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Home My WebLink About0068 HAWSER BEND - Health 68 HAWSER BEND Centerville A = 192 — 091 IN S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR n SUSTAINABLE `YJ FORESTRY MIN.RECYCLED TTT INITIATIVE CONTENT 10°k Cerglied Fiber Sourcing POST-CONSUMER www.sfiproprem.orp SN-01790 MADE IN USA GET ORGANIZED AT SMEAD.COM Commonwealth of Massachusetts /10 Title 5 Official Inspection Form fv, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `T 68 Haw�s�er Bend Property Address ;e a Josephine Roberts Owner Owner's Name lnfbrill t a fa on Is requir far enerve ✓ Ma 02632 5/17/2017 required r every Centerville pap, Cityfrown state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way.Please see completeness checklist at the end of the form. Important:When fipinD out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor'do not Sean M. Jones use the return Name of inspector key. S.M.Jones Title V Septic Inspection _ Company Name 74 Beldan Ln. Centerville Ma 02632 C.itylTown state Zip code 774 248-4850 smjonestitle5@gmaii.com SI 4522 Telephone Number U eense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 16.340 of Title b(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/17/2017 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 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. ""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. VAn 3M3 To*5 Orfiuer hWecwn Fwm:SLboxfeoe Sewage oiapml sysi m•Page 1loff J7 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fomn-Not for Voluntary Assessments 68 Hawser Bend Property address Josephine Roberts Owner owner's Name Informationquirefor is Centerville Ma 02632 5/17/2017 required for every Pap- CltylTown state Zip Code Date of Inspection S. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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 dwelling located at 68 Hawser Send Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank,distribution box and 2 precast leach pits.The system was found to be in proper working condition at the time of inspection. 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. Check the box for"yes", "no"or'not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrabon 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. ❑ Y ❑ N ❑ ND (Explain below): 6ne•3M3 TO 5 Ot6 W MepeWw Form:She Sewage tNe MI System-Pape 2 of U Commonwealth of Massachusetts OEM Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 68 Hawser Bend Properly Address Josephine Roberts Owner owners Name rnformatton isrequtr Centerville Ma 02632 5/17/2017 page.ed for every citytrown State Zip code Date of Inspection �� B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 falling to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1Xb)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ft•3/13 TA*5 OffroW kupettm fam:S%Osutm 69wa a owposat Sysim•page 3 of 17 s Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner Owners Name information for is Centerville Ma 02632 5/17/2017 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance; This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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. 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 ❑ ® Liquid depth in cesspool is less than 8"below invert or available volume is less than%day flow t5ft•aH3 Tnr"$OMWI Inspection Form:sum$ Disposal system•Pap 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments fib Hawser Bend Property Address Josephine Roberts Owner owners Name information is required for every Centerville Ma 02632 5/17/2017 page, City(Town State Zip Code Date of InspeWon B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.) ® The system is a cesspool serving a facility with a design flow of 20009pd- 10,000gpd. ❑ ® The system falls. 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 arty large system considered a significant threat under Section E or failed under Section D shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ft-3113 Tide 5 Official rnspedion Form&twjft a Sewage aspow system.Page 5 of 1 Commonwealth of Massachusetts mmmm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner Owner's Name Informarequire for is Centerville Ma 02632 6/17/2017 required ror every page. ckylrown State Zip Code Date of Inspedon C. Checklist Check if the following have been done,You must indicate"yes"or"no°as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with Information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ 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)1310 CMR 15.302(5)J D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5sns-W 3 TO 6 Ol6del tnspectim Form:60eu laoa Sewage Dleposel System•Pape 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 \Vj 88 Hawser Bend Property Address Josephine Roberts Owner Owners Name tnformsfion is Centerville Ma 02632 5/17/2017 peage�for�ry citylrown state Zip Code Date of Inspeatlon D. System information Description: Number of current residents. 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: sump pump? ❑ Yes 0 No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15h%•3M3 TO S tklfdal 1"Peetion Fomx Sutreudke Sewage Disposal System•Pape 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts owner owner's FumeInIlbrmation required for is Centerville Ma 02632 5/17/2017 required for every page. cltyrrown state Zip Code Date of Inspection D. System Information (cons.) Last date of occupancyluse: Date Other(describe below): Generat Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Aitemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ft•W 3 This 6 OrflW„opeOm Form:SW m%w Sewage Diepoaal Byetem•Pop 6 of 17 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner owner's Name r"Ibmiarm is quIred for Centerville Ma 02632 5/17/2017 requlreti for every page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: original system installed 1977, leach pit added 1992 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 1.5 Material of construction: cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feef Comments(on condition of joints,venting,evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 6,1 Sludge depth: tsins•3113 TO 5 Ofriaiet Inspection Forth:Sfsufaoe Sewage Disposal System-Pne 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner Owner's Name information is required for every Centerville Ma 02632 5/17/2017 City/Town!Town pap. ty state Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" Haw were dimensions determined? opened covers, tookmeasurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle --- Date of.last pumping: Date t5lns•3113 Title 5 Official inspection form:Subsurface.Sewape Disposal Syshn•Pape 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner Owner's Name information to required for every Centerville Ma 02632 6/17/2017 page. c4tyRown State Zip Code Date of inspection D. System information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Sins•3113 TWO 5 OMCW t-POWon form:"5Uftae Sewage Oftood System•Pain 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address .Josephine Roberts Owner Owner's Name infatuation isrequir Centerville Ma 02632 5/17/2017 page.�l far every !Town State Zip Code Date of I Page. qty aspectIon D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" 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 was in good condition, no rot,water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: f5bta•9H 3 Us 5 OMl W b spadlon Fare Gubuafm 8aiw D1$X l SyMM-Pap 42 of 77 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 66 Hawser Send Property Address Josephine Roberts owner Owner's Name Is re lorevery fOrOn ed Centerville Ma 02632 5/17/2017 Paw- Cty/rown per. State Zip Code Dale of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching Melds number,dimensions: ❑ overflow cesspool number. ❑ innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): second leach pit added 12-10-1992 was opened and was found to have 4'of standing water with no stain line higher. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to Inlet invert - --- Depth of solids layer ` Depth of scum layer Dimensions of cesspool Materiats of.construction Indication of groundwater inflow ❑ Yes ❑ No t5ine-3/13 Title 6 Offt et Yopedon Form:Subsurface Sewage Disposal System Page 13 of 17 Commonwealth of Massachuselft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner owner's Name inforrinatimreWiredfb Centerville Ma 02632 5/17/2017 required for every page, City/Town , state Zip code Date of Inspectlan D. System Information (font.) 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.): t5ins 3tt3 Tice 5 Mai hspedion Fornk Subsurfam S"Mo Disposal System Pays 14 of 17 Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 68 Hawser Send Property Address ,Josephine Roberts Owner Owners Name information is i Centervlle Ma 02632 5/17/2017 ret}ulredforearery Pep- City/Town State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System; Provide a view 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. Check one of the boxes below. ® hand-sketch in the area below ❑ drawing attached separately R °B 0 141 27 (St 3; V3 �7 ZY n A3 3� 6!7 ff �y 3Y 3° 1� yN dins-3H 3 Title 6 Oftal hepWm Fonre Sub"dece Seaape tnepoW System-Pepe 15 of V f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property Address Josephine Roberts Owner Owners Name Information is Centerville Ma 02632 5/17/2017 required suety page. myrrown state Zip Code Date of inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. 12'+ feet Please indicate all methods used to determine the high ground water elevation; ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installer;-(attach documentation) ❑ Accessed USES database-explain: You trust describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Bamstable groundwater contour map. Before filing this Inspection Report,please see Report Completeness Checkllst on next page. t5ins-$n$ Me 6 oNt W Inspection Form:&ftu ym Sewage Wepoael System•Pop IS of 11 �a • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 Hawser Bend Property address Josephine Roberts oWrW 6Wi&s Name mquii d b is Centerville Me 02632 5/17/2017 required torevery Page, cityfroam State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary.A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i5irb•3H 3, Title 5 of did kispedion Pon:st6wrfew Sewape Olepoeal Syetern•Pepe 17 of 17 TOWN OF BARNSTABLE LOCATION ,/f W A W.5-ep R e wat SEWAGE # 7)1 - S7 7 VILLAGE C e NyeR Elite ASSESSOR'S MAP 61 LOT INSTALLER'S NAME 4 PHONE NO. J. P m A c o M�040X+ .5-.aAl SEPTIC TANK CAPACITY f a LEACHING FACILITY:(type) 'el�' (size) b e u NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER � p DATE PERMIT ISSUED: CO DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ 0 A �� , �� s ��' k�� i No................ FIZs.............................. .. -<,�,' COMMONWEALTH OF MASSACHUSETTS �---� ° 3 AR® OF HEALTH ' corOWN OF BARNSTABLE Appliration for Disposal Works Tontrnrtion jJamit Application is hereby made for a Permit to Construct ( ) or Repair �X) an Individual Sewage Disposal �XXstem at: t5 Hawser Bend Centerville ................_--......_...................................................................... --•-•-------••-•----------•---•------------------•-----------•---•----•-------.................•. John Robert s Location-Address or Lot No. ......................-........................................_................................. ............................................._....res...•... ._......................_...------------ s WJ.P.Macomber sTx.�..Owner Add........-•----------------•--•-----------•-----•--- --•----...-- -•--........__.._.......------.........._._ Installer Address Type of Buildiig Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............. ...........................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ------------------------- -----•------•-•-•-••--•-....._ 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 Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a ..........-......................................................................................................••-••----••••••--......---•-•............... 0 Description of Soil....�. ant---g�---Gr-a�re i------------------------------------------------------------------------------••------------------....._...----•--••--•-------- W V .......--•.................•-----•••-•••--•----•-•--•--•-•-•-•-•---•-•-----............--._....----........................---•-•••------------•--.._..--•••-----•-••••.......-•-----•-•--......--•••- W x -------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------.--- U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------_..................... •1-10J0..gallon...leachin ..Pt._ acked in-•stone_,. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has eegt issue board of health. �(/ 11/16/92 Signed -- .............................. -------------------------------------- Date Application Approved By ..�... �.................... -------------------- ------ --- s. -�.Date Application Disapproved for the following reasons: ....... ----------------- -------------------------------------- ------------------- ---------------------------..................... - ...----------------------------------- -------------'---- - - -- --""---'--- - - r Date Permit No. 7 �� . ..--.... Issued ------..: Date 910- _17/_7� FEs..... ....3(J-...00 THE COMMNWEALTH OF MASSACUS,-•�1v1--`� � �3a�9�BOAR®O OF� !-IEALTHH ETTS TOWN OF BARNSTABLE App iratiou for Dhip sal Workii Toutitrur#iun rami# Application is hereby made for a Permit to Construct ( ') or Repair (XX) an Individual Sewage Disposal System at: 6t3 Hawser Bend Centerville ................-................................................................................ ............._..-•-•...---••••....._._...-----••-----------------••-•-----•--..................... John Robert s Location-Address or Lot No. ....................... . ...... ...... ................................................... ........-----------•••----......-•----........•-•----•----•--•---•------........................-- Owner Address J.P.Mac omb..r ..r...................................................... -•--.....•---------...----....._..---•----••-•---•------•-••-•---••••••-•.........--•--------..... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ..._._... 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 Distribution box ( ) Dosing tank ( ) IH Percolation Test Results Performed bY--------------------...................................................... Date........................................ W Test Pit No. I................minutes per inch Depth of Test Pit...---.............. Depth to ground water..................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----------------------------------------------------------•----------•-••---------------------.---------- •-•------------- ••••••.............. .------------ -. D Description of Soil--- - -•--------------------•----•---------------•----------------•------------------••------•--........-•--•---....- x .`Miff i•- isY`t�'v' ---------------- U •-------------------------------------••••-----....••------------------•------------•-------------------•-------------------------•-•-------------------•-----------------...------.......----••--_..... W V Nature of Repairs or Alterations—Answer when applicable.-.............................................................................................. -_1-l�JQQ.. allon---leach......_.. t_- a,ctod---a_n__..tnna -----------------------------------------------------------•---............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 11/16/92 �. Signed, , - < .. .. .�.. "riv --------------------------------- - --------- .e Application Approved BY1� ........ --- ................. ------ ---�� x Date Application Disapproved for the following reasons: ...... ...............................----------------------- ---------------------- ------------------- ------------------------------- -- ------------ ---- ---------------------- -------------........................................-------------------------- ............ --.�...........----- ...... ---- -- '7' .... .^7.. Issued --------//--I.--- ! ' 4e ;Permit No. ..............: Date-..-.... ..............�......... -- THE COMMONWEALTH OF MASSACHUSETTS .a BOARD OF HEALTH TOWN OF BARNSTABLE Cer#tftrate of Tantlaltttnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or.Repaired (XXX) J by--. .,.P.,.Xac.omb.er----tl r.a------------------ ----------------------------------------------------------------------------------------------------------------------------------- ------------------------- h8 Hawse Bend Centerville Installer at -------------------................... has been installed in accordance with the provisions of TITLE 5 .o5f The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... �...--� 7_';� ..... dated ....- / THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 11 , DATE..........................1.. ?-..r...I G ./ N.- ------------------------------- ---- Inspector .....----V '---------- ...................................... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 30.00 No.................... FEE........................ �i��rrr,��t1 >ark� ��a��ruan rrnti� J P Macomber Jr. Permission is ll hereby granted ----------------------------------------------- to .Construct Hacvserep�aeirn(hXGIEMtIenr lu1aIeSewage Disposal System atNo.................................... Street as shown on the application for Disposal Works Construction Permit Ng' Dated..; ------- , --------------------c- �. => . ... DATE. _ Board of Healtl,, FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION 14AW5,eX SEWAGE # S ,7 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME &. PHONE NO. .T. P A A ,- 0 Mj0'-9g(+ •SdA/ SEPTIC TANK CAPACITY f « � LEACHING FACILITY:(type) (size) /• a NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER .: _T DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 � ?y 0 I