HomeMy WebLinkAbout0056 HI-ONA HILL ROAD - Health (2) 56 Hi-Ona Hill Road
Centerville
A= 207—090—001
S M E A D
No.H1630R
UPC 10259
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I
COMMONWEALTH OF MASSACHUSETTS i
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: . / -
j N
z& 3 Z/ :-
Owner's Name:
Owner's Address: Z y
Date of Inspection: cD,
-7/ /V ja00 7 .
Name of Inspector:(please print) Joseph M.Martins
Company Name: Accu SepcheckW, ran
Mailing Address: 17 Northside Dr., S.Dennis,MA 02660
Telephone Number: 508-385-5"1
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 the inspection.The inspection was performed based on my
training and experience in the proper fimction 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:
_asses
Conditionally Passes
Needs er Evaluation by the Local Approving Authority
'1
Inspector's Signatu Date: 7 7 0 7
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.
Notes and Comments:
Sig /e/j
-Q04 4 t
****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.
Page 2 of 11 ►
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
56 Hi On a Hill Rd.,Centerville, MA
Owner: Monroe
Date of Inspection• 7/10/2007
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
have not found any information which indicates that any of the failure criteria described in 310 CNM
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Condit' al Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or r ,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`Sot determined"please
explain.
The septic tank is metal and over 2 ears old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltratio exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a com 'ng septic tank as approved by the Board of Health.
*A metal septic tank will pass' ion if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less an 20 years old is available.
ND explain:
ti f sewage backup or break out or high static water level in the distribution box due to broken or
obstructe ipe( or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of B d of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 56 Hi On a Hill Rd.,Centerville,MA
Monroe
Owner: 7/10/2007
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 failing to protect public health,safety or the environment.
1. System will pass unless Board of Health deter es in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner wh' M protect public health,safety and the environment:
Cesspool or privy is within 5 of a surface water
_ Cesspool or privy is wi ' 0 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 wi in'16-0 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 e I of a public water supply.
_ The system has a septic tank and SAS and the SAS is 50 feet of a private water supply well.
The.system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a
private water supply well". Method used to d ine distance
"This system passes if the well water ysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compo indicates that the well is free from pollution from that facility and
the presence of ammonia nitrog d nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. y of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 56 Hi On a Hill Rd.,Centerville, MA
Monroe
Owner: 7/10/2007
Date of inspection:
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
t/ 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 6"below invert or available volume is less than'/z day flow
—Jl 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 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 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.]
N(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 most serve a facility with a design flow of 10,000 gpd to 15,000
You must indicate either`yes"or"no"to each of the following:
(Tice following criteria apply to large systems in addition to the crit ' bove)
yes no
the system is within 400 feet of a sur �inkingwater supply
_ the system is within 200 f a tributary to a surface drinking water supply
_ the system is 1 in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a lic water supply well
If you have veered"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.
o.r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
56 Hi On a Hill Rd.,Centerville,MA
Owner: Monroe
Date of Inspection: 7/10/2007
Check if the following have been done.You mast indicate'1es"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
f/ Has the system received normal flows in the previous two week period
ZHave large volumes of water been introduced to the system recently or as part of this inspection
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
t," Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs ofbre out
KG�
f/ Were all system components, g the SAS,located on site
_✓b l_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
th of e es 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.
t✓ 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))
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
56 Hi On a Hill Rd.,Centerville, MA
Owner. Monroe
Date of Inspection: 7/10/2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design)aa Number of bedrooms(actual):_q
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): J [if yes separate inspection required]
Laundry system inspected(yes or no):tV�' Z.D p b: Ca 9l o O® Ale (T�
): NO
Seasonal use:(yes or no
Water meter headings,if available(last 2 years usage(gpd 200 S . 7&O OC!
Sump pump(yes or no):J J'0 J ��rr f'4�rm X JV
Last date of occupancy-4 tJ
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present not ):_
Non-sanitary waste discharged a Title 5 system(yes or no):
Water meter readin a able:
Last date of ancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: ra eK (r1 a-oy Olcv r QK or QS
Was system pumped as part of the inspection(yes or no)- � 2 `��
Gt
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping:
TY E 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/Alternative technology.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 known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): N!�
r
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
56 Hi On a Hill Rd.,Centerville,MA
Owner: Monroe
Date of Inspection: 7/10/2007
BUILDING SEWER(locate on site plan)
� 1
Depth below grade:
Materials of construction: iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:
0 it
Material of construction: ✓concrete metal—fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 7/1/ (/ X
Sludge depth: t�
Distance from top of sludge to bottom of outlet tee or baffle: 2 Z
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: ,,
How were dimensions determined: U CQ r 42
Comments(on pumping recommendations,inlet and outlet teY or baffle condition,structural integrity,liquid levels
as r lated to outlet invert,evidence of leak ,etc). �I
re a d cep s 1,A P Qe '40 elf k., k vo 1u►t,.t
/ v
Nd e ul a"Pw ct ol a PG tow
GREASE TRAP:_(locate on site plan) ^V 4v- bvfi o t
Depth below grade:_
Material of construction: concrete metal fiberglass yethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top otputreitee or baffle:
Distance from bottom of scum om of outlet tee or baffle:
Date of last pumping:
Comments(on p g recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
56 Hi On a Hill Rd.,Centerville,MA
Owner: Monroe
Date of Inspection: 7/10/2007
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal f glass polyethylene other(explain):
Dimensions:
Capacity: lions
Design Flow: allons/day
Alarm!ev7e
nt(y no):
Alarm • Alarm in working order(yes or no):
Date opumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: rA+ (V1 1,I A-r
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaks a into or out of box, c.):
1lk lJ 1 ,NO
0, C
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps an enances,etc.):
Page 9 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
56 Hi On a Hill Rd.,Centerville,MA
Owner:
Monroe
Date of Inspection:
7/10/2007
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: X b w S��
leaching chambers,number:
leaching galleries,number:
teaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): �—o 1 LC a,) 1 0 4P()��� ) 1— t'S G ,P A r�
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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 infl (yes or no):_
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: l
Depth of solids:
Comments(note condition of soil, ofhydraulic failure,lercl ofpunding,cundition of vegetation,ctc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 56 Hi On a Hill Rd.,Centerville,MA
Date of Inspection: Monroe
7/10/2007
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.
1
��Ck
2
3
o � r
�2r 7ID.S, � � 6
1/0 ,63= 3
�17 .Sys �3
l
Je
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 56 Hi On a Hill Rd_,Centerville, MA
Date of inspection: Monroe
SITE EXAM 7/10/2007
Slope
Surface water
Check cellar
Shallow wells ? ,�; / �[
Estimated depth to groundwater > 3 L �/�� 'Pt-L �70*k-
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:_
Checked with local excavators,installers-(attach documentation)
✓Accessed USGS database-explain: U 57 S ff'rj Quf29
You must describe how you established the high ground water elevation:
Sk ( s 50 ' �• S.
��d��tl�v PJ�v��in� •C �� !
`P�
TOWN OF BARNSTABL /p
LOCATION �+J / / N /GL SEWAGE# f`a 2
VILLAGE ��� r�i �� ASSESSOR'S MAP&LOT AP-] _oJ_-pL I
INSTALLER'S NAME&PHONE NO. 'Po ,u`s 00
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) A w', titJ Z f� /!e—(size) LGO�J g
NO.OF BEDROOMS Ale
B=EROROWNER t'�f�
PERMTTDATE: • 2t• -7 / z 0oZ=.
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 feet of leaching facility) / N IQ' Feet
Furnished by
F_ TOWN OF BARNSTABLE
N�� ,
LOCATIO � ODl/.'� JJiCJ SEWAGE # 9'--3
VILLAGE% ASSESSOR'S MAP 6z LOT167-01646 J
INSTALLER'S NAME & PHONE NO.
.SEPTIC TANK CAPACITY )
LEACHING FACILITY:(type) / r>S (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER'
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/'
�Q�GE
4z�3 r
7 �� (a c s T
r
!b r
'd ' , D 0 X
Fas...�30.00........
t
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH � APPROVED
TOWN OF BARNSTABLE
Nrnstable Conservation Devartment
b
Appliration for Uiripoottl Wnrk!i Towitrurtinfi rat#
0
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
56 Hi-ona-hills Rd
....---• .................................. ----
Mrs. Mur Location- ddre:s or Lot No.
phx
Owner Addres
W 4d.E. Robinson Septic Service P.O. Box 1089 Centerville
---••E -q:
Installer - Address
VType of Building3 Size Lot............................S feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .-....._...--.-..--_----- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
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 ( )
aPercolation Test Results Performed by--------- -----------------•--------...----------•---••-•---•----•-------- Date........................................
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........................
9 ...-------•--------------------•---------•------•--•-----•-•---•-•--•------••....••••-•--•--.............••••-•-•------•--•-•-------•--.........••----.•----.
0 Description of Soil....sand-------------------------------------------------••------•--------------..----•-----•----
W
U .....................•--••-•-•-----•----••••..•-------•••-•----•-----......-------•-•--...............---•-•----•----..........---------••.......----•--•....---•---•---•...----•--••••-•-••-•---•-...-•--
W
-- ---------------------- -------------------------------------------------------------------------- -------------.....................................................................................
U Nature of Repairs or Alterations—Answer when applicable..................... . . ....................
install a 1 ,000 gal tank, D-box and precast stonepacked l.eachpit
---•--•-••-•--------••---------•-••-••----••----•-•-••--••-•-----•••---••---•-•------•••-••-•--•--••----••--------------------------•----•------••-•---•---•----.......---..............................
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 undersi ned further agrees not to place the
system in operation until a Certificate of Compliaa/nte has b e issued h oard of h h.
Signed ...------C./.. ..
.............. '..... - .............. ... �-Vie.... ..
Application Approved By ............. -t .......�. ............... ....(...... .�.. �..
Dace
Application Disapproved for the following reasons: ... . ................................................ .......................
........ ...................................................................... -----.................................................................................... -------
........................
.........
pp Date
Permit No.* ........... ... ---"---�-S_�� . ........... Issued
Date
«, y,.�a .6- .•,.1r,.. .... -., ..n. ..- .Y � .. .,,,,., s,.... .... .W...a v 'tom' -. -.. ✓. _, � ... .`�. .� ._ y.
No... 30 00
�✓� THE COMMONWEALTH OF MASSACHUSETTS l
\ BOARD OF HEALTH
TOWN OF BARNSTABLE
'Alip iratinit for Diripniul l nrk,6 Toustrnrtinn rrrntit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at
56 Hi—ona-hills Rd -1., ' t
..............•----------•-••---••••. -•-• ..--- .--- ...........-----••---........ .....-............................................................................................
Mrs. Murphy Location-Address or Lot No.
Orencr Addres
W W.E. Robinson Septic Service P.O. Box 1089 Centerville
Installer Address
UType of Building 3 Size Lot............................Sq. feet
I-. Dwelling— No. of Bedrooms._..............................._-....._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures
d -- ----------------------------------------- -----------------------------------••----••----------•-------
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
i W Septic Tank—Liquid capacity............gallons Length---------------- Width............---- Diameter.--------------- DIipth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---------- ............................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 .....-----••-----------------------------------•-------•-•-----•-•-••-•-----•---..........----.......-•-•--•---...........-•-------•--........----•---•-----
ODescription of Soil....sand.....................................•----•-----------------••---------------------------....------------z
V .....•--•---•-•--•••---.....••-••-••••--•--•------•---•-----------------•--••-•--•-•---•--•--•••----------••-•----...-------•-------••------•--•-•-.......-----••-•------•------...........----••--------
W
U Nature of Repairs or Alterations—Answer when applicable............................... ... :..._.............. e install a 1 ,000 gal tank, D—box and precast stonepackec� leaahpt
-•------•---------------------------------------•----------•-----------•------------.............-•-----•--------------------------------------•-------....---...-----------------------•-•-•--•----•••.
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 undersined further-agrees not to place the
system in operation until a Certificate of Compliance has b e issued h oard of health.
t Signed ... :`......-.......
- -- --------------------.f'"............... .. 1' _e.:.. ..
Application Approved By ------------- - � - ........ .. .a e.... '
Application Disapproved for the following reasons- --------- ---------------------------------------------------------------------------------------------
.. . ....................... ........ . . ......... ............................................................................. ....... .......................................
PermitNo. -----------! ._ ... .... .`� Issued... ........... ...-.........................------..................Dare......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C'Ielr#ifi ate of (11-ampliance
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( x )
by .. W.E. Robinson Septic Service
...Installer
at .....56 Hi-ona-hills Rd Centerville
................_................. ....._............._........ ... .......-------------------.......----....-----------------............-----------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .......�3.-.lep".9L_ dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................t/ -- --A--.. - ?.' Inspector ------ ..._........._.........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE $30.00
No.--- FEE........................
is n�tt1 orks Tonotrurtion Wrtnit
W E Robinson Septic Service
Permission is hereby granted----- ..... ......------•---•-----------------•-•---........----•-..............--•-------------•----•------•--•----................
to Construct ( ) or Repair ( x) an Individual Sewage Disposal System `
at No.•---56--H-i-ona-=hi-lis.Ra---•Centerville--------------- •---•-•---•-.....
Street oo '
as shown on the application for Disposal Works Construction Permit No/�ll�dr�.. Dated...........................................
---- ------------------------------------------------------•-•-•-
----------------------------•----•--•• Board of Health
FORM 36508 HOBBS B WARREN.INC..PUBLISHERS