers ( ) — Cafeteria ( ) Other fixtures .........._••----------------------------------------- W Design Flow________________ ............................ WSeptic Tack—Liquid capacity,—"�-gallons Length---------------- Width................ Diameter---------------- _.__-_ Depth-__..... .._... x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area------"-------------sq. ft. Seepage Pit No.....�..........__ Diameter____ '' ��l._ Depth below inlet____________________ Total leaching.area.... ft. z Other Distribution box (v)`' Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date_..__----------_--------------__-------. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-------"---.---_-.--.... �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water............__-____..._. W ••--•-•----------- ------------------------------•-•-•-•-----................................•-.............................. --•-------------- O Description of Soil_-----------/....... xU - y . TTWi W VNature of Repairs or Alterations—Answer when applicable--------------------------------------_-------------------------------------------------------. ----••-----------------•--------•-•-- ----------------------- -------------•----------•--------------------------•-------------------------------------•----•--_-------------------•-------•----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i/ssuued/lby the board of•health. Signed-------/-_.-'�---.....0.' ff/'...... - _ A �G Date f � Application Approved B f PP PP y---------------L --- Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ ........................."--------------------------- ..................---.................-----•----------------•--_._.._.....-••-.._._._...-------------------_------------------------------- Date PermitNo.------- `f-----------------------------------• Issued......................--................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH W. rrtifiratr of f�ontpliatta THIS-LS TO CERTIFY, That the Individual Sewage Disposal System constructed (' oor Repaired ( ) Installer at---- ----------------- ..................... -�;--------------- ---- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------rl_"l._____________________ dated__..ZL- :._7_�._.__....__.__.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---- -------- ­- •------------A. a` --- Ins ector -�... THE COMMONWEALTH OF MASSACHUSETTS �.-- BOARD OF HEALTH OF..._......:: ......................................... No........ - ....................... FEE........................ Dinpasal Mork, ion trnrtion rrnt #_ Permission is hereby granted............ - -n ..'` - �r. '^ :.- to Construct ( fir Repair ) an jndividual Sewage Disposal System at No......... �.-------- Gs r t r e ----------------'---------------------------- -�........................ ------------------------------------------------............. Street as shown on the application for Disposal Works Construction Permit No..__.r>'.t!l__._ Dated....%_.................................. ............................................................---------................................. Board of Health DATE---------------------------------------------------------•---------------------- FORM 1255 HOBBS-& WARREN. INC.. PUBLISHERS 4,A; A LO�C A'T ION �j O j �Jl� SEW AGE PERMIT NO.. VILLAGE ,-�� / 0(-/) &NiTtzv i INSTA LLER'S NAME & � ADDRESS �v �6 PC 4+ . i) cH t4ift B UYLDE R OR OWNER. _ DATE PERMIT ISSUED ( jay 6 DATE COMPLIANCE ISSUED tf 019 1 ail c Ya � c a A, �ttl1E TOWN OF BARNSTABLE y nAsa. ,, gO�FFICE OF BOAR OF HEALTH m°,ems 039. 4 397 MAIN STREET HYANNIS, MASS. 02601 i To : Building Inspector` From: Health Department Subject: Test hole and Percolation Test A examination of the oil atA (Lot) Address) ( Village) was made on � �"' � �- l/am' and found to be (date) suitable for sub-surface se,laget at. site of test hole. Building Permit will not be approved-or sewage permit issued until Health Department receives two codes of plan shoeing building, systems and all other details listed in Board of Health instructions to sewage applicants. This a-D-,)roval does not constitute a final decision concerning the installation of a sewage system. 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