HomeMy WebLinkAbout0130 HOLLY POINT ROAD - Health 13 , Holly Point Road
Centerville P
A = 288 068
I
U>C 12543
No. 53LOR
NASTINGS MN
:_CuXII U SEWAGE #
`,-;!-LAGE Tr
ASSESSOR'S KUP.& LOT-
INSTALLER'S NANE&PHONE NO.
TANK CAPACITY "-.
LEACPJNG FACMITY: (type) 3-x,,svvm\ftNbcs (size)
NO. OF BEDROOMS.
BLTLDER OR OWNER v-,C,\(L tk,\S,
COWTILLMNCE DATE:
Separation Distance Belwc,-,,i the:
NI'laximum Adjusted Groundwater Table _8!i m?41 kr et e!4 F.-,-,
lliivati Water Suppiy Weli and Lcactiing Facility (If any wells exist
or site or within 200 fee,of leacung facihry) Feet_
'Edge of Wed ind and Leaching Facility (If arty wetlands mist
witHir 300 fee,of lcac,drg facdiry) F,-
MII—Illshtd by. D&b-gr
Z
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o
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2 3� a
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s , 63 �17
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i k2) q �}--
DATE : 6/Z9/03
PROPERTY ADDRESS: 130 llo.P.Pypo.int Road
-----------------------
---CenZeav1.9Pe, /Va.a.s.------
0z63�
On the above date, I inspected the septic system at the above address.
Tn.is system conslsts of the following:
1. 1000 gai.Pon 3e/at is tank
Z. 1-Dizt2.iPat.ion &ox.
3. 3-.in/.iiP -aato/tz .in ze/t.iez.
Based on my inspection, 1 ,certify the following conditions:
4. 7h.iz .iz a t.itie live zept.ic zy.stem. (78 Code)
5. 7he zept.ic .6y,3tem .iz .i.n pAopea woak.ing o2de)z at the
/Ae'6ent time.
6. Syztem wa,3 .inzta.P.Ped 815194
SIGNATUR �2;;04 ---' ---
Name : _ J__ P__Macomber-Jr __--_
�7
Corripany : . q4 tph .P._ Ms r4mt tC 8- Son, Inc . L-TOWN
z------------ 2003-_CeJU2rYLLLe.-Na--Q.U32-0066NS�ABLEEPT.
�none : 508- 775_ 3338 -----
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SONJINC.
Tanks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P.0 Box 66 Centerville. MA 0263
775.3338 775.6412
I
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
y
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 130 Ho22y Po-.nt /?oad
Centeay.iiie, fla-3a.
Owner's Name: Nichae—P Pu,3ate2i
Owner's Address: 1350 /3n»onpy /?nnrl
.Siiifo 115 1/;_.in.ia 22101
Date of Inspection: CAL 2010.3
Name of Inspector: (please print) to-6eRh %. Placomge2 a2.
Company Name:,, %. Nacougal? R Son Inc,
Mailing Add ress./3ox 66
ranfo QP,2 T- AA 02632
Telephone Number: 5 08-77 5-3 3 38
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:
Z�Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: I DatAj—;V e
The system inspector shall mit-a-copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFIC
IAL INSPECTIO
N FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 130 floUy Po.irzt Road
Owner.J7.ichae P�zn,ezu
Date of Inspection: 6128103
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D �1
Syste Passe • t
_!CL 1 have not found any information which Indicates that any of the failure.crit�tr))'a described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are indicateeLbclow. J
Comments: / 11
The 6ept.ic z ztem i,6 .in /22o/2ea wo/zkiny oadea
at the pazzgnt time.
i:.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
,0 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A.'metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
.�O 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 pipc(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
h0 The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 130 ffo—Uy Point Road
Centeay.iiie, Nazz.
Owner: Michaei %u satea.i
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
V10 Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,.safery 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:
.(Z Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
-0 The system has,a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/!J� The system has a septic tank and SAS and the SAS is less than 100 feet bu 0 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: 130 Ko.2.2y Po.tn.t Road
Cent e2v t P Ee, Na.6.e.
Owner: l'l.ichae-e Puaa.te2-i
Date of Inspection: 61215103
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No /_ rr ackup 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
Az Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool 3,',v,•LT)�W r* SZ;j e, ,t4^y
_ 1--Required
� squid depth incseapoef is less than 6"below invert or available volume is less than IA day flow
pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped 6 .
_ _A1 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
Rater supply.
,V Any portion of a cesspool or privy is within a Zone 1 of a public well,
l/__ y 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.)
(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
_ 2 �tth,
the system is within 400 feet of a surface drinking water supply
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
Y g
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 130 Ho eiy Point Road
Centz/tviiiz, Nazz.
Owner:t�ic%ap—e P u.6atezi
Date of Inspection: 6129103
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?
Z/ Have large volumes of water been introduced to the system recently or as pan of this inspection ?
— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
d Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out ?
y _ Were all system components,10AW"luding the SAS, located on site
z— 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 ?
Z— Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b)J
5
- I
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 130 Ko.f.2y Point Road
en e2U.e e, Naz.6.
Owner: Michae.P l uzate2i
Date of Inspectlon: 6/ O3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):—L Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms): yla
Number of current residents: A
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system( es or no)� (if yes separate inspection required)
Laundry system inspected(yes or no):2
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):2001=29, 000 ga.P 20 n.=7 9. 4 6 glo D
Sump pump(yes or no): 2002,3 ga.P.Pon.6=106. 8 5 gPD
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design now(seats/persons/sgft,etc.):
Grease trap present(yes or no):d¢
Industrial waste holding tank present(yes or no)✓Ili¢
Non-sanitary waste discharged to the Title 5.system(yes or no):
Water meter readings, if available:
Last date of occupancy/use: ,U
OTHER(describe): �✓�
GENERAL INFORMATION
Pumping Records
Source of information: eWe-
Was system pumped as pan of the inspection(yes or no):
If ycs, volume pumped:_gallons-- How was quantity pumped determined? .p,1►¢
Reason for pumping:
TYPi£ OF SYSTEM
Septic tank, distribution box,soil absorption system
.J&Single cesspool
,,(,Id 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 syste 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:
f�— am�:,o a cl¢ 815194
Were sewage odors detected when arriving at the site(yes or no): NO
6
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 11o.P.Pu Po in.t Road
Cente2v.i2.Pe. Na,3,3.
Owner: t3ichae-P Puzateai
Date of Inspection: (t/,?&/0 3
BUILDING SEWER(locate on site plan)
Depth below grade: l
Materials of construction: 4-Cast iron 40 PVCr!!fO other(explain): V4
Distance from private water supply well or suction line: W y`
Comments(on condition of joints,venting,evidence of leakage,etc.):
co-i n t.6 a 12.12 e a/z I ghI No P-" 'dv �p{�� .Pei k aav Tho AU s p n2 1 1 vented
th2ough the houze vents.
SEPTIC TANK: ✓(locate on site plan)
�!
Depth below grade:
Material of construction: ✓concrete�metal.Ud fiberglass polyethylene
,,lPother(explain) 4—
If tank is metal list age:_V-107 is age confirmed by a Certificate of Compliance(yes or no); (attach a copy of
certificate)
Dimensions: 6,1�.r,� av
Sludge depth:1!!k G
Distance from top.2f sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from to of scum to to of outlet tee or baffle:
P P -kC
Distance from bottom of scum to bottom of outlet tee pr baffle:
How were dimensions determined: zeel4. /l
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumrz the 3eat-ic tank evezu 2-3 Uea2.6 In Pet & QutPzt tees, ane
.in /2iace.-Zhe ta.rzk i,6 6taucLaaaLeuzound and .shows no Avidenag
o� Peakage.
GREASE TRAP(k!K(locate on site plan)
Depth below grade:G9
Material of construction,&—coneretef/�metaW fiberglass4_polyethylene+Alother
(explain):
Dimensions:
Scum thickness: I-e114
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
g2ea.se t1ta/2 .i•s not /a.ceeent.
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 flo22y /)o int /toad
en eay.e e, aye.
Owner: 12-c nv_ P /Ii
Date of Inspection: j/2&j n 3
TIGHT or HOLDING TANWeL(tank must be pumped at time of inspection)(locate on site plan)
Depth below grader
Material of constructio��concrete metal J/ fiberglass�olyethyleneA*� other(explain):
Dimensions:
Capacity: AIA gallons
Design Flow: A111 allons/day
Alarm present(yes or no):
Alarm level:_A44 Alarm in working order(yes or no):AIA
Date of last pumping: 46,
Comments(condition of alarm and float switches,etc.):
7.igh.t olt hoid.ing .taake a/te no.f fl2ezen.t
DISTRIBUTION BOX: t� (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: .eJ-h
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.i,6bt.igut.ion Sox ha.6 one .Pa.teltai, No evidence o� eoiid-6 ca22y
oven. No evidence o ea age .cn o 02 out- o e Xox
PUMP CHAMBEPVkC, (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 and appurtenances, etc.):
Puma ehamgen iz no pAe.3ent.
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:130 flotey /olnt 12oad
en e/tv.ii.Pe, 0a•6.6.
Owner: N-ichae.2 Pu.6ate2.i
Date of Inspection: 6/2010 3
SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required)
3— in�i2taato2.s .in .se2.iez.
If SAS not located explain why:
Located; See /Oaoe 10
Type
Vo leaching pits, number:_A� _
ieaching chambers,number: i — AW7P-0rA"5►
;1�0 leaching galleries,number:
VO leaching trenches,number, length: G�
leaching fields, number,dimensions:
a overflow cesspool, number:
4.6 innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamu sand to medium 4ine •sand. No .6.icln.6 o-1 hUd2aui-ic la.iiu/ze
_nQ T nn ing- .CnJLA rino riny_ Vonoini nn !A nnmmnh
CESSPOOLS —(cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: -Z}
Depth—top of liquid to inlet invert: AA
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
I
Ce.S.SROO.Qb rz2e not /22e.sen1.
PRIVY.G&T.e(locate on site plan)
Materials of construction:
Dimensions: /lJ
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Loim_ i.t not nnoAonY_
I
9
f
Page 10 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address; 130 Hoi,044 Pn)n t Road
Cerzte2L�.p . l'In.s.s,
Owner; MichaeP Pa.6a.fea-i
Date of Inspection;
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system Including tics to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 Net. Locate where publie.Vter supply enters the building.
e
��. 10
voQ� o
LOCATION > � li l�'�2?I)�I `'<<, �e SEWAGE #--
VIL LAG ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY O n
LEACHING FACILITY:(type ►(s )
NO. OF BEDROOMS i PRIV E WELL OR PUBLIC WATER
BUILDER OR OWNER �� rt
DATE PERMIT ISSUED: / ,' cc L/
DATE COMPLIANCE ISSUED: .=s 1 y
VARIANCE GRANTED:. Yes No
0 /do fF f
1 �
�53
l
i
i
Page 11 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 130 lio-tetl P o.in.t Road
C'ente2v.i.2.2e- l7abb.
Owoer:N-ichae.e Pubat ea i
Date of Inspection: _612MI03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water jt feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed: 6120103
US Observed site(abutting property/observation hole within 150 feet of SAS)
qgL&Checked with local Board of Hcalth-explain:09ta.ined ab gu.i-et ca/td.
qf—, Checked with local excavators, installers-(attach documentation)
qZ,�Accessed USGS database-explain:,htt12:Ili-own. &aanbtag.t?e. ma. ub.
You must describe how you established the high ground water elevation:
Lbed: Gahzp-tu R NiUa.,z Node- 121V 94 (iaound wate2 e.Pevat.ionb agove bea .PeveP.
:bed: USq _0PA017?)aYinn woPl dr jo 9uno 199.
'bed: LLSG 01100-fin 97 nnn 9 pp,f„ #7 4nn// / 0 ?rina" o4 alzound
tvp o
3 in/iitaai-o2b
N ;cct
7
GroundwateA Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim ter P p Method
Therefore,the vertical separation distance between the bonom
of the leaching pit and the adjusted groundwater table is
feet.
11 ,
i y •r*�n ram.-n••rr-•rr 'n:am•nl�rrTR+w•►.rmm�7++Tws+rl�n.n r�v.wlu.rrw+�n TAFlom .TV-rrr-4*-tr•..-..�. .
1 TOWN OF Baanztcgie BOARD OF HEALTH
.9011SUNFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I,
` •r�-r•.-: .-r. ,-.-,-..n,n,,,-nnn,�R+es,..,.-rer,,.-s,r,n.nni a...r-r..n....w..1.....,�.. An. .,...-r,•-•,--�. _..A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 130 Koiiy Point Road Cente2v.i-eie, Na.6h. '
ASSESSORS MAP, BLOCK AND PARCEL 9288-068
OWNER' s NAME Nichaei P utate2•i
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber .Jr.
COMPANY NAME J P Macomber & SoR Ind'.*
COMPANY ADDRESS Box 66 Centerville Mass. 02632
Street Torn or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
Dr I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
ecoinmendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
S s e y t m PASSED
The inspection I+hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this for►n.
System FAILED*
The inspection which I hav\econ-dacted has found that the system fails to
Protect the jiublic health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
y
Inspector Signature
Date
ne copy of this a rt.ification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF HEALZ'll.
* If the inspection FAILED, the owner or•"operator shall u d
within one year of the date of the inspection, unless allowedorthe requiredm
o therwise as provided in 3.10 CMR 16 , 305 ,
purtd , doc
, --� CO\I.ION\\E.UTH OF MLaSS.aCHt;SETTS
EXECUTIVE OFFICE OF EN-VIRONMENTAL FA,I1
- 'C= DEPARTMENT OF ENVIRONMENTAL PROTEC
-- 01E R"I\TER STREET. BOSTO\ M_� 0210S (615) 292-$.50u
A PEC 2 TRUM CO?:
199
� 0" B<SF"_F
T
ARGEO PALL CELLtiCCI ti
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Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
W�,Q a
ii,2Q PART A
�(.�"` -!�i CERTIFICATION y
►�G1- " \-` ?��` i�p���t Name of Owner�Q�Zi\C� q�{�\
Property Address: \ _
c C� lb"W— lddress of Owner: '34NV N.
Date of Inspection:. IL
Nana of ktspector: (Please Pnrri Ch EL
I am a DEP approved system inspector pursuant to Section 15.I340 of True 5 (310 CMR 15.000)
Company Name: �r t EJiS^+ !^� r- ti,. r t.'f u F
Marring Address: rr1_/L., + L 3 24 E-/ E�n Fr N oL�i 4
Telephone Number: / SOS
I
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system.
Passes
'X 1-i
_ Conditionally Passes 4
_ Needs Further Evaluat' n the Local Approving Authority
_ Fails
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 thirty (30) days of
completing this Inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the Inspector and the system owne
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tttt
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98, 6geIof11
. C: p,jed on Reeyekd Paper
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (coatirwed)
'roperty Address:
Jwnef:
pate of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
xI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
—`T criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If 'not determined-. explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced -
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspection If (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 I Pserlofu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
i
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CM 115.303 (1)(b) THAT THE SYSTE►,
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water '
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt mar h.
1
J
i
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well.
_
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
_
private water supply well, unless a well water analysis for eoliform bacteria and volatile organic compounds indicates that awell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.- Method used to determine distanye (approximation not valid).
3) OTHER
I
revised 9/2/98 Ps;c3orill
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM F ILSr
following:
You must indicate ither "Yes" or "No" to each of the ollowing
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination,is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
\�
_ Discharge oi,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 cesspo I is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more\t\lon 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped�.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is\within 100 feet of a surface water supply or tributary to a surface water supply
_ Any portion of a cesspool or privy is within a Zone I of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less-than\100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
'coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10.000 gpd or greeter(Large System) and the system is a significant threat to pub
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system i!Lwithin 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 II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local region
office of the Department for further information.
revised 912 pit p4oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes
Pumping information was provided by the owner, occupant, or Board of Health.
— None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
— As built plans have been obtained and examined. Note if they are not available with N;A.
The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
x — The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
X _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
-+-\ or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
— Existing information. For example. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b))
x n- ac
The facility owner (and occupants, if different from owner) were provided with information on the proper aintenaa-0f
T\ SubSurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ��� g.p.d./bedroom
Number of bedrooms (design):_Cj Number of bedrooms lactuall:
Total DESIGN flow�C-j
Number of current residents: O
Garbage grinder(yes or no):—W
Laundry(separate system) 1 es or no): If yes, separate inspection required
Laundry system inspected (yes r no)
Seasonal use (yes or no):-L
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no):-L-±.a
Last date of occupancy:�Q.,YT
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)rl'
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: �� •�
Sewage odors detected when arriving at the site: (yes or no) U�
revised 9/2/98 P2ge6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
*roperty Address: (L\�'�k
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _cast iron_40 PVC — other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_ S
(locate on site pla I
tl
Depth below grade:
Material of construction: Lconcrete_metal_Fiberglass _Polyethylene—other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle:
M
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:_ 1 L]Ll
How dimensions were determined: Lt\
:omments:
(recommendation for pumping, condition ol inlet and outlet tees or baffles, depth of liquid level in relation to outlet i vert, str turel integrity.
c.)
v \AA 0%w
e dance(of leakage,et G s J
GREASE TRAP: V,
(locate on site plan)
Depth below grade:_
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,.
evidence of leakage, etc.)
revised 9/2/98 Page 7oftl '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
JJ ( wN 1
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: 62i (Tank must be pumped prior to, or 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/day
Alarm present
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches. etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: a t�t
Comments:
(note if level and distrib]uti n is equal, evidence of solids carryover, evidence ofie k ge into or out of box, etc.)
PUMP CHAMBER: V*,
(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 and appurtenances,etc.)
i
revised 9/2/98 r,ges°rII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
4operty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): S
(locate on site plan, if possible: excavation not required. location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number.
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology
Comments:
(note condition of soil, signs of hydraulic failure,_level of ponding, damp soil, condition of vegetation, etc.). l
�6 �. (` t .�^ \) f' i�i`. J' i — �r `•11/\\ i�a ( 1`1 i
CESSPOOLS:4�
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater.
Inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:O
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydrauric failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'Iroperty Address:
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
J
/may
l
L�
revised 9/2/98 P;Agc10ofII
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
i2��� l SYSTEM INFORMATION (continued)
roperty Address: 6•�
Owner:
Date of Inspection:
NRCS. Report name iA—z� - — ---
Soil Type_ — -- — --
Typical depth to groundwater____
USGS Date website visited 00
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope M
i
Surface water: s
Check Cellar N(A
Shallow wells pts'.
Estimated Depth to Groundwater {ko Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
hole basement sum etc.)
Observed Site Abuttiri property, observationP
Obse (Abutting P P Y
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 page it or it
v r
c. TOWN OF ,BBARNSTABLE 9q ,
3 y
LOCATION t�, ' 'SEWAGE #
VILLAGE��� LQ �-✓� I ��- ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY O y J o n• t
LEACHING FACILITY:(type) - z_!,,- sue)
NO. OF BEDROOMS PRIV E WELL OR PUBLIC WATER
BUILDER OR OWNER 6k S
DATE PERMIT ISSUED: f -1- 17 L-/
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r2
� y�0o0I 0
S
r c. TOWN OF BARNSTABLE
LOCATION 3
VILLAGE. �Q �-✓1 1�.e- ASSESSOR'S MAP LOT I-gg-66F
INSTALLIER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size). ��
NO. OF BEDROOMS ' PRIVAXE WELL OR PUBLIC WATER
BUILDER OR OWNER tJ ✓ o v,
DATE PERMIT ISSUED: /' 9.•7 - �(
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No (�
0 /°aof�l
_ 3Y
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
arnstable Conservation Department BOARD OF HEALTH '0 c�1
TnWN OF BARNSTABLEl
Signed Date
Appliration for Di►ipti ul Workli Tonstrnrttnn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (C�/an Individual Sewage Disposal
System at:
00
o l� _p®6wV� C•SG
+/A'^•,, L cpi�t .n Addre / or Lot No.
O- ....................................d
C.4 1.4 Installer Address
Type of Building Size Lot.................... .....Sq. feet
U
Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p,, Other—Type of Building ---------------------------- No. of persons-..--..--..-------..-------- Showers ( ) — Cafeteria ( )
Other fixtures ............................... . .
- ----------------
•------
W Design Flow. _... �-----------------------gallons per person r day. Total da'y flow..-ram.. 6_...............................gallons.
WSeptic Tank Liquid ca acityk -.gallons tLength -------- Width__5----------- Diameter---------------- Depth................
x Disposal Trench--No.q,_p.._.4- Width.... ............ Total Length.Qp'.5�C.-- Total leaching area....................sq. ft.
3 Seepage Pit No..............I....... 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........................
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ....
•---------------
---------------------
•---------
•.....
.-....
•.......
...•••-•••.................
••-•••••-•..............
...........
•---••---------------
•--
ODescription of Soil........................................................................................................................................................................
"4
U .-------------------•----...-----•--•--....--------------------..........-•-------------------------••------------------•-------•--•-•-•---•---...--•••---•-------------------------.......-----...•-_..
W -------•••-•----------------•------•---•--------------------------------------------------------------------- - ....... ......-------------------_.... ........
UNature of Re Alterations—Answer when applicable.- ----�Q O�
� .�T fl— -----..�- ----------- --------- ---------
�� 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 ' ued f healt
Signed ................. ....... -- --- . ...... . ------------- ......
Application Approved By ..:....... ...
Dare
Application Disapproved for the following reasons: ..................... ........... . . ......................................................................----
... ........... .. . .............................. ... . ....................................... ....... ........................................
Permit No. ........................................... Issued ...........................'.�..... `... ...
Date
i .............. /Fizim.A
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OE HEALTH w cry {
a""7-`MTOWN OF BARNSTABLE
Apphratiutt for Diripuutti lVnrk,5 Corm#rur#turi ramit
Application is hereby made for a Permit to Construct ( ) or. Repair ( L)an Individual Sewage Disposal
System at: 1
-------------------------- ------ -------------------------------•......................�/� Llocation-:\ddress / or Lot No.
......................i R t C Cam: __....��. ............ (.. ....._.._...
Oaa- cr Addres
= c� Add
Installer V Address
UType of Building Size Lot............................Sq. feet
F-I Dwelling— No. of Bedrooms.__�---------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures ...........................................................
Design Flow......_�`-_-..........................___....gallons per person per day. Total daily flow.. ............ ..............................gallons.
f� Septic Tank--Liquid capacity _.gallons Length-� -------- Width.157.___.... Diameter................ Depth................
Disposal Trench--NoLq,_7 f e_ ._. Width_.4�1...__.__.. Total Length_CD-.��C.... 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. 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........................................................................................................................................................................
W
c, ---••-•-•••--•-----••....-•-••--••-•-•-----.....••------•---•••--------•--••••-•-•-•••---•-------••-•---•-•-•••-•-•-••-•••--•-••--------•---•----••--•-••---••...................................•......
U Nature of ReCp,a/irs or Alteer�pattiio'ns—..yA�n�sw�er p/w`hie`n a appl`icabCle__—_- ��`�_K4....��}�J' �����-V�--?-�-�r �...: .........
..R ......_....tl:.w C_ ../-^.v. ........_.}.t...:,... ....x_ �!i_.3�.4.�_I_--VY�-"•.41I `�___1 J.----- --::..._.`..............................................................
Agreement: 7
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_boardof health.'
i ----- ......
Application App B ............. a . <-- "
�Z
Dace
Application Disapproved for the following reasons: .................... . ...... .. ..........................................................................................
.................................................... . ... . ................ .._............ . ...-
j Date
L
Permit No. --..........T.... .................................... Issued ................- .. .. .. 17�...
Daze
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Complianre
THIS IS TO CERTIFY,, That the Individual Sewage
//Disposal System constructed ( ) or Repaired ( -
yVV Ao
\( Installer n
at ................ .........._._ ..........._... ....I.� ..... ,(. -� -- ,.� / Yv`-.r. ....-...........-..
II, has been installed in accordance with the pro i i ns of TITLE of The State Environmental 9de as described in
the application for Disposal Works Construction Permit No. ...��-. ..... .- dated 6......�. � . P.Z
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT WE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,DATE..... ............._...�..:. .......... ........................... Inspector ----------------- ;.. :a..-.... -- ----.-----.---..........-......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.............. FEE.......................
�iu�usttl Turku �unu#r�r#iun �rrmi#
Permission is hereby granted........... 111 ------ _�1_.-C-. � f>,.__.
to Construct ( ) or Repair ( Ll an—Indlvldual Sewage Disposal System
at No----------------•----•------�:70....--...�_� :�-�._. -ht `!_. �/�- -r ``
Street� ��� �� r
as shown on the application for Disposal Works Construction Per Nol�_____.. ._ Dated........
v 1.Aff?.........................................
BZd_ of Health
DATE----- ` �� ...45 --1�- -.-.............................. �J
FORM 36508 HOBBS A WARREN.INC.,PUBLISHERS
i
No........... t 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
.................OF......... ................................_.-...........------..........................
Appliratimri -for Disposal Works Tote urtion Prrmiit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at: .
..........--•--- �c0 c t 1 .............................. ........... ----------
Locatiory�ddress o
a ...................................... ... a.. .......•....
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------9.............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _______________ No. of ersons........_._..__.__.____._-__ Showers — Cafeteria
t� YP g ------------- P ( ) ( )
L4 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 Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.-------/.......... Diameter...........£-.... Depth below inlet-------C........_. Total leaching area...._-..lj-/.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by------------- -----------------------------•-•--------•-----------•------- Date---------------------------------------
,a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-..-___________-__-_----
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-_______.._-_______- Depth to ground water------------------------
PA --------------------------------------------------------------------------------------------------------•---------•---------------------------------------..
ODescription of Soil-------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- --
x
W a
UNature of Rairs or ratio —Answer en ap cable.- --' � !�---------�----------------
--- --- r -
Agreement:
The undersigned agrees to install the aforedesc bed Individual Se ge Disposal ystem in accordance with
the provisions of Article XI of the State Sanitary e— The undersig f ther agree not to place the system in
operation until a Certificate of Compliance has bee issued by he bo ealth.
Date
Application Approved BY------ .....
--•.•••. •. --- ....... Date 7�
Application Disapproved for t12e f o owi g reasons_____________
•.................. ..........••.._......•--•-•--._.._..............-•----...Da......-•---•----
--------------------------------------------------------------------------------------------------------•--------------------------------------------------------- -------------------------------------
Date
PermitNo........................................................ Issued........................................................
Date
- — - -- ---------------------------------- '---
No.............t-_ _ � Fss..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.. . . -- ..........OF......../............................
Appliratioo -for II-gV ial Workii Tomitrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (,><) an kndi - u Sewage Disposal
System at-
Ce1i C
-------------------------------------------------- -- -------------------------•--------- ------•••---------------------•--------------. .................................................
Loc..... Ad-= A � �r Lot No.
.i/ C — / .
a ------------------ ----.._..............• ----------- ----------- .............................------------------------
Installer Address
UType of Building Size Lot____________________________Sq. feet
Dwelling—No. of Bedrooms.................. -------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building --_-_.--_________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures •---------
-----------------••--------------------------------------------------------------------------
. .
W Design Flow__________________-:s, ..............gallons per person per day. Total daily flow--_-__--_-.-e�__u
-------------------------
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width----------- ---- Diameter................ Depth_..............
x Disposal Trench—No----------- --------- Width____-___�-.__------Total Length.................... Total leachingarea_-.----__-._-J--sq. ft.
3 Seepage Pit No............(------- Diameter----------__________ Depth below inlet.._....___..._..__ Total leachin area.--_._...._._ ._..sr. ft.
�° 2�'
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.___-_-.----.---..-----
f3:4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.------_-__-__---___
9 ---------------------------------------------------------------------------------------------------•---------------------------------•---------•--------
ODescription of Soil-------------------------------------------------------------------------------------------- -------------------------------------------- -----------------------
x
W ----------------------------- -----------------------------------..............-...................
x ---------------------
Nature of Repairs
e sirs✓ itera ' ns—Answe hen ._ . _.. .
.._ � j/.--.-..
tt--- --- -------- ----•----•-••-•-------------•------------------•-------•---------------
Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Co —The undersign further agrees not to place the system in
operation until a Certificate of Compliance has bee Issued by thq boar(Vt f Kealth.
----------------------------
,5'9
y, �� / ate
Application Approved By---.... r% ---•- - -- - --------• --��............ ...:------------- -------U-- -- 7�
Date
Application Disapproved for the f ollo • g reasons:---•---•---•---•---------•-•--------------- -----------•----................_....----•-•----••-•------••---••--•
.......-----•-•-•............................................••-•------...-••••--•---•----••-•---------•..........--••-----••----.-•.-•--••-----•••-•----------------...--•--•--------......---------•---
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................oF...........j.. 1./J� .(.. '...................
v
/ � �rrtifir�te f�out�littnrr
TI /CE1' he Indio' ual w�a e a,` Glsal S-s structed 0) or aired ( )
y �,` `
staller�/. ^i/'
at......................---------------------------••-•--------------••--•-------------------------= -------- f �..4
as:._
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_________________________________________ dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CO U S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�
DATE. 4 ---------------------- Inspector
.
THE COMMONWEALTH O MASSACHUSETTS
G � 1 'J�OARD O6ACXrA '-I_
................. OF.. .....
........................................................
FEE........................ I
t
Per ". 4.
me
A
to Construct ( ) or Repair ( ) ndividual Sewage ispo.S. stem / �S^ 7G
tr -
at No.............................................................................................•.......... ..�- --- �' �f ------------- -----•--•--
� GI��G�
as shown op�hga�l atio�I fo posal Works Construction er it No____________________ ated. r
CC%% .............................................................. ........................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LOC'y T ION : 1 SE�W�6) �E�P ERMIT U O.
VILLAGE
�.�.
IWS-,TNLLER 5 h.I,&ME ADDRESS
= � W — - - —
BUILDER 5 Q A E e ADDRES
--!\IA"4 JcLYWZ
DATE PERWT ISSUED
DATE COMPLI &KICE
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