HomeMy WebLinkAbout0086 EMERSON WAY - Health 86 Emerson Way
Centerville P
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No. 42101/3 ORA
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DATE- 3/5/02
PROPERTY ADDRESS: 86 Emerson Way_________
-- Centerville,Mass_
------ /apF
02632
------------------------
On the above date, I Inspected the septic system at the
This system consists of the following: C I iE
1 . 1 -6 'X8 ' block cesspool .
2 . 1 -1000 gallon precast leaching pit. 6 'X9 ' MAR 0 7 2002
TOWN OF BARNSTABLE
Based on my Inspection, I certify the following conditi0 HEALTH DEPT.
3 . This is not a title five septic system.
4 . This is a sewage system.
5, The sewage system is in proper working order
at the present.
6 . Pumped the cesspool at time inspection.No water intrusion.
The cesspool is structurally sound.
a . Waste Water is 55" below the invert pipe of le hing p ' .
SIGNATURE:1
Name:_�_'�_ Macomber
Company: Jos_eph_P_ Macomber_& Son , Inc .
Address: Box 66
--------------------
__Centerville _ Ma ._02632-0066
Phone: 508-775-3338
------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachf lelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775.6412
' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 86 Emerson Way
Centerville,Mass.
Owner's Name:Jane Onei
Owner's Add ress6 4 Cinnamon Lane
Osterville ass. 02655
Date of Inspection: 02
Name of Inspector: (please print)J.P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address:Box 66
02632
Telephone Number: 08-775-3 38
CERTIFICATION STATEMENT
1 cenify 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
rraining and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15,000). The system:
Passes
_ Conditionallv Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authoriry.
Notes and Comments
-*This report only describes conditions at the time-or Inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Pase 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 86 Emerson Way
Centerviller
Owner: Jane Oneil
Date of Inspection:3 5 02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A'. S=Passes.-
ave not found any informatio hich indicates that any of the failure criteria described in 310 CMR
15.303 or to CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The existing sewage system is in proper working order
at the present time.
B. System Conditionally Passes:
_,d,2A 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.
&he a�itssubstantial
s metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exh 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:
il/a�ff& Observation of sewage backup or break out or high static water level in th istribution boy ue 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
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 86 Emerson Way
en ervi e, ass.
Owner:Jane Onei
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Alb 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
4& 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:
A,jO 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.
4& The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
d&The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
,0 The system has a septic tank and SAS and the SAS is less than 100 feet but 0 feet or more from a
private water supple well". Method used to determine distance old
"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.
3. the
The system consists of 1 -6 'X8 ' block cesspool. The
cesspool acts as a septic tank. Solids are contained in place.
The effluent passes from the cesspool to to a 1000 gallon
precast leaching pit. ( 6 ' X9 '
3
Page 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 86 Emerson Way
Centerville,Mass.
Owner: Jane Oneil
Date of Inspection:3/5/0 2
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ _V ackup 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
�tC Static liquid level in th istribution box bove outlet invert due to an overloaded or clogged SAS or
cesspool
�squid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—L.
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
L/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 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. (Tbis 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 forma
X/o (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 determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of io,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
_ Zhe system is within 400 feet of a surface drinking water supply
_ V
e system is within 200 feet of a tributary to a surface drinking water supply
e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped
Zone 11 of a public water supply well 71
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 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 66 Emerson Way
een t e—r—v—i e,Mass.
Owner: Jean Onei
Date of Inspection: 3 5 02
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes �Xpumping
information was provided by the owner, occupant, or Board of Health
ZWere any of the system components pumped out in the previous two weeks
_ZHas the system received normal flows in the previous two week period?
a/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?
z _ Was the site inspected for signs of break out?
-'/— - Were all system components,# cluding the SAS, located on site ?
. 61t Were the a tic anholes 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.
Y — 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))
5
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 86 Emerson Way
Centerville,Mass.
Owner: Jane Oneil
Date of Inspection: 3/5/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):—1 Number of bedrooms(actual): .�
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Ad
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system ( es or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):�
Water meter readings, if available(last 2 years usage(gpd)): 2 0 0 0—3 8, 0000Ga11ons 1 04 . 1 1 GPD
Sump pump(yes or no):26 2001 —40, 000 gallons=1 09 . 59 GPD
Last date of occupancy:L/�
COMM ERCIAL11NDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): .riQ gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): ,�)i9
Industrial waste holding tank present(yes or no):AL/
Non-sanitary waste discharged to the Title 5 system(yes or no):,04P
Water meter readings, if available: 11,14
Last date of occupancy/use: ,6/
OTHER(describe): A)4
GENERAL INFORMATION
Pumping Records
Source of information:
Was system.pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons -- How was ua tiry pumped determined? /�"-4'/1P2,
Reason for pumping: f -
r
TYPE OF SYSTEM
�d Septic tank,distribution box,soil absorption system
/ Single cesspool
X-110verflow.sesspee}-AAydr
Z Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
Wd Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
1�k Tight tank .lam Attach a copy of the DEP approval
Other(describe):
Approximate as of all qornpone date ' sailed(if,,gown)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 86 Emerson Way
Centerville,Mass.
Owner:Jane Oneil
Date of Inspection: 3/5/0 2
BUILDING SEWER(locate on site plan)
Depth below grade: P
le
Materials of construction: cast iron Z40 PVC,,_)aother(explain): 1011
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
Joints appear tight.No evidence of leakage The system is
vented through the house vents.
SEPTIC TANKS(locate on site plan)
Depth below grade:_4,64
Material of construction:oconcrete te2/ metal,,to fiberglass.N.>7Polyethylene
4M other(explain)_ 41A
if tank is metal list age:,4� Is age confirmed by a Certificate of Compliance(yes or no):, (attach a copy of
certificate)
Dimensions: ,vA
Sludge depth: -*!V
Distance from top of sludge to bottom of outlet tee or baffle:*_
Scum thickness:4A
Distance from top of scum to top of outlet tee or baffle: _
Distance from bottom of scum to bottom of outlet tee or baffle: A/A
How were dimensions determined: AO
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Septic tank is not present
GREASE TRAP�f(locate on site plan)
Depth below grade:/W
Material of construction4l9 concrett,!A metal,0 fiberglass polyethylene/ other
(explain): 4/�9
Dimensions: A0
Scum thickness: 414
Distance from top of scum to top of outlet tee or baffle:_�_
Distance from bottom of scum to bottom of outlet tee or baffle: �1q
Date of last pumping: llt/
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Grease trap is not present
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 86 Emerson Way
Cen ervi e,Mass.
Owner: Jane Oneil
Date of Inspection: 3/5/0 2
TIGHT or HOLDING TANK46 (&(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: eO
Material of construction:410 concrete 2jmetal d?d_fiberglass d2d polyethylene 4JA other(explain):
,�>rf
Dimensions: dM
Capacity: d9 gallons
Design Flow: 4/4 gallons/day
Alarm present(yes or no): A&
Alarm level: A), Alarm in working order(yes or no):,4,W
Date of last pumping:_/*
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not present
DISTRIBUTION BOXfh S (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: .U/9
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.):
Distribution box is not present
PUMP CHAMBEWL4c (locate on site plan)
Pumps in working order(yes or no): ,V4
Alarms in working order(yes or no): 0
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
ump chamber is not present.
8
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:86 Emerson Way
Centervi e,Mass.
Owner: Jane Oneil
Date of laspection: 3/5/0 2
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1 -6 X8 block cess as tan 1 -LP 1000 as overflow. 6 ' 9 '
If SAS not located explain why:
Located see page 10
Typee
d leaching pits. number:
leaching chambers, number:
leaching galleries,number:
�Q leaching trenches,number, length:
Teaching fields, number, dimensions-
,0 overflow cesspool, number: 0 �
.cJd innovative/alternative system Type/name of technology;����� /"mil �7o':
Comments (note condition of soil, signs of hydraulic failure, level o ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand No signs of hydraulic
failure or ponding.Soils are dry Vegetation is normal
Waste water is 55" below the invert pipe of the pit.
CESSPOOL,,§§: cesspool must be pumped as pan of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet vert:
Depth of solids layer:
Depth of scum laver: /
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.):
Sam s as abov Cesspool should be �
pt�ae every 2 3 years
PRIVYrj,�&&(locate on site plan)
Materials of construction:
Dimensions: CG��
Depth of solids; d&
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy is not present
9
Page 10 of I 1
OFFICLA.L INSPECTION FORM - NOT FOR VOLUNTARY ASSESSM
ENTS
SUBSURFACE SEWAGE DISPOSAL; SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 86 Emerson Way
en t ervi e, as .
Owner: Jane Onei
Date of Inspeclioo:3 5 02
SKETCH OF SEWACE 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 fcct. Locate where public water supply enters the building.
t7-44)
O
1
I A""
i
10
,Page 11 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 86 Emerson Way
Centerville,Mass.
Owner: Jane Oneil
Date of Inspection:3/5/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Esumated depth to ground water& feet
Please indicate (check)all methods used to determine the high ground water elevation:
4 Obtained from system design plans on record- If checked,date of design plan reviewed:
bserved site a 9-ffL-n-g--pr-o-p-el5Yobservation hole within 150 feet of SAS)
-4/0 Checked with Inca oar of Health-explain:
77 Checked with local excavators, installed gdocumentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used; Gahrety & Miller Model. 12/16/94 Ground water elevation
above sea level .
Used; USGS Observation well data Tine 1992
Used; USGS_ Annual Tx0 ground wafer elevation for Cane end
un 92-000-1 Plate #2
Leaching
Pit A/ Feet
i
Croundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim ter Method
P P
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
II
+•.7sRr..-n rr�*-.-n- rnrmr•nnnrrnn re.rrs*r:-.�.+++�nr�+rn++a+�rrersnu*+s,.r+an st+
TOWN OF Barnstable BOARD OF HEALTH
SUIISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D..- CERTIFICATION
.•••T!R•r••.••.: —T..17.-.�TT.'1T:'TT.Tl.TTiQTTfTn1T'r—•.'7�'IM�t'\71'R1R-TnRQAt R�•'�IR� ��111
-TYPE OR PRINT CI.EARL)'-
PROPERTY INSPECTED
STREET ADDRESS 86 Emerson Way Centerville,Mass.
ASSESSORS MAP, BLOCK AND PARCEL # 1
OWNER' s NAME Jane Oneil-
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber & Son Inc.
COMPANY NAME Joseph P.Macomber Jr. ..w
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Strvvt Town or City St to LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
• i III;,,,I,
Check one;
_ZZ-1/System: PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Lhe. environment as defined' in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection whicfl I have con acted has found that the system fails to
Protect the j)ublic health and the environment in accordance with Title
6 , 3.10 CMR 16 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Insector Signature Date
p
ne copy of this certification must be provided to the OWNER, the BUYER
( Where aPplioable ) and the BOARD OF HEAL711.
* It the inspection FAILED, the owner or" perator shall upgrade
he syste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 .
partd . doc
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE �U+"!�/` ��� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 6A E
LEACHING FACILITY: (type)
J^��1010 �'kl (size)l�i
NO. OF BEDROOMS O
',BUILDER OR OWNER— � ' l�
PERMITDATE: COMPLIANCE DATE:
I
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 fee le in fa ty) Feet
Furnished b f
0
. �
-'
i � �' �� r�
�' ��
TOWN OF BARNSTABLE
LOCATION
t/`1 �=w�c_,r�(�� SEWAGE #
VILLAGE ('�c,��w � _ ASSESSOR'S MAP & LOTALI
INSTALLER'S NAME & PHONE NO. L (M c�c.� ��r1
SEPTIC TANK CAPACITY L
LEACHING FACILITY:(type) (size) �p(j
✓ v'
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER..,
BUILDER OR OWNER E DQ ,j. ,r,Q tQ Z c
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 5's 7 4s - SS or .
VARIANCE GRANTED: Yes No x
�ss�°G
t' -
No.... .".. 5 Fps.... '...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........................... ...............O F..................................._..........
Appliration for Uhipos al Irorkii C ontitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair { ) an Individual Sewage Disposal
System at:
........ �/.{:�M.k�l3Ct n...... 1, ...... ...... ------••-•----------------------------------------------------------------------------------------
Lo on-Address No.
c ---------------------------- R .. ?.....C�'cad s.--1 z� .`- --------------------------
Owner Addr s
�L-.........................
Ins ler Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............. _.._.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons........L.................. Showers ( ) Cafeteria ( )
dOther fixtures ----------------•-------•------•----•------•----...---•••-•-•••••-••-••--•••••--•-•-••--•--••••••••••••--•----•••-•-•-•-.....--•-•-•.....:-
j
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.W W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter...------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---•-------------•-•-••-••••••-•-•••••----•------•••--••••-•--••--•••••.. Date......................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
IX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---____-_-------__--___.
P4 •--•--••••-•--•-------------••---••-•••-•-•-•-••••••-•-•••-••-•.....•-•-••••........----•-•---------..........................................................
0 Description of Soil........................................................................................................................................--------------------------•--•-
x
W •--•••--------- ---------------••--•----------•-•-••----------•--•--•---•-•--•--------••......--••-•---- _........
VNature of Repairs or Alterations—Answer when applicable___ _..._1.et�vCn._..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI I E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been •ssued by the board of health.
Signed ---••7772f0-------
--
Date
Application Approved By.............. ••--• -- .. -----------------------•------•-- ........... 7 5'-----
Date
Application Disapproved for the following reasons:...............................................................................................................
••---•••----••••••••----••-••-•••...........................•-••-••--•-•--------•-•--•--------....•••.....__....-••--•••••-••-•••••-•••••••-•-••--••....................................................
Date
PermitNo........ .. J� + `5 .................... Issued:-......................................................
Date
No.--"
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF
Apptiration for Di-quit alWorks Tanstrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
7.....
19L. -
......RQ........ck.�'V'v IL-114. ..................................................................................................
(2 ..—7 Loc -Address 0 X.
. .92 n,
............................... ........................
Owner '0AddrC tj ........... ...C.W.( _ a C,
.... ...... .............. ................... S.....k� ............
�4 I.Iskr Address
Type of Building Size Lot----------------_---------Sq. feet
Dwelling—No. of Bedrooms..............a..........................Expansion Attic Garbage Grinder
filOther—Type of Building ............................ No. of persons........I.................. Showers Cafeteria
QI
Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid*capacity...........gallons Length________________ Width__.__.______.___ Diameter_--_--__________ Depth__.___-_______..
Disposal Trench—No..................... Width_..._.....__._._._._ Total Length.____....___.__.-_.. Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter__.__._.._._.__.___. Depth below inlet__.___._._____.._._. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutesperinch Depth of Test Pit_..._____._____.___. Depth to ground water_---__---___________._..
0�4 Test Pit No. 2................minutes per inch Depth of Test Pit_.._._._..._._______ Depth to ground water.---_--____________--_.
P4 ............................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
W ........................................................................................................................................................................I.................................
U
............................................................................................................. .............. •........ ................... ..........
Nature of Repairs or Alterations—Answer when applicable.._�._-.00.....1--e- -,[----------- . . 0 e-X, S.1 4 V C_
UI . ......................................_
................................................................................................................ ............................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
1-1
operation until a Certificate of Compliance has been issued by the board of health.
Signed..&d ....... . . ......
-)4------------- -------:71271.165........
Date
... ...... ...)a .........
Application Approved By................. - --------------------------------- Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
Permit No........91:1.k.._:"_33_:E.................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........./* ........OF........ ...... ........................................
Tntifiratr of (Comptiatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (>q6m
r-_ -
by----------------- ..........._ite.O.Avv� .........................................................................................................................
Installer
at...................?&...... ....... ............ ...........................................................................
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._.___.. ....... d-ated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
cDATE.......................... ............................. Inspector.....-------------- .............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... .........OF......... ...... . ...................................
No FEE..... ............
Permission is hereby granted............... ......lkn:!
------------- ------ .......
to Construct or Repair (,,\4) an Individual Sewage"Disposal S stern.. .......Q, .... ..........
atNo......... ................. .............................................................................
Street
as shown on the application for Disposal Works Construction Permit No.__. ......... .. Dated__________________________________________
................................ -0.......................................................
DATE-------------------- ................................ Board of Health
FORM 1255 HOSES & WARREN, INC., PUBLISHERS