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Home My WebLink About0062 HILLSIDE DRIVE - Health 62 Hillside Drive Centerville P A = 193 039 No. 4210 1/3 ORA Pendaflex° 10% SEWAGE INSPECTIONS GOCAn6' 62 H.�.. izide Dzive DATE 9/20/03 VF—LAGE Cente2v�Pie, l'la��. ASSESSOR'S MAP & LOT 03c? INSJP O'PO& lo,3,el2h P. Nacomfe2 J,c. SEPTIC TANK CAPACITY ! 0 l LEACHNG FACII.ITY: (type) �`� (iizc) NO. OF BEDROOMS Z BUILDER OR OWNER Jean Ven. ru zozo OWNER MAILING ADDRESS 78 f o2e s.t Pa2/t D/z ive Nendon, Na.s,3. 07756 si1o, �-- ®/ ® t\ \ Oil- 0 r � I� r sZ � D DATE : 1011103 PROPERTY ADDRESS : aean Ventulto.3o 62-K.i eiz-i.de- Dlt ive -- - - ------- ----------- __�erzte2��2Pe, Na.3.6_02632 _ RECEIVED On the above date, I inspected the septic system-at the above addressOCT 2 12003 Tnis system consists 01 the following: TOWN OF BARNSTABLE 1. 1- 1000 ga eion .segt i.c .tank. HEALTH KEPT. 2. No di.6tn.igation fox. 3. 1- 1000 ga.e.2on /2aeca.st ieach.ing /2.it. 8aseo on my inspection, I certify the following conditions: 4,. 7h i.s .i.s a t it ie live- •6e/2t.ic h yzs &em. (78 Code) _ 5. The •3e/2tic .system is .in /12o/zea wonking oade2 at .the /?2eaent time. 6.' Oazte wate2 -i,3 60" ge.2ow the invent /2.i/2e ole the .2each.ing /2.it. SIGNATUR Name _ - _- P_ -Macomber-Jr _ �Ompany : ,?4 ��h per_ M��Qm��r d_ Son, Inc . AOor25S : @4y _�6------ ---- Ce-nsf9LYLUP—- �ja - _2Z632- 0066 Pnone : _ _508 . 775_ ) ) 38 -- ___ ___ TmIS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspooli•t.eachIIeIdI Pumped & Installed Town Sewer Connections P 0 Box 66 Centerville, MA 02632.0066 115.3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION PropertyAddress:62 fliii.s.cde Daive Owner's Name: lean Ventuzozo Owner's Address: Same Date of Inspection: Name of Inspector: (please print)Jo-6eRh P. Nacomgea aa. Company Name: I. P. Macom9ea & Son inc. Mailing Address: Box 66 Cvn,tvn»r.PYP-- Nrz .6. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 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 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: k�asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: f Date: j"U i The system inspector shall mit a copy of this inspection repo 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 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION (continued) Property Address: 62 H.iii,6-ide D z-ive en e,zv.t e, . Owner: aeon Ven uao,so Date of Inspection: Inspection Summary: Cbeck A,B,C,D or E/ALWAYS-complete all of Section D 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 3e/2t-ic .bybtem ih .in /22o/2e2 woak.iny oade2 at the �nv.iertt .2`-ime- B. System Conditionally Passes: /VD 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. BUD 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. 'Am etal 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: etM 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: 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 62 H.ii.ezide Da-ive en t eAV1 Owoer:aean Ven uno-6o 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 determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water 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. 4b 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. 4)0 The system has a septic tank and SAS and the SAS is less than 100 feet but 5 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 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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 62 K.cQ.Pz.ccle D z-ive en e,zut e, Owner:ae¢n Ven ulto,�o r... Date of Inspection: 0 3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No / _ 1/ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool e/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool iZ�(�tyE Static liquid level in the distribution box bove outlet invert due to an overloaded or clogged SAS or cesspool �� w ( 0"1 �/�squid depth in4e99p"I is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped d. _ y portion of the SAS, cesspool or privy is below high ground water elevation. �y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface e�water supply. portion of a cesspool or privy is within a Zone I of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. :i_zy 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.] (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 no/ Y the system is within 400 feet of a surface drinking water supply e 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 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 S of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properry Address: 62 K.i-tez.ide Dlt-ive en t eavt Z Z e, -a . Owner: lean en ultozo Date of Inspection: 7011103 r.;.. Check if the following have been done. You must indicate',yes"or"no"as to each of the following: Yes No/ ' r/ 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 ? _ I 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 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 com onents, / Y p 4luding.the SAS, located on site ? d _ 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 ovmer provided k maintenance of subsurface sewage disposal systems ? )P tded with Information on the proper The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _ J 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 I I OFFICIAL INSPECTION FORM — NOT FOR VOLU NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:62 fl t.P2,5.ide DA ive en 7 eav7e, a Owner: lean Ven ago-T Date of Inspection: 7017103 RESIDENTUL FLOW CONDITIONS �. . Number of bedrooms(design): l Number of bedrooms(actual): DESIGN now hued on 310 CMR 15.203 (for example: 110 Ypd x M of bedrooms): Number of current residents: Z> Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system,�Ycs or no):;EJ� (if yes separate inspection required) Laundry system inspected es or no): Seasonal use: (yes or no):,* LC Water meter readings, if available(last 2 years usage(gpd)):2001=2, 000 ga"P Pon.6=5. 48 910D Sump Pump(Yes or no): _ ga-e—on.6=279. 46 g11D Last date of occupancy:Z)"Irf COMM ERCLAL NDUSTRiAL Type of establishment: A,l} Design now(based on 310 ChJR 15.203): zDd Basis of design now(seats/persons/sgft,etc.): A Grease crap present(yes or no): Industrial waste holding tank present(yes or no): 1/4 Non-sanitary waste discharged to the Title 5 system(yes or no):,oO Water meter readings, if available: 11t14 ) Last date of occupancy/use: 4j4 OTHER (describe): Pu GENERAL INFORMATION m'pinQ Records ' Sourccofinformation: None Rva.iPa&-Pe Was system pumped as pan Qfthe inspection (yes or no): If yes, volume pumped: allons •• How was quantity pumped determined? Rcason for pumping: TYPE OF SYSTEM Scptic tank, 644444en- ft, soil absorption system 6 Single cesspool Overflow cesspool Privy Shared system(yes or no)(i(yes, attach previous inspection records, if any) S47- 41 K Innovativc/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from syst�em�n owner) Tight tank /V/1 Aaach a copy of the DEP approval �OOther(describe): �1 A roximaaQe fall components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no)14-4 6 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 62 K.ii-e,s.ide Dz-ive e nt ei v tz Z e, a6.3. Owner: aean Vent u2o,6o Date of Inspection: 1 1/03 BUILDING SEWER (locate on site plan) Depth below glade: Materials of construction: cast iron � PVC-Qother(explain): ,( Distance from private water supply well or suction line: -,0 f Comments (on condition ofjoints, venting, evidence of leakage, etc.): 'e vented th/zou h the tool vents. SEPTIC TANK: r(locate on site plan) 16W9Y4 S Depth below grade: / Material of construction: yconcrete vD metahe4 fiberglass polyethylene .oLPother(explain) If tank is metal list age: is age confirmed by a Certificate of Compliance (yes or no);,&(attach a copy of certificate) ni Dimensions: 244e& Sludge depth: Distance &om-top_qf.�ludge to bottom of outlet tee or baffle: Scum thickness: i Distance from top of scum to top of outlet tee or baffle:��.e�,e� Distance from bottom of scum to bottom of outlet tee o baffle: How were dimensions determined: r� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pum/2 6e/2t.ic tank annua2.Pu gia26age di,6Ro.6ae j,3 /22e,6ent In—Rat /ty In n nno Yank �,t tfn�inf,in�, 00y Anund nna hhow,6 no ev.cdence o� leakage. L-iquid .Peve.P at the out Pet invent n G�`> EA� TRA13GLk(locate on site plan) Depth below grade:low Material of construction;,�concretodLmeta berglasWy Polyethylene�et other (explain): AJ Dimensions:_�� --� Scum thickness: yam/ 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: et/y Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): J�n0rrA 0�'A�i,n i .t nn7�' nnnAQ.�tt 7 Page 8 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress62 K.i.P -i.de Dz-ive en e2v.e e, Owner:lean Ventu zozo Date of Inspection: 7017103 TIGHT or HOLDING TANKt&Le,(tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: XA Material of construction: concrete metal_ZY fiberglass&2/lpolyethylene 4other(explain): Dimensions: Capacity: i(J gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: —A1 Alarm in working order(yes or no): ./J/� Date of last pumping: Comments (condition of alarm and float switches, etc.): 7i.glzt o2 0 any an .6 a2e no /)2eaen 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.): D-izt2 igut.ion ox tz no n PUMP CHAMBER!NJP-(locate on site plan) Pumps in working order(yes or no): A/r0 Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 221im0 rham0. on ;A nOt nae�sent 8 Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �• SYSTEM INFORMATION(continued) Property Address: 6 2 K.i.2. -6..de DIt iue . Owner: dean Uen.tulto,so Date of Inspection: 10/1/0 3 SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan,excavation not required) 1- 1000 ga Edon /22eca.6.t teaching /2...t. If SAS not located explain why: /nrntvr/: SPP_ Page 10 Type leaching pits, number: leaching chambers, number: 6 &0 leaching galleries,number: d leaching trenches,number, length: D leaching fields,number,dimensions:a 0 overflow cesspool, number: O d innovative/alternative system Type/name of technology: C2i Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamil wand to medium dine nand. No .6ign..6 o/ hydzauece Zai-Pulze 02 lJOnCLGnG. OL G ate day. veyetuttutz tz izv-"MU: . CESSPOOLS(&/e-(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: Materials of construction: dA Indication of groundwater inflow(yes or no): - Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Same a.6 a ove PRIVY/ (locate on site plan) Materials of construction: Dimensions: .,l//J Depth of solids: A%1 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 'gal g !A nn.7` Alze.6erzt, 9 Page 10 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 H.itgzide Dlz�ive en T e/Fv- e mma.3.6 Owner:aean Vet UltO.60 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 5,0 71 I �o O 10 Page I 1 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 li i.2Pz.ide Dlt iue Cente2v.i-e e, ma,6,3. Owner: lean Ven.tuzozo Date of Inspection: 10/1103 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 616'/feet Please indicate (check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record - if checked,date of design'plan reviewed: NA NSObserved site (abutting properry/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: NA UF.SChecked with local excavators, installers-(attach documentation) (NE_SAccessed USGSdatabase-explain:httR:Ili-own. &a�cn,3ta&-fie, ma. u.a. You must describe how you established the higgh ground water elevation: LL�ecL: G¢h2ety 9 t7.ii.Pe2 flodee. 12/16/94 gAound wate2 e.Pevation,3 move Sea ievei. U6ed: u�.aS ' 0f—iP,, ) czi nn waii daita. Zune 1992 U-6ed: LL-')�.S: 7vrhnirnP Pi-O P-i n 9 —000 1 P #2 Annuai zange,3 o,,' g2oand mrjfo17—oPounfinnA I up at urouna Leaching Pit 'eet Groundwater: t=eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bosom „ r Of the leaching pit and the adjusted groundwater table is feet. 11 TOWN U? j1pli-agie t�()A!N) OF HLAL"I'll WAUF DISP)SAL nYSTEM INSUCTION ( OHM - PART D vERTIFICA71ab -TYPE OR PRINT MAW- OPE' STREET ADDRESS 62 jilizide Daive Centeaville, Mazn. ASSESSORS MAP , SLOW A40 WHO 4 ZeEzn Ven.tuaozo ......... ---------- 'Val' V N A h E 01 1 A 0 P i-.'. i J .......................1.11 ... ......... CONPONY N A H CONPANY KDRESS 0 2 6 3 2 ------- CCHPANY TELEPHUE 508 195 3 3 38, FAX 50B 790 -157i Sye Puts0nullY inspected the sewage disp,,j, his nddress nnd that the informaticn 1'Cp0Vt,j 1, I D� l OmPlote ry of He 00 Of � iWPOUNn The inspQcLion vaq POH&PTCd "com"n'..::. . i „ I;. "Y" ing 09 We , malM LeMuncu , and rOPRI V are consi start wi Oh mY training and experience in the PvopQr function and m& nt0nn,,, y site setage disposal bystems , Check One ; System, PASSI'�J) We inspection whiah I have c0njuckd nuL fuund any which indicaos that tho system fail; to adequately prote, t WIN ov Lho environmepL ap defined in 110 CHR 0 =3 , Any fajjup._, Oniterin nK evninvtod Apo aq 9 ( , t ,d in the FAILUK CSITERIn Ohio Coro , SYstes FAILED e WsPa& jon which 1 hove cvn Wkj hn; found that PWrOWCL the [ublic Wal Uh and Lhe he SY00M Ni ! 4 15 , 303 , e n v i rOwment in nccurdance wich Tjtj ,., and a s SWificallY noted on PART C FAILURE ORITERJA of this inEpection form , of this CK ILI f Wtion must ba Prov idud to thu OwNER UPP"Cublu ) nnd DOARD OV HEALTH , 1 cc tic n F A I LED a D r uC thO unIclu PUCK r� No...!_. FEB.... .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratinu for Diripngal Markii Towitrur#inn ramit Application is hereby made for a Permit to Comstruct ( ) or Repair (� an Individual Sewage Disposal System at: j n nt ... ........ .42...._.....Cr4 4l ------ e4 ac£ 6.i- .---•- Location-Address or Lot No. ........ :.V�C,b.......`� �✓��.................................................... ..................................................... .....•................................... Ocncr Address Installer Address UType of Building Size Lot............................Sq. feet .. Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons----------------------.----- Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------------------------- ----•----•••......----------••---••••. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- -Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No----------------_-- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by---------- ............................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----_.................. a -----------------------------------------------------------------------••------------------------------------ •.......... .-------------- "--------------------- O Description of Soil........................................................................................................................................................................ x U w x •--••••••.............•-----....-------•---------••------•-•-------.........-------••-•-.....-•----•-----------•----------------------•-----•------•--------•••--•---------••--- U Nature of Repairs or Alterations—Answer when applicable......6Ql)_____.�___� _..__�_Cto -•----•---•-------.-•- 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. gnedi _........ .. -------------------------------------------------- -------- -ace �-vv---=------ .......................................................................................... ..........APPlication Approved By ...... re Application Disapproved for the following reasons: . ....... ............ ..... .. .. .. ..................... ..------........ ......... .................................................. . . ...................... . ........................................................----............ -- ............................... Dace PermitNo. ............................................ ..................... Issued .................................................................... Dare •"""'4s'�S�a�-:�,..._... -�. _c...• .i. ..,. -.� :-,_... ..,M .. ,, ,...r . .,. -.._-�. ._.k a••.,. .....-itr�.r••_.....a,.,. _.,......ar.".__...�.,.. �..3. No .7...... .4 Fas.. l....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripooal Work,5 Tonotrnrtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair (� an Individual Sewage Disposal System at: •. •-------------------------- Location-Address or Lot No. f r . ....--- 4--�........ 4F-=---------------------------•----------......._, --•�-•-•--•---•-•-•=------.................................................................... o.sner Address Iustaller Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.- ..............7::__-__----_._----_.._.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ----------------'-........ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 --••--•---••----------------------------------------------------------•-••------•------......------..........................................................O Description of Soil..............................................----...................................................................................................................... x w x ----------•••---------------•---•--------•••--------------------------------•--•...---------••••-••---------------------•------------------••-•-•------------•--••-----.............--•--------------•-- U Nature of Repairs or Alterations—Answer when applicable......i A_19_0............. e!�.�...... 4!f.!j�ka'j..................... 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. igned ........ .. ............................................... .................................:...... bate Application Approved By --- ----- ........ s/ .Y....... Application Disapproved for the following reasons: ...... ..................... .. ..... . ... . . .............................. ........................ ....................... ..... .......................................... .... ............... . . . ................... ...... ...... --.............................. ........................................ Dare Permit No. ------------ ....-............... .. Issued Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE l V1 Eztifirate of Qlaraptianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�) by .........N<X. .. .............ea S .....-------------------------------------------- Insrdlcr at .. /..7....... .K .<S/!k: ........... ../. ............. ---. -------`----------------------------------------------------- --------....---------------------....._------- 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. .Y....y. -_........__._ dated ,... tl ..... ..................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ....._........................°�........Q.._ r. s....-- ---------... --- Inspector .... ..........�� .. � 1 lI J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C�Y TOWN OF BARNSTABLE UW;insal Workii Tonotrurtion f rrmit Permission is hereby granted.....0-------GiO��g651z:-_-e.l.! ..... e'-e*Al. ............................. to Construct ( ) or Repair ((,b) an Individual Sewn J Disposal System atNo.----...0.......G,Q C n1.vL f ----Q-t�C----------....Lw .................... ---------------•------------------- Street as shown on the application for Disposal Works Construction Permit No�_'/___y� Dated 57j'�....................... ..............................DATE G1 Board of Health J_..---/-- /---•------------------------------------ FORM 36508 HOBBS✓sr WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION SEWAGE # l Ys VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME G PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Z,ec;j-'- (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER—/VW'z/ BUILDER OR OWNERZ,t� 'DATE PERMIT ISSUED: 3r o DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ieo vF rJS� 3� ,�q Al �/