HomeMy WebLinkAbout0070 GREELY AVENUE - Health 70 GREELY AVE.
Centerville
A=246 - 216
i
UPC 12534 o-
No. 2� 1553LOR
NASTINGS.YM
IFROM•:RIPAF�IAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:36AMµ P1
a
RIPARIAN PARTNERS, LTD.
Investment Banking
FAX COVER SHEET
��DATE: Jc J-/(�'�
FROM: ��
To: 5ha►-e;r)
COMPANY:
FAX#: 6LIE- 790 ~630 `1
NO. OF PAGES (including cover): 1 of
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C.
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,1"�IIAA�
2400 FWANCIAL P1..A7.A PROVU)ENC'E, PHOr)T; ISLAND 02903
401-272-;3020phone • 401-274-4933.fux
FROM :RIPAkIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:36AM P2
COMMONWEALTH OF MASSACHUSETTS
ExECUTm OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSISRFACE SEWAGE DISPOSAL SYSTEM FORM
PART•A
CERTIFICATION
Property Address:_ 70 Greeley Ave. CSC
Owner's Name: Jose2h Flanagan
Owner's Address:
Date of Inspection:
Name of Inspector:(please print) Wi 1 1 9 am P_ .Rain; nson Sr.
Company Name: William E. Robinson Sep•t;ic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 75-1@7 7;6._
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sect' a 15.340 of Title 5(310 CMR 15.000). The system-
Passes .
Conditionally Passes
_-
Needs Further Evaluation by the Local Approving Authority
Inspector's Signature;. —� Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.if the system is a shared system or bas a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
. n
*'This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 lnspcctinn Form 6/152900 page 1
FROM :RIPARIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:36AM � P3
. Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAM DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 70 Greeley Ave.
� W flyannisport
Owner: — Flamagan
Date of Inspecttow o-
Inspectloa Summary: Cheek A,B,C,D or E I ALWAYS complete all of Seetfon D
A. �Syst�e •Passes:
1 have not Bound an information which indicates rsates the!any of the tltilure criteria described in' 310 CMR
13.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. Syst m Conditionally Passes:
O a or more system components as described In the"Conditional Pass"section need to be replaced or
repaired. he system,upon completion of the replacement or repair.as approved by the Board of Health,will pass.
Answer es,no or not determined(Y,N,ND)in the for the following statements.If'ytcet determined"please
explain.
e septic tank is metal and over 20 years old*or the septic tank(whether metal or nos)is structurally
unsoun ,exhibits substantial infiltration or exftlt ration or tank Jbilure is imminent.System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the•Board of Health.
"A m I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indic ng that the tank is less than 20 years old is available.
ND ex aln:
bsenration of sewage:backup or break out or high static water level in the disuibution box due to•broken or
obst m pipe(s)or due to a broken,settled or uneven distribution box.System will pass Inspection if(with
appro of Board of Health):
broken pipes)are replaced
obauctionisremoved
disribudon box h leveled or replaced
xpiain: .
The system required pumping mot;than 4 dates a year due to broken or obstrutmd pipe(s).The system will
pass inspection if(with approval of the Board of Health):
�—broken pipe(s)are replaced
_--obsovction is nm ved
ND explain:
FROM, :RIPAOIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:37AM P4
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 70 Greeley Ave.
WHyannisport
Owner:
Date of Inspection:
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 fai ' g 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
yytem 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, stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syste 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
urface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I 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 uank and SAS and the SAS is Icss than 100 feet but 50 feet or more front 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 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 fotitt.
3. Other:
3
FROM :RIPARIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:37RM 11P5
Page 4 O1 I l
OFFICIAL INSPECTION GE FOR —NOT FOR M
SYSTEM INSPECTION FORM ASSESSMENTS ,
SUBSURFACE SE PART A
CERTIFICATION(continued)
Property Address: 70 Greele •Ave.
ann sport
Owner: F anaga
Date of inspection: IQ'
D. System Failure Criteria applicable to all systems:
yo t indicate'y ee,or"ne,to each of the following for p�inspeetions:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspoo
Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid leveler the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than V below invert or available volume is less than V,day now
Required pumping more than 4 times in the last year 1NQT due to clogged or obstructed pipe(s).Number
of times pumped r;
Any portion of the SAS,cesspool or privy is below high ground water elevation.
ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. of a public well.
y portion of a cesspool or privy is within a Zone 1 p
Any portion ore 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. IThls system passes if the welt water analysis,
performed at a DIEP 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.)
es/No)The system lalls.l 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. urge Systems:
To b considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
11Pd-
You ust indicate either-yes,,nr"no"to each of the following:
(The f flowing criteria apply to large systems in addition to the criteria above)
yes o
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 locateii in a nitrogen sensitive area(Interim Wellhead protection Mica—1WPA)or a mapped
Zone II of a public water supply well
I ou have answered"yes"to.any questii Qn in Section E the system is considered a slgnific nt threat'or answered
g y or of wW large system considered a
"y s"in Section D above the.far e system has failed.The awns paP upgrade System in accordance with 31 0 CNflt
sig ifteant threat under Section E or failed under Section D shall u gr .
15. 04,The system owner should contact the appropriate regional office of the Department.
4
FROM :RIPAkIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:37AM P6
Page 5 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 70 •'reelpy Ave
W, Hyannigport —
Owner:_ Flanagan
Date of Inspection:
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, tic Board of Health
_r t�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?
p_ Have large volumes.of water been introduced to the system recently or as part of this inspection?
Werc 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 se-,gage 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)J
5
FROM :RIPARIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:37AM 11P7
Page 6ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 70 Greeley Ave.
— W f—ann sport
Owner: F an8 an
Date of inspection: �•— d
FLOW CONDITIONS
RESLDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:Je-� A
Does residence have a garbage g grinder(yes or no): '
Is laundry on a separate sewage system(yes or no):�> (if yes separate inspection required]
Laundry system inspected(yes,or no):
Seasonal use'.(yes or no):,a)
Water meter readings,if avaikble(last 2 years usage(gpd)): 7 Q Q 0_ 18R .Qfl 0 gal.
Sump pump(yes or no): A,d 1999 526,000 gal.
Last date of occupancy: /
CO ERCIALOMUSTRIAL
Type establishment:
Design ow(based on 310 CMR 15.203): gpd
Basis o design flow(seats/persons/sgft,etc.):
Grease ap present(yes or no):
Industri 1 waste holding tank present(yes or no): ,^
Non-s tary waste discharged to the Title 5 system(yes or no).
Water eter readings,if available:
bast da of occupancy/use:N
OTH (describe):
GENERAL INFORMATION
Pumping Records
Source of information: M ! t�
Was system pumped as paroof the inspection(yes or no):
If yes,volume pumped:-gallons--Now was quantity pumped determined?
Reason for pumping:
TYvSYSTEM
eptic 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 teelutology. 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 knownjand sour a of information:
Were sewage odors detected when arriving at the site(yes or no): v
6
FROIrr :R I PAR I AN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:38AM P8
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Gireeley Ave.
W F nn i annrt~_
Owner: F 1 a n a aan
Date of Inspection: -,10
BUIL. ING SEWER(locate on site plan)
Depth Blow grade: _
Materi Is of construction:_cast iron _40 PVC_other(explain):
Dista a from private water supply well or Suction line:_
Comments(on condition of joints,venting,evidence of,leakage,etc.):
SEPTIC TANK: 6f(locate on site plan)
Depth below grade:_
Material of construction: �%concrete metal fiberglass_polyethylene
_othcr(explain)
if tank is metal list age;_ Ns age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate) ► t'
Dimensions:,_
Sludgc depth: .3—9 ''
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: -r j' 1 ,
Distance from top of scum to top of outlet tee or baffle: e
Distance from bottom of scunt to bottom of outlet tee or baffle:,�2
How were dimensions determined: '<.;
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, tc.)f y� d
—.
G ASE TRAP:_(locate on site plan)
Dep below grade:
Mater 1 of construction:_concrete_metal fiberglass polyethylene_other
(cxpla ):
Dime ions:
Scum hickness:
T)ista a from top of scrim to top of outlet tee or baffle:
Dista cc from bottom of scum to bottom of outlet tee or baft1c:
Date f last pumping:__ .__...
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as r ated to outlet invert,evidence of leakage,etc.)-
7
FROM :RIPARIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:38RM r,P9
Pages of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Gr 9 y AV-0.
4? H�r2
Owner: F]�ane
Date of Inspection: zL a54
T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
...Dep below grade: .
Mate ial of construction: concrete metal fiberglrtsa_,_polyethylene other(explairi):
Dimei lions:
Capac q, _ __gallons
Desig i Flow: —gallons/day
Alam present(yes or no):
Al level: Alarm in working order(yes or no):
Date f last pumping:
Co ents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:. .,1-4if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:__& evidence of
Comments(note if box is leva;l and distribution to outlets equal,any evidence of solids carryover,any
leakage into or out of box,etc.):
40
PU CHAMBER: (locate on site plan) _
Punnp in working order(yes or no):
Alarm in working order(yes or no):
Com ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): __
FROM :RIPHRIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:38AM P10
Page 9 Of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Greeley Ave.
W Hyannisporl,
Owner: Flanagan
Date of Inspection: l
SOIL.ABSORPTION SYSTEM (SAS): ./(locate on site plan,excavation'not required)
If SAS not located explain wh;y:
Type
eaching pits,dumber._
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,
CES. POOLS: (cesspool must be pumped as pact of inspection)(locate on site plan)
Numb r and configuration:
Depth top of liquid to inlet invert:
Depth f solids layer:
Depth scum layer:
Dimens ris of cesspool: -------- - ----- - - - —= - _ -- ---- -
MaterialI of construction:
Indicatin i of groundwater inflow(yes or no):
Commet is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Maieria of construction:
Dimens ons:_
Depth f solids:
Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
FROM :RIPARIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:38AM P111 „
Page 10 of 11
OFFICL4L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE; SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Greialey Ave,
W-R an sport
Owner: Flanag3n
Date of Inspection: �'�
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 feet, Locate where public water supply enters the.building. .
qi
S
10
FROM ;R,IPARIAN PARTNERS LTD FAX NO. :401 274 4933 Oct. 24 2004 09:39AM P12
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Grealt-y AAv`e-
W-Hya-n0r'po r t
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depot to ground water irD 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•: G/:> 1?141
Checked with local excavators,installers-(attach documentatiolA
Accessed USGS database-explain You must describe how you established the high ground water elevation:
5 4
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cyn Q` i. f �4:'"i'[ n' Y,r f' iS�gl..'- ��n•�T
CERTIFIED SEPTIC SYSTEM REPORT 'pa0.� s� ��{';a�V ; =t � 7
REMOVED
LOCATION DEC 7 1995
70 GREELY AVE. HEALTH DEPT.
SPQR MA 02672 TOWN OF BARNSTABLE
NNIOttMAP 246 PARCEL 216
PREPARED FOR
SETIER
RICHARD AGNEW, TRS.
FIRST PROPERTY MANAGEMENT
832 MAIN ST. SUITE F
OSTERVILLE, MA 02655
I
BUYER
MR. & MRS. JOSEPH FLANAGAN
77 CHARLESBANR RD.
NEWTON, MA 02158
PREPARED BY
HILLIARD HILLER
P.O. BOX 250
CENTERVILLE, MA 02632
508-778-1472
• T
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
WIIIIam F.Wald
ciammor
Trudy Core
s.�m.n.E
David B.Struhs
Comrnlniomr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
apITIFICATION
Property Address: 7o a4'CX1'y -AA17 4 ' Address of Owner:
Date of Inspection: /a/11/1951' Of different) c�
Name of Inspector: f//1-U41ZO lf/LZXR
Company Name, Address and Telephone Number: �X a� 83a ��/� ST• �i?E f'
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
_ eeNeeds Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: /���/�'•' Date: /oA/s/rj.�
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 flow of 10,000 gpd or greater, the inspector.and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B&?or D:
A] SYSTEM PASSES:
1 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.
6] 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,car 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
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street a Boston,Massachusetts 02108 a -FAX(617)SS6.1049 a Telephone(617)292-SM
sue,Primed on Recycled Pape
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ]O v4 W
Owner: /qk. /Q,l:/ ,140 /`al-41"I
Date of Inspection: /19/111�511
6]SYSTEM CONDITIONALLY PASSES (continued)
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. S,5d= aAEQT/G T^rAl
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 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within i00 feet to a surface water supply of Uibutary to a
surface water supply.
_ The system has 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 system 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:
1 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 ordogge�SAS r---
cesspool.
(revised 8/15/95) 2
r
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7O 49-<, l-Y 44,14, Lri,
Owner: ^,4 / A:^-7" f�.�v.��✓
Date of Inspection: /a/l/ys/
D]SYSTEM FAILS(continued):
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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool.or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 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 rw
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.
E]LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow 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 0WPA) 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
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
' s
(revised 6/15/95). 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7v 6.oa,&ZL Y oWA G�/. /_ Yi9A_.#"/_s 1Q0W f_ 100y 11
Owner: #10ve. 9,V o07t" ^goco%ow
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
_None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
!/As built plans have been obtained and examined. Note if they are not available with WA. IX16rOZCZ4
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
L/The site was inspected for signs of breakout.
_/AII system components,Stluding the Soil Absorption System, have been located on the site.
(/The 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. ./15 1144--17
.ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
(/The facility o%%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
T
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7p `,�,g,�y �vE G✓. f/y�,vv[s/�ie7 .Cii!
Owner: ",f
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:_
Number of current residents:-
Garbage grinder(yes or no):_ALO
Laundry connected to system (yes or no): yFs
Seasonal use (yes or no): LX>
Water meter readings, if available: C
Last date of occupancy: /1� 4 y
COMMERCIAUINDUSTRIAL:
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 infor ation:
System pumped as part of inspection: (yes or no)
If yes, volume pumped. Qallons
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)
Other(explain)
= APPROXIMATE AGE of ail-components,- date installed (if known)and-source:of information: -
c�a�rPGl�vGE
Sewage odors detected when arriving at the site-.(yes or no)
(revised 8/15/95) 5
it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C• '
SYSTEM INFORMATION (continued)
Property Address: 70 C;,4Z PL`/ A�. W� Y�,v�/S�.CT
Owner: h.Q, A'k:, Aea 4G0C4C4C"
Date of Inspection: 4-AhAvi- ,
SEPTIC TANK:✓
(locate on site plan)
Depth below grade: 7 fie' /f,4,P4W
Material of construction: /concrete metal _FRP other(explain)
A Gokle �TE ZAriD C ovB.a'S qu_ L�6Jl T/�� laC�T
Dimensions: (JNit'.t/or.✓� Y7� Dfy�P
Sludge depth:_ 4'H AT /v1_E r IL AAn
Distance from top of sludge to bottom of outlet tee or baffle: ( Vr
Scum thickness: O d7- /,!/L$T jeAlw
Distance from top of scum to top of outlet tee or baffle: VAI
Distance from bottom of scum to bottom of outlet tee or baffle: 44AOA"
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.) GovLd vc/Gy G,Ii:T / lb / LRT
T F-dS coilfii riG F/lct THE JS'oy5/i /.ylz� 7,6',C
GREASE TRAP:=
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of «um to bottom of outlet tee or banie - -- - --- - --
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 Address: 70 4;04"GY /'N/G
Owner. V/f. /QaY`1/1.CD i9GpLG✓
Date of Inspection:
TIGHT OR HOLDING TANK:_ '
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP other(explain)
Dimensions:
Capacity: eal Ions
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ?
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution. cq;--!, evidence of so!id<_ carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan) -
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
.(revised 8/15/95) 7
1
r ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
!/ f7� AivivlS •�% /�t/�
Property Address: ;i:�7 Cs,<E1UY
Owner: AIX /h+it/�A✓
Date of Inspection: /a//Ayj/
SOIL ABSORPTION SYSTEM (SAS): v
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) '
If not determined to be present, explain:
leaching pits, number:
leaching chambers, number:_
ri
leaching g alle es, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
ST 7&46 iyk s
_ FvcG ?v Gr/A/fiv
7" /o1T 7-h'E.4E !v,EY1F Soc�i7S
aiQovvD Ti/E co dFiP A� S/G!/S of FF L yE.c1l /,v
CESSPOOLS:
(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(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7o L-:.Qay /�v� 4/, �{Y�.r/.v/SI'�o•�'T �f�
Owner: /7/f. XA:GIiW,o
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Poo
STF_,o3 t0�
W
A/T
1 �QsE �f �oA-G/16T� I r�i�
DEPTH TO GROUNDWATER
Depth to groundwater: feet
—method of determination orapproximation: -
a,5.W 'r V ,Or /5 // ' OfE.o THE 'rAe Z2992!f JZ�X'-X /9-5
D.e�9w/,yG -5h7 rs-S THI ly�fT�/l T�9r�Z/f !�T r4-4AeN9;?749A-' S. 7 Hc' SGS
(revised 8/15/95) 9
l N9.
a /I� �/
Fee �i—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppCication for Mi!6pool *pgtem Construction permit
Application is hereby made for a Permit to Construct( )or Repair( V)an On-site Sewage Disposal System at:
Location Address or Lot No. �``\Ac_ rd k fi rA_� Owner's Name,Address and Tel.No.
_? O Grt e.t, A V-f- G� \/
Installer's Name,Address,and el.No. J_ �'U Designer's Name,Address and Tel.No.
i��r�J vim`
Type of Building: r�
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
N ure of Repairs or Alterations(Answer when applicable) -� J-� 1�rtt hjr- W/Y�
�p r Je,,d L
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Cenifi-
cafe of Compliance has been is by this B and of
Signed Date
Application Approved by _
Application Disapproved for the Yllowin3g reasons
Permit No. 17 s-- N 70 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System insta ed( )or repai�rfd/i�placed (�on
by 5 5 Q (�G./ V
i r has been con ructed in accordance
with the provisions of Title 5 and tho4or Disposal System Construction Perm t No. dated
Use of this system is conditioned on compliance with the provisions set forth below:
oe
No. Fee C�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopoa[ *paem Conotruction i3ermit J-
Permission is hereby granted to '5( 11 M G', n�k `>S C G n-e- Cu A-S'�
to construct( )repair(✓)an On-site Sewage System located at C' i S Fo f+
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: _ _ / �� ���1 Approved by
a°
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
property Address: 7o GR,�y ,g ,C w• �,!Y�►,vv/sr�G�eT S�'� h 1
Owner. hR- /Qe- 1 ,O ffG,veui �I
Date of Inspection: /a1194- n•,n s'�'1'�v h' -�.o�-g (�
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
• G BTf
poo L
arb',os 10'
v
FHB of coA.r�L1•Jr / �0 `
4�9�K of h+�s�' •
DEPTH TO GROUNDWATER
r
Depth to Groundwater: feet
method of determination or approximation: �� T pi
n l Th�� /T !S l/ ' �c.�ii,��D !_✓iP Ti ,f JL,riE
THE :Z-56S
• G
!revised 8/15/95) 9
No. ' I v / Feet�—
THE COMMONWEALTH OF MASSACHUSETTS \/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplication for Mt5po5a[ *pgtem Congtruction Permit
Application is hereby made for a Permit to Construct( )or Repair( V)an On-site Sewage Disposal System at:
Location Address or Lot No. �``\A V- ( AC CA� j OwneF s Name,Address and Tel.No.
O Grt-e. A v°-C.,� FT Va
Installer's Name,Address,and el.No. ^�s� c; �`� G Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder(� -
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
N ure of Repairs or Alterations(Answer when applicable),�'�- �� �� �� W/L/
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is by this B and of
Signed Date I-, S
Application Approved by
Application Disapproved for the Yllowing reasons
Permit No. �L (� �D Date Issued _-L
No. pp
J .r O - Feer—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication "for Migool *pgtem Construction 'Verml it
Application is hereby made for a Permit to Construct or Repair ✓ an On-site Sewa a Disposal System at:
PP Y ( ) P ( ) g .,{ P Y
Location Address or Lot No. Owner's Name;Address and Tel.No.-
&yam - -
0
� G ice.L /�v•C.. c:fit D,s-
Installer's Name,Address,and el.No. 7 l= �:V Designer's Name,Address and Tel.No.
lc k Rd
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date '` Number of sheets Revision Date
Title I
Description of Soil
N tune of Repairs or Alterations(Answer when applicable)
SOU Le -r o j e.,A :17� ,�AxkC X
Date last inspected:
t* i
Agreement:
l KX
�r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
,in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in,operation until a Certifi-
cate of Compliance has been is d by this B and offr . /�
Signed Date
Application Approved by 9
Application Disapproved for the Yllowing reasons
Permit No./ .5� � 7 D Date Issued .Z —
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal S stem insta ed( )or repair dh laced(�on
by S 5 Cdr oft [,C-%r9 l-� �
4 \ r has been congfructed in accordance
With the provisions of Title 5 and th or Disposal System Construction Perm tNo. dated
Use of this system is conditioned on compliance with the provisions set forth below:
No. r Fee G r'
. THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migo5a[ *p!Aem Construction Vermit
Permission is hereby granted to S C() M 47c(.,,,ru- r'V55 CG
to construct( )repair(✓)an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: Approved by ��
L.�
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7o G. "WY /16AL c,�, /`��Y�i.d�/S�O•QT �Y/9 S �Vt 1�I
Owner: 17X. /Q,-iiW O 0YaC-Xa/
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:-
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
• 1.
C. BTE
POOL
srF_Ps tp'
t
v
DEPTH TO GROUNDWATER
Depth to groundwater: L_ .`7r feet
method of determination or approximation: [3/�*iQi✓51G/i' !,/S Sh'� s THE lc L.EuA7?c►K� TO /3E'
a S y 7-,YX Alf 15 T �E .�
TNgA 4yitT2/L T?9rSZ/f /4 T
-
as = 4-7
(revised 8115195) 9
TOWN OF BARNSTABLE
LO, CA,'1ON &tg>V e�4 &)-f- SEWAGE #
VILLAGE ( ASSESSOR'S MAP &LOT �X-
INSTALLER'S NAME&PHONE 10. c7 rCAA-
SEPTIC TANK CAPACITY L dQ C) Cr a L- (.^c L• P l
LEACHING FACILITY: (type) PeAL S t.J,'44% (size) ) GJvF•�`�
NO. ,BEDROOMS �% f yC S v'�
BUILDER OR OWNEER f
PERMITDATE: Ili/�i COMPLIANCE DATE: "'' '. ✓"
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /® 94 4 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 All p
within 300 fee f leaching facility) Feet
Furnished by Cy VL
_F•
0 Id
4-H 6Id PiA 33 I:t
(3 d PtA i(01
-
P-4-,o D Qtix to
No....-11'-1--......... Fps...... -...-.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7/4 �..........---....OF.......
Apphratiun -fur Uhipoiitt1 Works Tonstrurtiun P.erutit
Application is hereby made for a Permit to Construct ( ) or Repair (!�an Individual Sewage Disposal
System at:
ocation dress or Lot No.
y� Owner Address
a 1 = t .............
.......
Installer Address
U Vype of Building Size Lot............................Sq. feet
Dwelling�No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ----•- -•........................•-......_..--•-------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width. r _..._........._.. Diamete __......._...... 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.
j fw Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---------------- ......................................................... Date----=-------------------------••-.-----
,� Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water:..-_---_--_------.-__--
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground .water--.-------------_-__....
GW ... --- ------ •. .
G Description of Soil----- ....
---- ---- -------¢---'-`f="- --•-------------------------------=---------------=----------------•--•-- ----•----------------------------
x
W
U Nature of Repairs or Alterations—Answer when applicable.-:../ ---
......................
mod( f --------� _210::e— ----- -----------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the
board he Ith.
Asig d. -• ------- ------------ 0 C 1''wl�'s - �� /'�/
D/atet' "
l Date
Application Approved By---- -- -YR { /Date-
Date
` Application Disapproved for the following reasons-------------------------- -------------------------------------------•-----.-•---•-----------------
..............•--• -------- .-•- - ............................................................................................-----•---•---------•--------------•_------------•-•---•--•--•-----
Date
PermitNo......................................................... Issued....................... .................................
Date
No......................... FEa......0................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......OF.......l . ...: ...............................
Appliration -fur Ui,spu,oal Works Tvmn rnrtiun Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Aor an Individual Sewage Disposal
System at: ,
cation- d ess t or Lot No.
---------•---
Owner` r` Address
Installer, Address
U Vype of Building Size Lot............................Sq. feet
Dwelling ENO. of Bedrooms----------------------------------------------Expansion Attic ( ) Garbage Grinder .( )
aOther—Type of Building ...........:................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures -_--------------------------------------•--------- --------------------------------------•-----•••---•--------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic 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 Dist.ribu'tion box ( ) , Dosing tank ( )
Percolation Test Results Performed�by-------------------------------------------------------------------------- Date---______--•---•------------------------
Test Pit No. 1----------------minutes per inch Depth of Test Pit-.-..._-__-_______-- Depth to ground water........................
GT4 Test Pit No. 2----------------minutes per inch Depth of Test Pit........._.......... Depth to ground water--------------------
O - - _ ----- --- ---- ---- -- \.`....................................................................
Description of Soil----- t�:_ .t•------------------------- =
U a
------------------------
W
U Nature O Repairs or Alterations—Answer when applicable.:.../ !0? `'� '/�!a�_._-_s2t�e'n i,G�lll!......................
!� Is --___---;�-------� tt+V-:_*------ ........................................... ------------•---------------•-----•------------- = .
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to placeIthe'system in
operation until a Certificate of Compliance has bee Issued by the b and o he lth.
Signed. --- ----- Q ...........................
Date -
ApplicationApproved BY-----------------------------------------------------------------------------------------------
Date
Application Disapproved for the following reasons:---------------
-----------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_..-____-_-_____._____
Date
Permit No.......................................................... Issued.......... R
Date
THE COMMONWEALTH OF MASSACHUSETTS:., t='
BOARD OF HEALTH
........ ir.� ?�..........OF
....... ....................
Trrtifiratr of 1051,11mplinnrr
T IS IS TO CBR F t the In�div' ual Sewe Disposal S stem constructed ( ) or Repaired (6..
by -i� % 40
A.r% pe .�g'z,. t.L - -
Installer ) /
k.
----------- t t-----------------L fry ...... ....."
has been installed in accordafewith of Article XI''of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------------------>-_____.__-______---_-_ dated-----
___-___-___---______--_-.-____-____________
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......I. r / .. ...
-••--- -•----• ---�--�- ...............-.............. Inspector......... .................................�------------•---------------
THE COMMONWEALTH OF MASSACHUSETTS
—A
BOARD OF HEALTH
...... ....C..V19lr-�.............OF_--�.��-
No. FEE ..............
0 1 u k Cn n . rtiun rrmit
._ •-'
Permission is hereby granted_ l._._- ____________ / .._.__.:.
to Construct ( ) or Repair ( twKn I dividual Sewage Disposal System
atNo. ................................................... --------------------------------------------......................................
as shown on the application for Disposal Works Construction Pe - it o._ _�' .. ted_ _______________________________________
T - ------------------------------------- -- ----------
Board of ealth
DATE-=-- ..........................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
�--
1�S 70 — — —
LOC&T10N : 5EWaC4E PERMIT UO.
IWST LLER 5 1JW E ADDRESS
BU`LL DER 5 ►J &MF- ADDRESS
D47E PER"VT ISSUED — /L ?7-Y — _
0 TE COMPLI WaCE
F
i
ok
s
TOWN OF BARNSTABLE
LOCA iT ',T SEWAGE# �S y/lam
VILLAG'' %(?i,�A SESSOR'S MAP &LOT We-hlC
INSTALLER'S NAME&PHONE NO. Oljp L. A
SEPTIC TANK CAPACITY vtiN
LEACHING FACILITY: (type) (size) LXC
NO.OF BEDROOMS r/
VUH;HE OR OWNER % lche5r /•Co�c,�ry emirs, G�s✓r.�,r/� U5T
PERMTTDATE: / /,1115— COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility <7 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 I hhing facility) Feet
Furnished by /b 5 e
-�. ,�
� � I
���.�.
'� �
��
�� \
/ „��
� \
I