HomeMy WebLinkAbout0079 GREEN DUNES DRIVE - Health 79 Green Dunes Drive
Centerville
A= 246-200
S M E A D
No.53LOR
UPC 12543
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RONALD J. CADILLAC, PLS, RS
Professional Land Surveyor & Registered Sanitarian
P.O. Box 258, West Yarmouth, MA 02673
(508) 775-9700 (800) 520-5591
February 1, 2002
Mr. Edward F. Barry, Health Inspector
Barnstable Health Department
200 Main Street
Hyannis, MA 02601
r
Re: 79 Green Dunes Drive, West Hyannisport
Property owner: Mr. Patrick Goggins
Dear Mr. Barry:.
At the request of Mr. Joseph P. Macomber, Jr, certified Title 5 system inspector,
and based upon his Inspection report on 79 Green Dunes Drive dated Jan. 16,
2002, I have calculated the 1978 code capacity of the system,
As follows:
System has a 1500 gallon tank and
2 precast 6' deep pits. (amount of stone unclear, 1' is min., 2' likely)
Capacity (1' of stone) = 2(8'[3.14]6'(2.5gpd/s.f.) + 2(3.14[4]4 (1gpd/s.f.)
— 753.6 + 100.5
= 854 gpd = 7 bedrooms
Capacity (2' of stone) = 2(10'[3.14]6'(2.5gpd/s.f.)+ 2(3.14[5]5(lgpd/s.f.)
942 + 157
1099 gpd= 10 bedrooms
The system in place has a minimum design capacity of 7 bedrooms under the 1978
Code. Please call with any question.
Sincerely,
Ronald J. Cadillac
Z4G
-DATE:1/1 6/02-----
PROPERTY ADDRESS: 79-Green_Dunes Drive
--West Hyannisport,Mass. __
------------------------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 -1500 gallon septic tank.
2 . 2-1000 gallon precast . leaching pits packed in stone. 6 'X10 '
Based on my inspection, I certify the following conditions:
3 . This is a title five septic system. ( 78 Code )
4 . The septic system is in proper working order
at the present time.
5. Both of the leaching pits are dry at this time.
6 . No evidence of soilds carry over.
SIGNATURE- J VA
�
Name:_,L_p_ Macomber 7r-_--__-
Company: Josei)h_P . Macomber_& Son , Inc .
Address: Box 66 'RECEIVED
Centerville , Ma ._02632-0066 ,1AN 4 ZOO �
Phone: 508-775=3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
rJOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
` L\ COMMONWEALTH OF MASSACHUSETTS
r 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: 79 Green Dunes Drive
West Hyannisnort Mass.
Owner's Name: Patrick Gnggi ns
Owner's Address:226 Kiaq Street;
NorthamLton,Mass _ 01060-2332
Date of Inspection: 1 116 10 9
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc
Mailing Address: P=n= Box 66
rantarvilla Ma 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that 1 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 Section 15.340 of Title 5 (310 CMR 15.000). The system:
Z-/Passes
_ Conditionally Passes
_ Needs Funher Evaluation by the Local Approving Authority '
FF-a it SA
Inspector's Signature: r Date:
The system inspector shall s mit 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
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address 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
I
• Pape 2 of 1 1
i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 79 Green Dunes Drive
West yannispor , ass .
Owner: Patrick Goggins
Date of Inspection: 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A:' System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order
at the present time.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined" please
explain.
L The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
.L13 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: 79 Green Dunes Drive
West Hyannisport,Mass.
Owner: pat-ri k Goggins
Date of Inspection: 1/1 F f 62
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
•f/Z� Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment: ,
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is,within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
oeO The system has a septic tank and SAS and the SAS is less than 1 0 feet but feet or more from a
privatewell".water supply ell". 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 form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:79 Green Dunes Drive
West Hyannisport,Mass.
Owner: Patrick Goggins
Date of Inspection: 1 /1 6/02
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No
✓/Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/ cesspool g�mvJi Colt)
Y Liquid depth in eesspeelis less than 6"below invert or available volume is less than h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped 0.
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (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 form.)
IJ16 (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 flow of 10,000 gpd to 15,000
gpd•
You must indicate either yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes n/ to�
_ he 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
e; the system_ is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
••yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 79 Green Dunes Drive
West Hyannisport,Mass.
Owner: Patrick Goggins
Date of Inspection: 1 /1 6Z02
Check if the following have been done. You must indicate'�es"or"no" as to each of the following:
Yes iv'o
_c//Pumping information was provided by the owner, occupant, or Board of Health
1/ 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 ?
YHave large volumes of water been introduced to the system recently or as pan of this inspection ?
Were as built plans of the system obtained and examined?(if they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out ?
Were all system components,*x-cluding the SAS, located on site ?
L —
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the bafnles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
,/Existing information. For example, a plan at the Board of Health.
_ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 79 Green Dunes Drive
West Hyannisport.Mass.
Owner: Patrick coggi ns
Date of Inspection: 1 /1 r,/p 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 6� Number of bedrooms(actual): 7 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 6 6O
Number of current residents: _6
Does residence have a garbage grinder(yes or no): �
Is laundry on a separate sewage system (yes or no):. 0 [if yes separate inspection required]
Laundry system inspected( es or no): S
Seasonal use: (yes or no): _T4,ue— sf'� 6. l
Water meter readings, if available(last 2 years usage(gpd)):ptw
1
Sump pump(yes or no): ll��
Last date of occupancy:
COMMERCIAL4NDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): A) gpd
Basis of design flow(seats/persons/sqft,etc.): i1>
Grease trap present(yes or no): �/9
Industrial waste holding tank present (yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):��
Water meter readings, if available:
Last date of occupancy/use: i�_
OTHER(describe):
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 quantity pumped determined? •L�i¢
Reason for pumping:— �
TYKE OF SYSTEM
,/ Septic tank,�is�+butiea-fie , soil absorption system
AZ Single cesspool
Overflow cesspool
44 Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
4�01rinovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
V
ed from syste owner)
ght tank Attach a copy of the DEP approval
1�1_60ther(describe): 14,4
Ap��cima a aee of a I co ponents, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 79 Green Dunes Drive
West Hyannisport,Mass.
Owner: Patrick Goggins
Date of Inspection:1 1 6102
BUILDING SEWER (locate on site plan)
Depth below grade: ✓���u
.Mat enaIs of consmicti on. _cast ;-,On f 4' 0 PVC 4kother(explain):
D,stance from private water supply well or suction line: '7,
Comments (on condition ofjotrits, venting, evidence of leakage, etc.):
Joints appear tight. No evidence of Solids carry over
The system /ins vented through ,tt'h-,e�. house vents.
SEPTIC TANK: d (locate on site plan) /400--J y
�v
Depth below glade:
.Material of consrructionn cncreteX/6metal,d�frberglass,110 olyethylene
.(tother(expla:n)
If tarSc is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)Dimensions: 1d,9l-lx -ire"l IX ",)Vr !`1
Sludge depth. 1,e4j,4—
Distance bom top ofsJucge to bottom. of outlet tee or baffle: /-t4ca t>
Scum Thickness: Zd,-,j.L
(Distance bom top of scum to top of outlet tee or baffle:
Diswce From bonom of scum to bonom of outlet tee or baffle:
How were dimensions determined:
Comments (on pumping rece^_mendations, inlet and outlet tee or baffle condition, structural integriry, liquid levels
as related to outlet invert, ev:Jtnc_ of leakage, etc.):
Pump the septic tank annually,Garbage disposal is present
Inlet & outlet s ar _ present_
CREASE TRAF (locat on site p!an)
Dcpth below grade:&/9
Material of consauction:'L1 concretelVIYmetaVj/�, fiberglass/&polyethylene�Qother
(explain): xl Q
Dimensions: /W
Scum thickness: 411/
Distance From top of scum to top of outlet tee or baffle: il/r4
Distance from bottom of s:u:n :o co^om of outlet tee or baffle: eV
Date of last pumping: 1
Comments (on pumping recomme:.dations, inlet and outlet tee or baffle condition,-smmvcrural integriry, liquid levels
as related to outlet invert, evi':nce of leakage, etc.):
Grease trap is not present,
, - 7
h
• Page 8 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 79 Green Dunes Drive
West HYannisport,Mass.
Owner: Patri rk Goggins,
Date of Inspection: 1 f 1 9/o 2
TIGHT or HOLDING TANK*�OS(tank must be pumped at time of inspect ion)(]ocate on site plan)
Depth below grade: A i'
Material of construction: X)4 concretej/d metal 4,14 fiberglass 1(,,1?Polyethylene.f!/1 other(explain):
Dimensions. 'A ¢
Capacity: I gallons
Design Flow: leAl gallons/day
Alarm present (yes or no): :L_
Alarm level: W,4 Alarm in working order(yes or no): J&
Date of last pumping: 1I14
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are n .
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER4&f(locate on site plan)
Pumps in working order(yes or no): -410
Alarms in working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump cham er is no presen
8
I.
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 79 Green Dunes Drive
West Hyanni PQr_t1Mass.
Owner: _P_atrirk Goggins
Date of Inspection: 9 i 16.10 2
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
2-100
If SAS not located explain why:
Located; Spe page 10
Typ leaching pits,number:
�>leaching chambers, number: 4
—v leaching galleries, number:
leaching trenches,number, length:
D leaching fields,number,dimensions:
_T overflow cesspool, number:
A0 innovative/altemative system Type/name of technology: 7Y /y�
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loam No e—
r pon ing.Soi s are dry.yegetAtion is
CESSPOOLSti&JI (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: p
Depth—top of liquid to inlet invert:
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.):
C
PRIVY��(locate on site plan)
Materials of construction: /y/9
Dimensions: AM
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy
9
I _
Page 10 or I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address; 79 Green Dunes Drive
West yannispor ,Mass.
Owoer; Patrick Go ins
Date of Inspectioo;1 1 6 02
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 rect. Locate where public water supply enters the building.
L
6
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A 1- 39 B I - 32 0 2
Z" y1%,
3" so , 3-
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Y Page I I of I I j
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 79 Green Dunes; nrive
West Hyannispnrt,Mass.
Owner: Patrick Goggj ns
Date of Inspection: 1 .116.109
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
bt fined from s stem desi plans on record If checked,date of design plan reviewed:
Obsery d site abuttin ro erty bservation hole within 150 feet of SAS)
�hecked with local Board of Health-explain:
_Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller M061P7 12f16,/_94 Ground water elevation
above sea level .
Used; USGS Observation well data. June 1992
Use S Annual ranges of around water- fnr r'ar,a Oad.january1 992
I op of roun 92-000-1 Plate #2
Leaching
Pit ,eet
41 old
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
11
. ,•�.T,r„-n,-.f.•,T..,..-,m'P,,...,-,...,,.,..,,,.i•.,.�,...,,,,.T.T,.T.,,m,-�,T..•l�.,R�'i ..
'I'ONN OF Barnstable WARD OF HEALTH �
SIIIISURFACE SEHAGR DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
T!•.�T••.••.'t-T,.t/.�.�1TIR T.TII T.IT.TIIr.RT.TTr'R11'}-•.'1••11T1'R'ti�1TTTl'AAf/TRII�':'�1R7 RRf i ..�I•T'l�-�. �..1
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 79 Green Dunes Drive West Hvannisport,Mass.
ASSESSORS MAP , BLOCK AND PARCEL # 246/200
OWNER' s NAME Patrick Goggins
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & Sin Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
Street Town or City State t1P
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 1 790 -1578
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage disposaj system at
this address and that the inforination 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 .
Check one :
/ System; PASSED
The inspection «hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 15 . 303 , Any faililre
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
\
The inspection which have con i�cted has found that the system fails to
System FAILED*
Protect the j-)ublic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , &nd as specifically noted on PART C - FAILURE
CRIT RIA of this inspectI n form .
I1 � -
Inspector Signature Date
7 Allk z
ecopy of this certification must be provided to the OWNER, the BUYER
On
where applicable ) and the 130ARD OF HEAL1'I1.
* If the inspection FAILED, the owner or' 'Perator shall up
grade ayatem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CFIR 16 . 305 .
partd . doc
17 TOWN OF BARNSTABLE
LOCATION ' f ° SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /01D
LEACHING FACILITY: (type)v ��f (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 fee f hir�g�facility) Feet
Furnished y �1���
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1-1
pyl'QM Lsws.Th.original purchaser or this E FICIM# 1 bat
"'tfl IF uot 'd
ho—�Sln ths olam.Modiflostion or Prof—fond 5uRding U�igher
to o— only
—p-d --lol—voh.
LOCATION:
eOe lio,
P.O.Boa'11V9• y14e... MAo2601.900.,103q22 oF,t,
No.... ...... Fi ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OX HEAD
• r
0 F 41...........
Appli.ration for Ulopviial Works Tonstrudion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair) an I ividual Sewage Disposal
System t
Loc-i -,Address or t No.
.... o ...................... .. . .... . ._._.... .6........ ..._..
�" 1 G g
GV Owner L�y�'- L C.�1.5 dr s
... .....................•-••• •--•--•-•........................ ............•.... •......•••• -•••........•----•-•-.._.........................................-
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling-No. of Bedrooms._..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ._ . ��`
Design Flow___________________ ____ ____ WU�Ilons
lions per person per day. Total daily flow....._..... _._-_...........gallons.
Septic Tank Liquid capacity/ Length................ Width____.__________ Diameter---------------- Depth................
x Disposal Trench—No..•.........C:._..... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit Nol.............. Diameter-------------------- Depth below in t..... ....... tal leaching ................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .........
-- ••. Date
a1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch D th of Test Pit.................... Depth to ground water............_...........
a' ----•-•----•---... . -• ••-•--•----•----•---------------•••-•-....................................................
O Description of Soil................................ r'�.:
"�
W ------------------------------•-•---••••••-•-----••-•--•--•-•--...--••------•-------•-------------•--•--•••••••.-----------------•----•-----•-•-----••-•-•---...--•---•----•--------•-•----•----•-.....
UNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' ued b- the b rd of health.
t Signed -------•.........
P � � ^ D e
Application Approved By /lL���' � 1�� i -R / �=� ,..�}
/ Date
Application Disapproved for the following reasons:....................................
}. Date
tPermit No........J . ....._-•-•-----------•-•... ------ Issued.........- _D...---•-
--------------------------____-_._____-_- ------ -------- ---------------------------------------
No...y.. r'`...... F�$. ................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEAL`
---- ---OF....... ... ..... ..
. ........... A
Anpfira#ivtt fox Diiinv,iai orks'T notrurtion Punfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst t
..._..
Lo i Address
• ------ o
r:...t No.
a+ +....•. ......... r
Owner
dd s
Installer Address
Type of Buildin `+ Size Lot............................Sq. feet
aDwelling'4KNo. of Bedrooms...........V---------------------------Expansion Attic ( ) Garbage Grinder' ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures '....... !r" _,.:.................
Design Flow ............ llons per person per day. Total daily flow._..:.. gallons.
WSeptic Tank/'Liquid capacit ldlis Length----------------Width................ Diameter................ Depth................
Disposal'Trench No s_W�dth _________________.Total Length Total leaching area:___._..______._____sq. ft.
S&page Pit•No ...... Diameter --:............. Depth below i ...._._ T tal leaching area..._.._.........._sq. ft.
Z__ r
Z Other Distribution-,box ( ) Dosing tank ( ) r
Percolation Test Results. Performed by--------------------------------
............
---k.....- Date-----------= ................
Test Pit No.. 1.................minutes per inch Depth of Test Pit....:............... Depth to ground water_.........
................
P� Test Pit No. 2................minutes per inch D th of Test t.................... Depth to ground water........................
•-•--------------- - .............................................................
0 Description of Soil................. -----••-=- ' .........................................................................................
W
x ------------------------------------------------•..........................................=....... ..........................•-----•-•-------------•-•-.-----:--•-----•••---------•••................
VNature of Repairs or Alterations—Answer when applicable.___.......................:.....:........:...............:.....................................
•-------------••------•-•---._...••----••--------------------•-•----•---•---•--•-•-•----•-•---••-------•-------------•---_-------•-----•--------•---•------=--------...------------••...._............
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal.System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is ued the b rd of NA lth.
-
1 Signed. --- `��•---
c
_. Application Approved By
D.:e_!_ _
t; �` `3► ate d
' licat
ion Disapproved for;!lie`following reasons:. '
.................. -- . . ............................................... •--------- --••- ............... ............---.................
Date
PermitNo......................................................... Issued..... jl
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
71
..... ...........
O F...
y` 4 rifir�i$� f fuss
T S IS 'CE That the Individual, .S e Di oral .System.constructed (. or epaired ( )
by •-• �!�" ..--•-Ct, ?E//��'' __ C +f,S {/L'/.r I .. Ins.._ r .. _. _��' .__...............................
at
---
has been installed in`acco ance with the provisions of Article�I�°f he State Sa tary e s descr> ed to the
a lic tir�ri for Dis osal Works Construction Permit No...............�. dated
T° ISSUANCE OF THIS CERTIFICATE SHALL.NOT BE CONS ED AS'A RAN'0'EE THAT THE
SYSTEM I� FUNC; IO''N SATISFACTORY
DATE:. . : " .:..... ....... -- Inspector.:
TH COMMONWEALTH' OF;'tv1ASSACHU E-4ts
BOARD .HEAL
ti! : .. OF.... ...................... ... ....
No.......
a,
FEE..
.. .
Permission ' reby granted._,*—"...... .;t '. �T' ... ..,.....
to Constru or R,gair - a an Individual Se ag Disposal System
at No .: :: ....
- street
as shown on the application for Disposal Works Construction Permit No...'.`................... Dated.._
.............................. ,+'�B.ard� ----...._----•••--_---• ...................
vDATE xe••••_. ._.--- ...-- �z alth
}<y
FORM .1255 HOBBS & WARREN, INC:-.`PUBLISHERS -
i.
s f
S' I
L o 7 NOM IER
I 9&' On /
7
— WALK DR/►�E N./,C,
I ,
THIS
IGN AND CONSTRUCTION
N BLUEP INT-,S THE PRODUCT Of AND
p:+IAS BEEN. COPYRIGHTED BY HOME,
PLANNERS, I NC.. OETROIT.AND IS NOT
TO BE COPIED OR REPROQUCED WITH=
OUT SPECIFIC PERMISSION'. z
'`�_ "'�• HOME PLANNERS INC. _ PLAN No.
• � �� •.ltt`/l1�Jl3�,�y�y� 16310 GRAND RIVER AVE. • DETROIT 27, MICHLGAN 16 Q B
SHNG OF
EET
SONAL �' il�iIIU7sbT Y i�
N,AND L IRVING E. PALMQUIST-ARCHITECTiLDING OF
ES, IN•
HOICE, �� $476 ,�� R.ICHARD .B. POLLMAN-DESIGNER r• ` _