HomeMy WebLinkAbout0194 JAMES OTIS ROAD - Health 194 JAMES OTIS ROAD, CENTERVILLE
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UPC 12543
No.53LOR
HASTINGS.MN
DATE: .12/7/98
PROPERTY ADDRESS: 1.94 .dames Otis Roaad
Center•ville ,Mass .
r
02632
1 t7
On the above date, I insp-ected the s-eptic system at:/the abo�v�e add?ee� .
This system consists of the following: ` ` RECEIVED
1 . 1-1000 gallon septic tank .
2 . 1—Distribution box . �Y DEC 9 1998
3 . 1-1000 gallon precast leaching pit .
TOWN OF BARNSTABLE
\ HEALTH DEPT
Based bn my Inecactlon, I certify the following condl;tions:
4 . This is a title five septic system. ( ''9` 6o'de ) `-f-A-Al
5 . The septic system is in proper working order
at the' present time .
6 . Pumped tank at time of inspection .
7 . Waste water is 59" below the invert pipe of
the leaching pit .
SIGNATUR":
Name . J P. Ka comber Jr...
----- -------
PY� J'
'
Company: . P.Macomber. & � on"Ync ,
-------------- ---- .
__Cent_ervijjt Lapj_; Q2632
Phone: _50g�
..5--�338------- --
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEP.H P, MACOMBER '& SON; INC.
Tanks-C•s.spools-Leachfleld&
. Pump+d 1: Instilled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632.0066
77.5-3338 7764412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 194 James Otis Road Name of owner Theresa P a t r a u s k a s
Centerville ,Mass . AddressofOwnar: 194 James itis Road
Data of inspection: 12/7/98 Centerville ,Mass . 02632
Name of Inspector:(Please Print) Joseph P-Mac u m b e r Jr .
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: J. P.Macomber & Son Inc .
MaNNAddress: Rex 66 CEntervillP ,MaGG _ n2632
Telephone Number: 5 O R 7 7=9 g
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
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails s ,� y f�
Inspectors Signature: A � `r Date:
The System Inspect all 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 owner
shall submit the report to the appropriate regional office of the Department otrEnvironmentM Protection. The original should'ba sent 1ovw
system owner and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Pagel of11
OJ Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSA4 SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Prop-tyAddire": 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Date of Inspection: 12/7/9 8
INSPECTION SUMMARY: Check A, B, C, " A
A. SYSTEM PASSES:
—$1a 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
VOne 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 NO). 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.
.f� 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 pumpirtg-more than four-times a yeardue to broken or obstructed pipe(s). The eystem will-paws--
inspection if(with approval of the Board of Health): - --
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Date of Inspection: 1 2/7/9 8
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
A)b 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 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.WILL.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENt80NMENT:
gg Cesspool or privy is within 50 feet-of surface water
4 Cesspool or privy is within 60 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 AND SAFETY AND THE ENVIRONMENT:
Alp 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 I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 60 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 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. Method used to determine distance A14 (approximation not valid).
3) OTHER
dC A
N
A
revised 9/2/98 Page 3of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddress: 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Dace of Inspection: 12/7/9 8
D. SYSTEM FAILS:
00 You st Indicate either"Yes" or"No" to each of the following:
1 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 fecilityror-ey*tem component due to an overloaded orclegged SAS-or•cesspool.
Al 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 IIn"the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
L!Liquid depth in Is less than 6" below invert or available volume is less than 1l2 day flow.
_ 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 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 organio.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:
4)6 The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No,
40
the system is within 400 feet of a surface drinking water supply
nag the system 4-within 200 feet-01-6 tributaryAOasurfaoa•drk*iag awter•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 regional
office of the Department for further information.
revised 9/2/98 Page 4of11
1
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-J 7
SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Date of Inspection: 1 2/7/9
Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following:
Yes N
/ Pumping information was provided by the owner,occupant, or Board of Health.
Y. None of the system ocornpoaants kamal)-men pop4pad4opacJeast two-4voWw aadtbe-rystem hasbaeaquceiwwgewsw W 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.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,eluding the Soil Absorption System, have been located on the site.
_ 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 orrthe 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)
115.302(3)lb))
_ The facility owner.(and.oc`pa=s.if differaat froaummer),ware4mauidad wish InfntmatioriDn rh,_ppar mnin�n,_,a Qf
SubSurface Disposal Systems.
i
I
I' revised 9/2/98 Page 5of11
1
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c..• J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Data of Inspection: 12/7/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: : P g.p.d./bedro m.
Number of bedrooms( esign): Number of bedrooms(actual):
Total DESIGN flow $7
Number of current residents:
Garbage grinder(yes or no):_,o
Laundry(separate system) l es or no):liD; If yes,separats Impaction.required
Laundry system inspected ( s�or not
Seasonal use(yes or no): O — �l �► Q/�
Water meter readings,if available(last two year's usage(gpd): Y 6l✓�Ff
Sump Pump(yes or no):
� VSF4
^Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment: A�J�
Design flow: AIA qpd ( Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)�J,
Non-sanitary waste discharged to the � 5 system:(yes or no)"
Water meter readings,if av�a le:
Last date of occupancy:
OTHER:(Describe) �Q
Last date of occupancy:
GENERAL INFORMATION
PUMPING R 9 and ource infor t�g� a TJ
a1, ,•� 1 . . .V ewC,
System pumped as part of inspection:(yes or no) I,
If yes, volume pumped: A0 gallons �
Reason for pumping: SL'1','04 ZI
TYPE OF YSTEM
Septic tank/distribution box/soil absorption system
Alb Single cesspool
Ab Overflow cesspool
_4e*(Z 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 Nol—k -Copy of DEP Approval
Other 4JI4 }
APPROXIMATE AGE of all components, date installediif known)-and source of4nformation:._
Sewage odors detected when arriving at the site:(yes or no)
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Data of lns don: 12/7/9 8
BUILDING SEWER:
(Locate on site plan)
0
Depth below grader
Material of construction:_cast iron/0 PVC_other(explain)
Distance fromprivate water supply well or suction line
Diameter
C nients:(condition of joints, venting,evidence of leakage,-etc.)
joints appear ti ht •No Evidenre
through
SEPTIC TANK:A"P00605
(locate on site plan)
U
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is(note],list age d&4 Js.age-confirmed by Certificate of Compliance (Yes/No)
t/
Dimensions: r ?lJt'L0(/"L!/V
Sludge depth:
Distance from top of Judge to bottom of outlet tee orbaffie:
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to b tt9Q1 of outlet ee or baffler
How dimensions were determined:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structuraHntegrity,
evidence of leakage,etc.) 'rPUMD septic tank Pvpr3A?_1Tearsg Iplet; a-61jti-"`
tees are in 1 n r p ; The—S-eT t-j-6 t•a•R-jE—j-s—s Ttr
satind and
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of constructionAAconcrete gmetaL4I Fiberglass t/APolyethylene4Ather(exp]ain)
Ala
Dimensions: .414
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of a um 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.)
Grease trap is not grpaPnt
revised 9/2/98 Page 7of11
i r
SUBSURFACE SEWAGE DISPOSAL rSYSTEM WSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Daft of 1nspectioo: 12/7/9 8
TIGHT OR HOLDING TANK:AI&IDTank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:✓
Material of construction:Aconcrete,gmetal, `�Fiberglass45IPolyethylene400ther(explain)
AIA
AJA
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In working order:Yeses Nw►!.4
Date of previous pumping: AA
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
light or holding tanks are not present .
DISTRIBUTION BOX:_/
(locate on site plan)
Depth of liquid level above outlet Invert:
Comments:
(note-it level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) —
Distribution box has one lateral ;No Pyir)PnrP of gnliric Cnrry
over ; No PyidpnrP of 1p2kave into nr Gut of the box
PUMP CHAMBER:A6M
(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.)
ump chamber is not present .
revised 9/2/98 Page 8oru
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Date of Inspection: 12/7/9 8
SOIL ABSORPTION SYSTEM(SAS)_"94Jj0W /f r*IA4 .
(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: In
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.)
Loamy sand to medium coarse sand - No signs of hydrnulir fnil „ra
nr pnnrii no Nn e�yi dence of damp ,j l-�jetati on i s normal
CESSPOOLS: Q
(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:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
0
Cesspools are not present
Comments:
(note condition of soil, signs of hydraulic failure,.level of pending,condition of,vegetation, etc.)
Cesspools are not present -
PRIVY:,6&vZ
(locate on site plan)
Materjals of construction: 107 Dimensions:
Depth of solider
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
rivy is not present .
revised 9/2/98 Page 9of11
• �f;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress: 194 James Otis Road, Centerville ,Mass .
O` nw: Theresa Patrauskas
Data of Inspection: 1 2/7/9
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)
� � y
A 13
4q �5
S 5 a 9y -TA me-f o Ce t, '//e
revised 9/2/98 Page 10 of11
-1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddreu:194 James Otis Road Centerville ,Mass .
Owner: Theresa Patrauskas
Date of Inspection: 21/7/9 8
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope FLat
Surface water NONE
Check Cellar D R Y
Shallow wells NONE
Estimated Depth to Groundwater 3 5 keet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
�Observed.Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Zhecked pumping records
—/Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used Water Contours Map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
_36
a•w.mr+ —n.rrT—..w�ww•naw..a"..a a�n+v.wnn.+r.w►rn.�aRw.+aa�ti An.'ar��l inn .rw-'ram--.�....-'..t..r'�
TOWN OF Barnstable WARD OF HEAI,TII
SUD`. ti-.�.,-..•.,.a--•„R_'� UIlFACF SEWAGE^t)I f'03Ah�SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
-TYPI OR PRINT CLCARLY-
PROPERTY INSPECTED
STREET ADDRESS 194 James Otis Road Centerville ,Mass
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Therse Parrauskas
v�
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J . P.Macomber & Scrfi' Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 1 775 - 3338 FAX ( 508 ) 790- 1578
w
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported �s,,tr0e , accurate , and
complete as of the time of .inspection . The inspection was performed and any
recoinmendatlons 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 ;
zystem PASSED
The inspection which 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 form.
System FAILED*
The inspection which I have con ted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( Where applicable ) and the BOARD OF HEAL1111.
* If the inspection FAILED, .We owner or""operator ehall upgrade ' the eyatem
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 3,10 CMR 16 . 306 ,
partd .doc
', Ali
It
T
i
No _..._.�._..�f FicE ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEALTH
...............OF.... .. .... .. .... .......
.................................
Appliratiou for Di-spwial Workii Tomitrurtiutt rrntit
Application is hereby made for a Permit to Construct (L-T"or Repair ( ) an Individual Sewage Disposal
syst - .._. - ------------------• --------•---------------.........-----_...
Add s or Lat
Lo .................0...._ ......... •--- ------------------------------------
- Owner Address
a ... . .......... �-------------------------- ---------- .- �- �..--------..........................................
Installer Address
d Type of Building Size Lot..�,.�.�_LT4'?b_.Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( *J 0 Garbage Grinder ( fib
`4 Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other res ._
w Design Flow..... _. gallons per person per day. Total daily flow------------ ...............gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.....-........_----- Depth to ground water____-_---__-__-_---__._.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_.................
---•------------------------------------------------------•----•---•-----------••-•------------•............................................................
0 Description of Soil............................................•..........................................................................................=................................
x
U
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of
p of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a C tifica of Complianc `has been 'iseve0by the r of hea
Sined ................. ...........
Date
Application Approved By••--•-c-- (: �......... ............................................................ ---•-• -• ..........
Da e
Application Disapproved for the following reasons:..............................•----------------------------------------------------............................
...--------••----•-----------------------------------------------------------------•------....--•••--•-•--•-••---•-•-•--••-----••-•----••••---•---•-------••-----•----------------••-•••-•-----
Date
Permit No.......< -tome_--- Issued_.......................................................
Date
g
N ��, -CrFEE .
THE COMMONWEALTH OF MASSACHUSETTS a
BOARD PF HEAI TH
?.................0F..,4g�' :d:
AVV iration for DigpooFal Warkii Tonitrnrtion "antic
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System-af:-) 2
6k
------.... ------------- -•---------------
iA" e,'R�,d^` I�oEat*ian Add4`e s �, f or L°ot 10..... - ------------------•
W " Owrer� / Address
a ................... ^': ' ------=`T=•--1 '5�_::a...............................
.. ......--•-
Installer Address
� Type of Building "` Size Lott /._r ..
_._ q. feet
Dwelling—No. of Bedrooms___..._:"..................................Expansion Attic (Xy cl Garbage Grinder
aOthe Other—Type of Building ............................ No. of persons.....__..............____.__ Showers ( ) — Cafeteria fixtures
W Design Flow.... __..._.° . :.._.gahons per person per day. Total daily flow........ . ..................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width------.......... Diameter---------------- Depth................
x Disposal Trench—.\?o. .................... 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........................................
1
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water___..._______-_---_--.--
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth,to ground water____--_____-____-...
0 9 ----•----•-•-----------•-••--•••-•••••.......--•••••••••..................•-•-......-•-'-•---.......---•'--••••--'••••••'-•-•••-••••--•-. -------------
Description of Soil--------°-------••---•-----------------------•---------•--•-------•----....--••--------•---------------------------•------------------------------- ------------
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U ---••------------------•--•----••••••••...-••••••-•-•--•-•-•---••-••••••••--•••-•-••-•-.......---••••--...-••••--••••-•--•-••-•-•------ ------•------
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U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
. --•-•--•-----•-•••-•-.....-•--••--•'•-...••••••................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
TT m,F"?
the provisions of 1 ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a iii of Compiian e has been,issued by theA-6ar� of healtk.
Signed----•--- -•-----••-----• ----• •-----....
DatjApplication Approved j� "" 1�� . ..
Date
Application Disapproved for the following reasons:-----•-------------------------••---......-------------°----------------.......................................
.....---••-•--•-•••...................•-••••-••••-•-••---••••-••••-•----•--•-•--•-•---•-...-••-----•••-••-•-........••••••-•••••-•-•------------•-•-•••-------••--••----------••------.................
_ . __.
Permit No. ...---- Date
Issued....-'•---•--•-------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
Cwrrfif irate of TontpliFanrr
T,Hi,S ISJO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
byF_... e=`. �� ------..... _"�---•--•-••--•--•------°---•-------•-•------'-----------------'-•----------'--•-•-----...--'--•-----•--•---•---•---'-------
Installer , fe-
at
��- ` r` .m.-< .,,...-`_,1C �►----------------'
has been installed in accordance with the,provisions of T!%1 j of The State Sanitary Code as d scribed in the
application for Disposal Forks Construction Permit No..__ ._�._._._ .. dated- ----•__-_______•-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT HE
SYSTEM WILL FUN ON SATISFACTORY.
DATE........................... ��S1'_ -.. ............ Inspector.................. '......5D.................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..1! OF.. '. . �:�--�......................................... —---�
FEE....._.-........................
Uiopoq�Fal orkii T.ono#rnr#ion "permit
Permission is hereby granted t ��:b_�._._........._.._..'.`�J�:-----•--•----------------•-•-•---------------•--....-------•.....................
to Construct or Repair ( ) an Individual Sewga e Disposal System
at No.-------- ...... .....------Cam-.... -'-............
street /
as shown on the application for Disposal Works Construction_.Permit IV �T�S }. ) �ate`d ' 1. _l'
��,.,�-�--•••---- _� ' c � A Board of Health
FOR 1255 HOBBS & WARREN. INC.. PUBLISHERS
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19 TOWN OF BARNSTABLE
LOCA1"�OI�d ( /� �,t�CIE s ��/� � � SEWAGE
VILLAGE Ce�efr-d0 ASSESSOR'S MAP 6 L0VV/d
ts.INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
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,,LEACHING FACILITY:(type) (size)
�4 0. OF BEDROOMS PRIVATE WELL OR PUBLIC WATT
BUILDER OR OWNER /VA AJ %✓�j4 J/
DATE PERMIT ISSUED: 17 = �
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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