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HomeMy WebLinkAbout0017 COTTAGE LANE - Health �1F COTTAGE LANE, CENTERVILLE MAP-229, PAR.-088-002 " � No. 42101/3 ORA PQ andaloosK, ESsE«E 10% (a O O O O �- ASSESSORSaA pa �?� G� PARCEL NO: No. ._. . I Frs........... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uiopoml Wor1w Tonotrnrtion V amit Application is hereby made Ifa�J?yrniit Con uct (�) or Repair ( ) an Individual Sewage Disposal System at: .................................. ------ - --- - -------------------••----------- ----------------------------- - oration-Address - / or Lot No. ...................... -¢ --------2-f- ----- 2 ffi ws .�L Owner Address a .............. Installer Address Type of Building �3 Size Lot____ZUz... ` .7.Sq. feet ® �� �. Dwelling— No. of Bedrooms........... Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ---------------•------------------•----•--------------------- w Design Flow............ _________________gallons per person per day. Total dail flow------------ ....................gallons. 9Septic Tank—Liquid capacity,/S� gallons Length--- o------ Width_ ..._. Diameter________________ Depth......r.�_.. xDisposal Trench—No.s.f-_Z_-_a!J!FWidth...0._..__...... Total Length.___ .*.... Total leaching area..._Y j....sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosingank ( ) 4Z a Percolation Test Results Performed b _ PrIVAd--____-_ .. ^� 2— Y !' -- / �Sr Date --------------------------- - Test Pit No. I................minutes per inch Depth of Test Pit____A 4_'_. Depth to ground water____...._............_.. LZ4 Test Pit No. 2..__.L' minutesper inch Depth of Test Pit---- .. Depth to ground water....ID!_,3..... 9 ..__....-••--------------------------•-•••..._..•--••---••-•---•......--•----•--•------------•............................................................... O Description of Soil-------------------_---���....ok=e........AL 4"'^�----------------...--------------------------------------------------------•------------ 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 TITLE 5 of the State Environmental Code—The, undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ---- . ,. .... .... ..... .. .. .. -- �. �� - ...:------ Application Approved Byf_ .. �Y . e - - ------------- Date Application Disapproved for the following reasons: ... .............. .. ......................................... .. ....... ........... ................ --------------------------------------------------_....--------..._------.....---------------------------........:.......__.................... ....... .................. . ............... ........................................ Dare Permit No. " -------------------- Issued ------------`J"`� Daze • ------------ Y Fss.. THE COMMONWEALTH OF MASSACHUSETTS BOARD_ OF HEALTH TOWN OF BARNSTABLE XpVtiration for Diopo!3tt1 Work.6 Tomitrnrtion rantit Application is hereby made fox a • mit to Cons~uct (�c) or Repair ( ) an Individual Sewage Disposal System at: 17 ..................................... .... ,. U l ocation-Address /2 or Lot No. / .Zr.. f..ILL J/I£ /✓LG/ G ... s Owner ' ��� /�y �f Address!C^/% Installer Address Q Type of Building Size Lot-_-_Zvi__y`'.7 Sq. feet U Dwelling—No. of Bedrooms---------- ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons---__-_--_----____-__----- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ W Design Flow..............J�------------------gallons per person per day. Total daily flow---------- _�� -------------------gallons. WSeptic Tank—Liquid capacity,/_/��gallons Length--_f©_-__-_ Width.... ------ Diameter---------------- Depth..... x Disposal Trench—No.�67_1�.P!_6Width...e------------- Total Length---.KY.... Total leaching area.... .L.sq. ft. Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area-------...........sq. ft. Z Other.Distribution box ( ) Dosin ank ( ) r a Percolation Test Results Performed by.__�oL�e.(.. _��_��4_C ..__... Date.._.. �" 2 Test Pit No. I................minutes per inch Depth of Test Pit _-�5�.... Depth to ground water...-_.-.--___-_-----._. 44 Test Pit No. 2.....�Z.minutes per inch' .Depth idf tTest`Pit__,//3.Y... Depth to ground water-.-- a. 3 --------------------- ----------------------------------' /.:.t Description of Soil a!1`r y�✓ .� t � .`..- .Y U -•••--••------•-•--•----••--••.............•----•-•-••-•-•------••----•-.--------------•---------......-------------------------------•----. -------------------------------------•------•----•------- W / UNature of Repairs or Alterations—Answer when`applicable................................................................................................ Agreement: t� - 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 been issued by the board of health. p, Signed ----- 11 7---------- Application Approved B ;^� f _.. .::. ... ..................................... .1 ------------ Application ` , PP PP Y _......._........ ...<� ''E r... Date Disapproved for the following reasons: ..... ..... .... .... ...................... ....... .... ..................... ......... --------------------- _------.. -----....------------------------- .............. ...... ---------------------- - - Dace Permit No. .. '- ff... _ Issued ------------ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C11Pr#ifi a e of Tantylian e THIS IS TO CERTIFY, That the Individual Se ge Disposal System constructed ( or Repaired ( ) by ........... ..... -...... ------------- - at &; � `�. V, - _---� --------------------- ----- --- -------------------------- : .. has been installed in accordance wlch't-he provisions of TITLE The State Environmental Code as described in the application for Disposal Works Construction Permit No. , ?" F - .......... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.DATE.-------------------------------f-- ..'. 1 ----------- -------- Inspector ......--------- 1 .------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,�+ TOWN OF BARNSTABLE ,v No �f�.u/S FEE. C�......... Au�t trudivit Vrrntit _ i Permission is herebygranted l----- g � to Construct (l� or Repair ( ) an Individual Sewage Disposal System �� s � at No. ""� -•---•---- •-•------- -s.. _ .: 'i ----------------------------------•-- as shown on the �cTlapplication for D/ins osa/>Vl orls Construction Perm et _ t( � L Street PP p t No. --- ------------lllated ,7 ......... / /, '"� DATE----------------9--�--•----/----••------....-/--------•----------------------- Board of Health FORM 36508 HOBBS!}WARREN.INC..PUBLISHERS = ASSESSORS MAP NO:� g IN - PARCEL NO: D 0 Commonwealth of Massachusetts Grad Executive Office of EnVironmental Affairs - Title VJoh Septic D.E.P. Title V Septic Inspector Department of - - - P.O. Box 2119 _ - - Environmental . Protection Teaticket, MA 02536 - (508) 5641-6813 WUllam F.Weld Trudy xe - 8aereta yto EA David'B.Struhs _ Comtniaioner _ — _ -- = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ��ram•�'�� ® PART A �b CERTIFICATION �,, Property Address: G' C.�MC � `' ;a��A�&ess bf Owner: �HE 9 1995 HEALTH DEPT. Date of Inspection: \�aS� R� (If different) TOWN QF BARNSTABLE Name of Inspector: Company Name, Address and Telephone Number. 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority L---F—at Inspector's Signature: v Date: �c �1 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design, flo\% of i0,000 gpd or greater, the inspector and the system o�%•ner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The oneinal should be sent tc the system owner anu cope: sen; to tht uu�er, if applicable and the appro.ins au:h;,riC,. INSPECTION StWIMARY�D) : 9� Check A, B, C, - A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. _ B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is of tic imminent. The system will pass inspection if the existing septic tank is replaced with a conforming g septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Wlnte►Strost Is Boston,Massachusetts 02108 a FAX(617)SWI049 9 Telephone(617)M-ss0o Printed on Recycled Paper - SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A _. CERTIFICATION-(continued) Property Address: Owner: . ( - Date of In;pe of -BJ SYSTEM CONDITIONALLY PASSES (continuedT = Sewage backup or breakout or.high static water level observed in the.distribution box is due to broken or obstructed -pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s) are replaced _ obstruction is removed distribution box is levelled or replaced - The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING 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 �.+•ithin 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIR0101ENT: _ I ne >%cjen' rd> d >ewi( ldnh anu �uii abtorptlon syiien. ailu is fcci ',, a iufdCc '•�aiC" iLPP!, G. t.. z surface water supply. _ "The sop ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The s,=ter, has a septic tank and soil absorption system and is less than 100 feet but 50 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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 dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART A - - CERTIFICATION (continued) Property Addrs: Owner: es - - --Date of InspeZIC*.0\' DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above-outlet invert due to.an overloaded or clogged SAS or cesspool. elow invert or available volume is less than 1/2 day flow. Liquid depth in cesspool is less than 6" b Required pumping more than 4 times--in the last year NOT due to clogged or obstructed pi.pe(s)_ Number of times pumped System, cesspool or privy is below the high groundwater elevation. _ Any portion of the Soil Absorptiony P _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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flov., of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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, The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requireme7tt5 of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information, (revised 8/15/95) 3 —SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B _ CHECKLIST -_ _-- Property Address: Owner: -Z -Date of Inspection: C \ `C`�f - Check if the following have been done: 1--f'umping information was requested of the owner, occupant, and Board of Health. Llf�_one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. built plans have been obtained and examined. Note if they are not available with N/A. _jhe facility or dwelling was inspected for signs of sewage back up. _Lyae system does not receive non-sanitary or industrial waste flow �- T e site was inspected for signs of breakout. 1_0 system components, excluding the Soil Absorption System, have been located on the site. (T*re septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. L-The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b\ non-intrusive methods The �2c,i;,,, , �,, ,� ;1Jiffprp�' irn, ov,,P,� were orovided with information on the proper maintenance of Sub Surface Disposal System. 4 (revised 8/15/95) s SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C — — . SYSTEM INFORMATION Property Address: - Owner: �O`\ - Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: — Number of current residents: Garbage grinder (yes or no):_ap - Laundry connected to system (yes or no): - Seasonal use (yes-or no):�� _ Water meter readings, if available: - Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:__gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informal a i� `i cC !� c�l System pumped as part of inspection: (yes or no) If yes, voluaae P1'1'P('d eallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system �7Smingle cesspool --***'Overflow cesspool Privy ttach previous inspection records, if any) Shared system (yes or no) (if yes, a Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: cs Sewage odors detected when arriving at the site: (yes or no)'�© 5 (revised 8/15/95) e- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM - - PART C _ SYSTEM INFORMATION (continued) -Property s: -_Owner: < Date of insped �� SEPTIC TANKQN3, (locate on site plan) Depth below grade: - Material.of construction: _concrete _metal _FRP—other(explain) - - Dimensions: - Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:Pj(locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum tnickne». Distance from top of scum to top of outlet tee or baffle: Dictanro from bottom n+ —1,— to hottorr.. of outlet tee or bathe- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) _ Property Ad ess:. Owner: \: - Date of Inspectiofi: TIGHT OR HOLDING TANK:D4DS _- (locate on site plan) Depth below grade: _ — Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: _ _ gallons - Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOXI;�\(-\- (locate on site plan` Depth of liquid level above outlet invert: Comments: mote if level and distribullun eyudi, e—de-ice o, so:iJ carr?u,cr, evidence of leakage into or out of box, etc` PUMP CHAMBER• (locate on site plan) Pumps fi working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 7 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM - _. PART C _ SYSTEM INFORMATION (continued) Property Address:" �.3 Owner: - - Date of Inspibr� -L SOIL ABSORPTION SYSTEM (SAS). +� - (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not.determined to be present, explain: - - Type: - leaching pits, number:" - leaching chambers, number:_ leaching galleries, number. - leaching trenches, number,length: leaching fields, number, dim sions: overflow cesspool, number: ��.� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: L� (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Cl>`) �' Depth of scum layer: `r Dimensions of cesspool: 14'�(� Materials of construction: indication of grow,d..a:_ ('P���c -f�.� inflow (cesspool must be pumped as part of inspection) i Comments: (note condition of soil, signs of h draulic fail e, level of ponding, condition of vegetation, etc.) U PRIVY: (locate on site plan) _ Materials of construction: Dimensions: Depth of solids: Comments: (note.: of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 S - - - SUBSURFACE SEWAGE::DISPOSAL SYSTEM INSPECTION FORM _. ,PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of I-nspo?t: SKETCH OF.SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' _ f—' I i R ' DEPTH TO GROUNDWATER Depth to groundwater:��feet c method of determination or approximation: f��sl� n v (revised 8/15/95) 9 C� TQWN OF BARN LE 1 LOCATION ` SEWAGE # VILLAGE IJ _ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS M� BUILDER OR OWNER k 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 within 300 feet of leaching facility) Feet Furnished by �Cfc6 ea EE$..........�5 ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripmml Works Towitrnrtinn runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............................. Location.Address or Lot No. ---......-•-•---- /�1 Y"1 !1 AE4 ....... ................................................-................................................. O cne Address Installer Address 4 Type of Building Size Lot___7V.,4 .9......Sq. feet Dwelling—No. of Bedrooms._-.--_-��____-_•-------------_---_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow...............��__._____ ....._ ..gallons per person Per day. Tot al dd�ily flow........._...--��—' ................ ions. WSeptic Tank—LiquTd ca,Pacity. r�Q�gallons Length__�'S_ Width-------,_it:_. Diameter________________ Depth.._ _. . x — —:�0`�_ :.D.!> �Vidth..8.� Ff-. Total Length.... Total leaching area :.(..sq. ft.Disposal Trench 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( e, aPercolation Test Results Performed by pc l___ _..... �Es�..................... Date.... 2Z---�L` .......... 1 Test Pit No. L.A—minutes per inch Depth of Test Pit----- `�... Depth to ground water--- N/A......... 44 Test Pit No. 2...�vniinutes per inch Depth of Test Pit...... i�_. Depth to ground water.......,. _ 3_�.. WG ...-----•--------------------------•-•-------------------------------•--................------.-----......................................................... 0 Description of Soil_.--•--•.Q.-- ......... r' A-.!5-A ,2 -- - ..`.-��- LS4.------ ----------•---------------------------------r" ..............----------------------------------------------------------------------------------------.....-------•------......... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...................•---------------•---------••-------•----•---•--•-----------------------------------•-•-------•-------------------------------••-------•-- ........................................... Agreement: The undersigned agrees to install the aforedescribed In 1 idual wage Disposal System in accordance with the provisions of TITLE 5 of the State Environ ntal Codee Th ndersigned further agrees not to place the system in operation until a Certificate of Corn la ce s "dn i sue the oarA of health. Signed .. ....... .... �... ... = .....:z .... .. ...... -----------'--- Dare ..... Application Approved BY -----.....a ^... .................... . . .................................. ...... ...---.�.9..-. .( Dare / Application Disapproved for the following reasons: .......... ...... .............. .................................... ...... . --- .............---.................. ................ .................. ..... ........................ .............. .................... ............................ . ..................... .......... ...... Permit No. .........1. 4/ U ..................... Issued ............... ....................................ice...... Dace —————————---————————————————————————————————————————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifirate of C amplianre THIS IS TO CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ....................... ....... -----------...... - _........._............._.... - - ... lnsc.a�er at ............. ®. ...�..............1 . ....... .. .............� � aco 1.._..!!�!�.......... _ .......................... 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. ........ ..../_.L...?,..... dated ......._------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... .. .._._-- -----...-----......------------.............. ----- Inspector ........ .... ......._._--- -------------------------------.......... -------------------------- --------------------- ----- ------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t� TOWN OF BARNSTABLE No...7 -=- FEE...../ ....... �is�rrrsttl nrk� �lan�tr�rtuan rrntit Permissionis hereby granted-----------_--- ------•---------------------------------------------------•--------------•-----•---..----- to Construct ( or Repair ( ) an Individual Sewage Dis )Dsal Syst at No..............-. a C;---------- Street as shown on the application for Disposal Works Construction Permit No..1_/7A__//? Dated........................................... -•..................•---•--•-•---•-----•-----------...---------------------------••••••-••------••••••... Board of Health DATE...........................----•-•--------------------------------------------- FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS r (A— No....�......`-...... g t ..........1.Q..o......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE r Appliratiun for Uhnpmial World, Tomitrnrtion Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........... ... ------..•••. -•-•----•-•----•-- =z= ..... .. Location-Address � - ^ or Lot No. / O cncr Address a •-••....... ` t� k--•••C61�-•••--•----•----••......---•••--••-•....._ ... ......................... .� Installer ---•---••••------- � Address UType of Building Size ......Sq. feet Dwelling— No. of Bedrooms---------_______----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) j a' Other fixtures ............................... . . W Design Flow............... ___..__..�-_.____._gallons per person er day. Total d ily flow------------ ��-� .................gallons. 9 Septic Tank—Liquid ca acity.a..t').l2l-gallons Length--� � ` p .5--- Width---.--.._.t __."Diameter Depth Disposal Trench-- No Ft:.D!rFW idth__r`3_ .ff._. Total Length---z6-- -!.s`_. Total leaching area... ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed ....................... Date.__.Z - 2 Test Pit No. L.`v minutes per inch Depth of Test Pit.....1.. .__. Depth to ground water......t!A---_---. f=, Test Pit No. 2... _v._minutes per inch Depth of Test Pit------ Depth to ground water..._._. ................ i ...-•---•--------------------------•----•------------------•----...-------------•---.........--••---......................................................... D Description of Soil--( .......Qn2:-f-z=',••-•-• T?Jt 1 1._.�,....... x V ����......-•--•c'•--- -T _ �� � � !"jam ..................................... ................ ---------------------------------------------r_2 ......._.....-----------------------------------.............------------------------•-------------------•--------•---•-----....-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•------------------------------•---•---•----------------•-•-•---••---••----•----••--------------------------------------------------.-...-..-------------------------••----- . Agreement-. The undersigned agrees to install the aforedescribed Ind1'vidual1Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code TheZridersigned further agrees not to place the system in operation until a Certificate of Comphapice has been i sued by th{eibo�arrdd of health. Signed .. " _.....` Y...._.14..// v...l1..K 411.................. - .................6......c............. Y Dare Application Approved B �.. � �c� :. ....... `. ----- Application PP PP Y - ie.. ....... 1` Disapproved for the following reasons: ....................................... -- ............---.................................................................... .... ............................................... ............................ ..................... -- . ................................. ............ PermitNo. � ...--------/-(-`T.�....................... Issued ........................--...--------.....-----......Dare...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifi ate of Comlalianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ........................... �,: - -. ..... ..... . ............. ....... ....... ---- ........__........ ...................... --- AA at ............ z` --------------- --- -t - ---..........-............. ............................. 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. ......_ --- dated _...................._...._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... ------------------------ ---------- Inspector ------............................................................................................ THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH TOWN OF BARNSTABLE N FEE.---. ..... Uwpofittl Vorkp �Tomitrudion rrmit ; Permission is hereby granted................ =- ' E'_: --------------------------------•-----------_.--•---- � .................... C to Construct (yt) or Repair ( ) an Individual Sewage Di s osal System _` �4,, ' at No. r.1 � - �r � �. ! � !>............... t • -v-------------------- Street q/_ ' as shown on the application for Disposal Works Construction Permit No._/_7.,.11_� Dated........... t - ...............•--------•---------•--•-------------..............--------•---------------••----•--••---•- Board of Health r , - DATE................................................................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS I .. a h h` Z TS TOWN OF BARNSTABLE LOCATION VILLAGE SEWAGE # She ASSESSOR'S MAP& LO INSTALLER'S NAME&PHONE NO. T SEPTIC TANK CAPACTry Gfm G LEACMG.FACILITY: s o (size) 1yr 8 X/ NO,OF BEDROOMS BUILDER OR OWNER o/v PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facili Feet on site or within 200 feet of leaching facility) (�any wells exist Edge of Wetland and Leaching Facili Feet within 300 feet of leaching facility) ty(Ren y wetlands exist Furnished by Feet Qa �7E TEeT AoLr, l-oGs aoN o Jul- 114 4 I 0 4�r g -444 1 '• ` •'' c. - . 4 M�,_, �as f - 1 � <».., I CATUM c-- .. F�.aM �a�a ti r.•� M.U�JIGIOAL.(,Ja.'T �/1111.4(31.�• �L�N)A!C-�' P!t �LtiJ(� a i !! 13 7-c' 4 3 P,P— PI,-�r� A, l FT U►.1t.�Sri lJ�EQL�115E �OYCD G O 4-� pG,."� � �DrJJj I�;�I I - �" 1 I ,r.1 c!T i V �O t�E 3�1 j� _ -- /� ro AA `` Y 4. 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