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V COMMONWEALTH OF.MASSACHUSETTS1 �
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
FFICIAL INSPECTION FORM NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 20 Cedar Point Circle
'Centerville. M.4 026321
Owner's Name: Effie Zisson L19 L
Owner's Address:
Date of Inspection: May 4, 2008
Name of Inspector: (Please Print) Jaynes M, Ford
Company Name: James M. Ford' >�
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
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 functiop 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
Po itionally Passes
Ned Further Evaluation by the Local Approving Authority
Fa Is
Inspector's Signature: Date: May 10, 2008
The system inspector shall submit _cop;-of hi inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this'in.. --n. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system t�. `ir shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the systei,.owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that .
time. This inspection does not address hory the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000. page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Cedar Point Circle
Centerville, AM
Owner's Name: Effie Zisson
Date of Inspection: May 4. 2008
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I 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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Cedar Point Circle
Centerville, MA
Owner's Name: aie Zisson
Date of Inspection: May 4, 2008
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
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 colifonn
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Cedar Point Circle
Centerville, MA
Owner's Name: Effie Zisson
Date of Inspection: May 4. 2008
D. System Failure Criteria applicable to all systems:
You must indicate either"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 in cesspool is less than 6"below invert or available volume is less than %day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to detennine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
_ 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.
4
Page 5 of 11
t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Cedar Point Circle
Centerville, MA
Owner's Name: Effie Zisson
Date of Inspection: May 4. 2008
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:
Yes No
✓ _ 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 15:302(3)(b)]. i
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 Cedar Point Circle
Centerville._MA
Owner's Name: Effie Zisson
Date of Inspection: May 4, 2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): N/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,.if available(last2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currentiv occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infonnation: Unknown
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Date of installation 12113194-per as-built.
Were sewage odors detected when arriving.at the site(yes or no): No
. 6
Page 7 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Cedar Point Circle
Centerville, MA
Owner's Name: Effie Zisson
Date of Inspection: Mav 4, 2008
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction`. ✓ concrete ._metal _fiberglass -_polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal
Sludge depth: 2"
Distance from top of sludge to bottom of.outlet tee or baffle: 30"
Scum thickness: S"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
4
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Cedar Point Circle
Centerville, MA
Owner's Name: Effie Zisson
Date of Inspection: May 4, 2008
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass polyethylene._other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alann present(yes or no):
Alarm level: Alann in working order(yes or no):
Date of last pumping:
Comments(condition of alarm.and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was clean. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Cedar Point Circle
Centerville. MA
Owner's Name: Effie Zisson
Date of Inspection: May 4, 2008
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 600 gal. Pit-per as-built
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.):
The pit had 6"of water on the bottom and the scum line was at the same level There did not appear to be any signs of failure.
e
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OF _FICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: - 20 Cedar.Point Circle
Centerville, MA
Owner's Name: Effie Zisson
Date of Inspection:. May 4, 2008
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including.ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feel. Locate where_public water supply enters the building.
64
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Page I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Cedar Point Circle
Centerville, MA
Owner's Name: fffe Zisson
Date of Inspection: May 4, 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
_Using Barnstable topographic and water contours naps-the maps were showing approximately 30'+/--to groundwater at this
site.
This report has,been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection.'This report is not a warranty or guarantee that the system will
function properly.in the future. There have been no warranties or guarantees, either expressed,written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
mow 7He r� ,
Town of Barnstable
p o regulatory Services
, AB Thomas F. Geiler, Director
y� 1659.
ATE , A Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction.Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
t
TOWN OF BARNSTABLE
LOCATION p o ce,& P0,�-i SEWAGE#
VILLAGE C ,A-r 'yh- ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY I CND
LEACHING FACILITY:(type) PI—r (size) w OD
NO.OF BEDROOMS 3
OWNER I sson
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
within 300 feet of leaching facility) Feet
FURNISHED BY 'CAs(�ee loll Forl s/y�o
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FEll... �..:.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ........OF....... �
Appliratiun for Biupuuttl Workri Tomitrnrtiun Permit
Application is hereby made for a Permit to Construct (,,k) or Repair ( ) an Individual Sewage Disposal
System at:
...el... ........-.---•- -°U-�...d B!� &� ............. ._. ..............
r
Location Address or Lot
Owner /.... ' ...
------- ---
Installer Address
d Type of Building Size Lot... 4LSq. feet
aDwelling—No. of Bedrooms..........3_..............................Expansion Attic ( ) Garbage Grinder (.a)
pi Other—Type of Building ____________________________ No. of persons___________________________ Showers ( ) — Cafeteria ( )
Q' Other fixtures .............................. -.............. .
--------------------------------------------------- --•---•------•-------
W Design Flow............... ..................gallons per person per day. Total daily flow------- 1AP....gallons.
WSeptic Tank—Liquid capacity/PVP.gallons Length_______&-____ Width__-_-YQ____ Diameter______ ______ Depth-S.__6__-.
x Disposal Trench—No. ____________________ Width..................... Total Length.................... Total leaching area................
sq. ft.
Seepage Pit No-------/----------- Diameter.....,/__-------- Depth below inlet___. r_ �._. Total leaching area...ZZ�__._sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by...... 1'� -___ _._ Y ____� ...... Date___._
a Test Pit No. 1................minutes per inch Depth of Test Pit__:_ _.______ Depth to ground water_____ __ _,_-.
Test Pit No. 2_.��_..minutesper inch Depth of Test Pit__.-/..�:_'_______ Depth to ground water-----A?/�_..
--
x { ----------------------------•--- ....
O Description of Soil... 7_'.__••- �--- -- -`� `?- -
-•-••-•-••••---------------•----•-----------•---•----•.........................
W
UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance been issued by the board of health.
Signed --------- ---- * �:y................
to
Application Approved By -- � .
.-..--...-. ..- .......... Date
Application Disapproved for the following reason : ........................................... ........... . ...... . . ................ .................
..................... ... ... ............................................................................ .-- ------- -- . -..............................------j-- ....................-----------------
Permit No. ......4 - -"'A .-�------------- Issued Date
ing .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH _
........ e-P. -.��a. .....OF...... � t.,f�-�%� �.,... ---......
Appliratiun for Biupuual Workii Tunitrurtiun trrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syste�.m• at: } y�
, ..... ... .. ....... .......:....... ........r.................._.._._..... ......._.._...._ .._.:x ._.. ........_..._.
�.- Location Address 7
.. . ......................................................... `- •••.. ........
W V Owner (�GX // dress
Installer Address
dType of Building Size Lot...fc'°? = Sq. feet
U Dwelling—No. of Bedrooms.........`.................. . .....Expansion Attic ( ) Garbage Grinder ( o)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures _________________________________ _
d
W Design Flow...............�$L5 ..................gallons per person per day. Total daily flow...... ....gallons.
WSeptic Tank—Liquid capacity/ArJ?_gallons Length_!_._��_.___- Width...�`�_.l _-_ Diameter__.-"_� _.__. Depth-S.. �'.....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No........ ...... Diameter...._1.2_....... Depth below inlet_... :__ ._` Total leaching area--- s q.
Z Other Distribution box (le) Dosing tank ( ) {
Percolation Test Results Performed
a by. C '
--.........
_-_. Date___..
Test Pit No. 1................minutes per inch Depth of Test Pit---- ........... Depth to ground water......l-�l�__...
Test Pit No. 2..A X-___minutes per inch Depth of Test Pit---- ....... Depth to ground water..... ?� ......
D Description of Soil-•�-r-----• p-:.2..:......�`'}� ,f �� C..
W ---•....-•-----------------•---•---•---------------••---•--•-.....-•----••-••--••-•------------•-------•----•-----------•--------------------•---••---......-•--------•-------------•---•-----•-........
UNature 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance' as been issued by the board of health.
--�I!
., .� Signed¢ .. - --------------------------------- . .
Application Approved By `` r .f . r/ ................... ....... e
r, : _e
Application Disapproved for the following reasons: i
- -------------_............... . .. .................................
.......... . ..................................................... ... ........:...................................................... . . . ............................................... ........................................
/- Dace
Permit No. r 1 ^r --...... Issued .-- /- 'T .:�r�'..
.......,.......................�.................. f � .
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ OF ......ZA7' -rL .�'.f ��..
Cfelr#ifira e of (fantylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......................!... ............ .�....r.. .... �..:@ ,r`f... ..�.
N�In .... ......... .. .................... .
at ...... �- ..... ..1,.1'".'.,;�":f�-..�.. .r.:....s '" r «!. r .....�g ......( •'' - .. �!
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. ..... ...f... �'_�..... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ;
Z� �. ..-----*------------- Inspect �:..� ��
DATE.....-�........................ .. .............../ - -..... - - .....:...-- -- ---.......-1 -- ----- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. FEE...... r� .1
Disposal Works Tunstrnrtiun "Prrmit
Permission is hereby granted............... .......
to Construct ( or Repair ( ) an Individual Sew age Disposal Systemm l ,�
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as shown on the application for Disposal Works Construction Permit No. r;. .�D�ted.._.._._ �..." .............
........................................ Y _ ..-.th
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^ Yard o f H eal
DATE ..:- C}...- I-------------------
Form 1255 H&W HOBBS&WARREN TM Publishers
j. TOWN, OAF B�ARN,S`TABLE
LOCAl-ION (,jT �'ez)ckl .A,,.v` SEWAGE # r
VILLAGE �
d� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 3 .
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) P ! (size) tlo®y } �
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER jLtAA, J.3o�Q 1`jae P ,
DATE PERMIT ISSUED: z —
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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t
co CAT r®N t -e�E� SEWAGE PERMIT N0.
VILLAGE
INSTALLER' N M AJkpl ,kSS
West ,Barnstable, Mass. 02668
BUILDER ON OWNER
DATE PERMIT ISSUED f4Y2
DATE COMPLIANCE ISS:UE'Day /j
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- DESIGN '
GENERAL NOTES : CRITERIA ./ TER / A . `INVERT EL E VA T l ONS
l . - DESIGN FLOW: INVERT AT BUILDING: 95. 00
THIS PLAN I S FOR THE DESIGN AND
ACCESS COVERS MUST BE WITHIN
3 10
Ioo.0 12 ot: FINISH GRADE BEDROOMS AT i G. P. D. PER 9 5
.� INVERT SEPTIC TANK. 4. 7
CONSTRUCTION OF THE SEWAGE DISPOSAL FIRST 2 To 330
BEDROOM EQUALS G. P. D.
SYSTEM ONL Y.
BE LEVEL INVERT OUT SEPTIC TANK.. 94. 50
- INVERT IN DI ST. BOX: 94. 40
4 PVC MIN. 2' OF
,..�- NO GARBAGE GRINDER
2. ALL CONSTRUCTION METHODS AND SCHEDULE 40 PEASTONE INVERT OUT D I S T, BOX 94. 20
MA TER I AL S FOR THE SEPTIC SYSTEM 95 o s4.2 INVERT IN LEACH PIT: 94. 10
94.7s - 3.s 314' - l 112' DIA. SEPTIC TANK REQUIRED;
SHALL CONFORM TO MASS. D. E. P. 90. 60
3 ourter WASHED STON 330 G. P. D. X 15oy 495 GAL .
BOTTOM of LEACH PIT,
T l TL E 5 AND LOCAL BOARD OF HEALTH
l0' MIN. loon GAL D-BOX SEPTIC TANK PROVIDED: 1000 ADJUSTED GROUND WATER: N/A
6• �� GAL .
REGULATIONS. SEPTIC TANK
LEACH PIT. OBSERVED GROUND WATER: NIA
3. ALL SEPTIC SYSTEM COMPONENTS LOCATED PROF I L'E : NOT TO SCALE
SIZE OF LEACHING FACILITY REQUIRED: BOTTOM OF TEST HOLE *2: 86. 60
330 G. P. D.
UNDER AREAS SUBJECT TO VEHICULAR TRAFFIC
OR GREATER THAN 3 ' IN DEPTH SHALL BE
DESIGN PERC RATE - � 2 M I N/I NCH
CAPABLE OF WITHSTANDING H-20 WHEEL LOADS.
- PROVIDED: I . 4-PIT(S) W/ 3 'STN.
4. ALL SEWER PIPE SHALL BE SCHEDULE 40
S I DEWAL L : 132 S. F.X 2. 5 _ 330 GPD
OR APPROVED EQUAL . BOTTOM: 113 S. F,X I . 0 _ 113 GPD
TO TAL : 245 S. F. 443 GPD
5. BEFORE CONSTRUCTION CALL 'DIG-SAFE'.
1 -800-322-4844 FOR LOCATION OF SOIL TEST PI T DA TA
UNDERGROUND UTILITIES. CO INDICATES " INDICATES
`�' PERCOLATION �- OBSERVED
6. VERTICAL DATUM IS: ASSUMED o
TEST _ GROUNDWATER
+ ZONE : R C P-8272
/ 106.E
/ / v TPA I TP+� 2
7. FOR BENCH MARKS SET. SEE SITE PLAN. / 1 SETBACKS: FRONT - 20 ' GRND EL. 99• l GRND EL. 98•6
SIDE - l0 G. W.EL. N/A G. W.EL N/A
8. APPLICANT IS RESPONSIBLE FOR OBTAINING ploo.9+� // �/ t / REAR l0 ' -
/00 Al I 19�.6 ; ,1 1 /04.k�- 1 \\ TOPSOIL TOPSOIL
DETERMINATION AS TO COMPLIANCE W l TH
�� 3F SUBSOI L SUBSOIL
DEED RESTRICTIONS OR ZONING REGULATIONS. f t t i �\ 2' ��. I 2' 96.6
, 11 ► t t 1 \ \ --
\ \ + t 1 It I 4+ \ f : MED I UM _ MEDIUM
3 -- ..._
II M8pe4S 0 -// ^-- SAND SAND
- � J
�/ try � \ \ \ /•�..�,i� � �t ,���
__
99.8 I `\ \ \ �i� SWALE 2e
j a - OPO Ep WATER `\ 102. �o No WATER No WATER
l2' 12' 86.6
DATE: SEP TEMBER 20. 1994
97.B+ fJ i
rH 02 _�, ;: / TEST BY: BAXTER NYE
v `.N \ WITNESSED BY: ED BARRY
m40 1000//GAL ��� - __ /�/9 11 PERC RATE: C 2 MIN/I NCH
4* PIT CAL
- � o
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BAO-M�ST COR CB/DH \\ \ ' i 99. / % v ,�� S E/ / / C' �J / �J / E/ V/ L/ E `J / �J / V
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0 is 20 40 JOB NO 94-335 FJELD:CFW/RVB GALC: SAH CHECK: CFW DRN: . SAH