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HomeMy WebLinkAbout0219 JAMES OTIS ROAD - Health 219 JAMES OTIS ROAD, CENTERVILLE A= 170 208 Slll J� � UPC 12534 No.2 HASTINGS,MN R rr DEC 91 a 999 O FBTMAORENSTA9(E Cr► BORTOLOTTI CONSTRUCTION, INC. 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 °� G 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 0,16� Date Of Inspection Inspector's Name:. - Ov%ne�a e and dress: ME CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T system: Passes Conditionall saes Needs Fu Evalu n By the Local Approving Authority Failur Inspector's Signature Z Date: The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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 of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. INSPECTIUN SUMMARY: A) SYST Z PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,'N,OR ND). Describe bases of determination in all instances. if"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exftl- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming 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): - 1 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced file 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. C)FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Health in order to determine it' the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION Lr ; ING IN A MANNER THAT PROTECTS THE PUBLIC-HEALTH°AND SAFETY AND THE ENVIRONMENT: . The system has a Septic Tank and Soil Absorption System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply: The System has a Septic'tank and Soil Absorption System and is with a Zone 1 of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: l have determined that the System violates one or more of the following Failure Criteria as defined 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. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ' Static liquid,level in the distribution box above outlet invert due'to an overloaded or clog- ged SAS or cesspool. . Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day now. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM.-INSPECTION FORM PART A CERTIFICATION (continued) 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 1 of a Public Well. Any portion of a cesspool or privy is within.50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private . water supply well with no acceptable water quality analysis. 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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: The system is within 400 Feet of a surface drinking water supply _.•The system is within 200 Feet of a tributary to a surface drinking water supply . the system is located in a nitrogen sensitive area Interim Wellhead Protection Area, (1WPA)or a mapped.Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the fo owing have been done: Pumping information was requested of the owner,occupant,and Board of Health. I'None of the system components have been pumped for atleast 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. I'As-built plans have been obtained and examined. Note if they are not available with N/A. _VThe facility or dwelling was inspected for signs of sewage back-up. I/The system does not receive non=sanitary or industrial waste flow. The site was inspected for signs of breakout. —�Ah system.components,excluding the Soil Absorption System,have been located on site. I%The septic tank manholes were uncovered,opened,and the interior of the,septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, r. depth of sludge,depth of scum.'' y The size and location of the Soil.Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - SUBSURFACE' SEWAGE DISPOSAL SYSTEM.: INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION: / FLOW CONDITIONS RESIDENTIAL: V Design Flow:33 gallons umber of Bedrooms:_N mber of Current.Residents: Garbage Grinder: fU aundry Connected To System: Seasonal Use: Water Meter Rea ngs,i ilable: Last Date of Occupancy: COMMERCIAL ANDUSTRIAL.• - Type of Establishment Design Flow: - gallons/day ._Grease Trap Present: (yes t,"- '' : " : ry',, rd Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged-To.The Title V System: Water Meter Readings,if Available: Last-Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION 14-1 PUMPING RECORDS any source of information: aol' Qua'X � ';'.) S ystem Pumped as part of inspection:. — If. es,volume pumped: gallons Reason for Pumping: TYPE F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool —Privy Shared System(If yes,attach previous inspection records,if any) - Other(explain): APPROXIMATE AGE of all components,date installed(if known)and.source of_information Sewage od detected when arriving at the site:���LQ�— -- _ -4- SUBSURFACE SEWAGE DISPOSAL'SYSTEM"INSPECTION FORM PART C / GENERAL INFORMATION (continued) SEPTIC TANK: !/ Depth below grade: Material of Construction: V1 concrete metal FRP Other (explain) Dimensions: 'X ' ' Sludge Depth: Scum Thickness:/* Distance from top of sludge to bottom of outlet tee or baffle: 3 Z // Distance from bottom of.scum to bottom of outlet tee or baffle: // Comments: (recommendation for pumping;conditioin of.inlet and-outlet tees or baffles,depth of liquid level in relation to outl invert,structural integrity,,evide a of leakage,etc in L/ i� GREASE TRAP: GZ Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to-top of outlet tee or baffle: 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,ete) .,,,.. FIGHT OR HOLDING TANK:�[� Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: !/ , Depth of liquid level above outlet invert: ��-,aft Comments: (note'f level and distribution is a ual,evideiWe of solids carryover evidence leaka a into or opt of box,etc.) PUMP CHAMBER: Pump is in working order: ; Couunents: (note condition of pump chamber,condition of pumps and appurtenances,etc.). _ 5 _ SUBSURFACE'SEWAGE DISPOSAL"SYSTEM INSPECTION 'FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): V (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) if not determined to be present,explain: Type: Leaching pits,number: a Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: . omments: (note conidtion of soil,signs of hydraulic fail level of pondin condition o vegetation,etc.)_ CESSPOOLS: /J() Number and configuration: y Depth-top of liquid to inlet invert: f Depth of solids layer: ` ! Depth of scum layer: Dime sions.•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: Materials of construction: Dimensions: Depth of Solids:. Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) �1 _:.. .�'. .. _.: �_ � C :.+ ¢ • -' ,.f c. 4(t ilia ri� ,{f a ,fin t' - 6 - SUBSURFACE'SEWAGE DISPOSAL, SYSTEM,INSI',EC'I'ION- FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM.: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method o1*Determination or Approxim tion: u - 7 - BORTOLOTTI CONSTRUCTION, INC. - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop p2/9 _/-Gaj"691 6/s Pc % Date of Inspec} Map arcel Own r 7� PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND 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 COLUMES 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. HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. y'ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. 1--'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 SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. L THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION RESIDENTIAL FLOW CONDITIONS ` No of Bedrooms t No of Current Residents A16 Garbage Grinder Laundry Connected to System Seasonal Use NON RESIDENTIAL: , Calculated flow WATER METER READINGS,IF AVAILABLE: Pumping Records and Source of Information: GALLONS SYSTEM PUMPED AS PART OF INSPECTION? N0 IF YES,VOLUME PUMPED= GALS Reason for Pumping: TYPE OF SYSTEM: ,F �. Septic tank/distribution box/soil absorption system g.,*II c' Single Cesspool Overflow Cesspool ivy Shared system (if yes,attach previous inspection records, R any) Other(explain) V Appr xi mat e age of all components. Date installed,If known. Source of information. ae�0 ba SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART B — SYSTEM INFORMATION (Continued) SE—TIC Depth below grade: Dimensions: / Material of construction: oncrete Metal FRP Other} Sludge Depth/_.,, Distance from top of iud,9 to bottom of outlet tee or baffle 137 Scum Thic �s Distance from Top of Sf}im to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle 2 of i Comments: ?Ao00 0.. -L' ►jlC i�fJ U v y� DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: Ilion PUMP CHAMBER: A Pumps in working order? Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE: Comments: CESSPOOLS: Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials of construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' aa� 5 DEPTH TO GROUNDWATER : DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA ti (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why.not) Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? N/ Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? IV Within 50 feet of a surface water? IV Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? IV Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies.only, not the SAS)? 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,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION (INSPECTOR: ROBERT J.BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508)771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION 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: V I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAI LS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM, I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: � 9�J ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(d applicable),APPROVING AUTHORITY TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSO MAP &LOT �e YNS 1 Toil 0 NAME&PHONE NO. �l0 0�6 SEPTIC TANK CAPACITY 1606 aa/ G LEACHING FACILITY: (type) 76% C--/ (size) NO.OF BEDROOMS 3 BUILDER O OWNER 7'/'iSei��G PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet .on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300_fret of leachhin facinvv�ZXC40) Feet Furnished byr ,"Z �;;Oc. e-A �!/y ' 7/ ocV- 31' 3 Fxs...... .......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEA TH C7g. ^t. OF...... ...................... ......... ....................... Appliration for Bi-spniiFal Workfi Tongtruritnn 1hrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst at: Locat' -Addr s or --------------- •-•-- .................. .......... - .......................................................... Address Installer Address Type of Building Size Lot__._ __a' Sq. feet Dwelling—No. of Bedrooms......... .............................Expansion Attic ( Allen Garbage Grinder ( 4,b 04 Other—Type of Building ____,....................... No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other JIxtures ..•.•--- ^................... .. 4 7 w Design Flow________ ._.�_�-_�__.�_______________gallons per person per day. Total daily flow-------- Qgallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.............._..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_ .-____-_-__-.___._- GL4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.__--____-•____-_____-. 9 --------------------------------------------------- •------------------------------------------------ -________----------•-------•--------------•-------_------ 0 Description of Soil........................................................................................................................................................................ x c, w ----------------•-------------..-----•------------------------------.....------------------------------------------------------------------------...---------------------------------- ------------------ U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------- -----------------------------------------------------------•------------------------....-------------------•-----------------------------------•------------...-----•------------------............---•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of il'�La: ' , p 5 of the State Sanitary Code—The undersigned f tl er agrees not to place the system in operations un_tillaa Certifi to o. ompliance has been ' e by the boat o ealth. 11� igned •--••-. G Dat Application Approved B 7 . g Date Application Disapproved for the following reasons:-----•----------------------------------------------------------------------------------------------------••---- .............................................._.......................................................................................................................................................... Date PermitNo. ................................. Issued....................................................... Date Al FEB...:.�.^,4...:. ........... `` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applilrntilln for Diipuual Work.5 Tinuitrttrfion rumit Application is hereby made for a Permit to Construct (4,-)"-or Repair ( ) an Individual Sewage Disposal Syst�m at: Y � y -...._. A" _ c oca +e " or ILdt b. ............ ............................................................... a o Wr-T I Address •-- ' ` ' ................ 't" .' 't`t-F"•'�` ---------------------•--•----------- -- ---- Installer Address UType of Building Size Lot___ '.------- q. feet a Dwelling—No. of Bedrooms........ ....................................Expansion4Attic ( Garbage Grinder O ' aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------•--•--•-------.....---------.......--------------..._...--- WDesign 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 ( ) W Percolation Test Results Performed by----------------------------------------------------------------......... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_---.-.-.___-_______--- f3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 .---•----------------------------------------------•---••--•--------•-•---------•-----•-•------..-•..........--------------------------...... •-------------- 0 Description of Soil....................................................................................................................................................................... W V •---•-•--•-•-•---••----------•--------------•-•----------------•-----------•--------.....--•-•-----•-•----•-•--•------•---•-•-•------------•--------------•-----------------•-•--•--------•---•--•----- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•-------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --•---------------------•---------------------------••---••--------------------•---•-----•••-------...--•-•---•-•-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT=.. ;of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate o ompliance has been ssued by the board'of ealth. 01 etee igned.............. ............................=�-- _ _ Application Approved By- �=•------ :; .�-a,�_c' :...�.� c ! r.:. a(. Date Application Disapproved for the following reasons-----------------------------•---------------•----------------•---------------------------------------........_ -------------------•---............................................................................................................................................................................... Date PermitNo------------- '?:..-•==`=='------------------ Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH � 1 (Irdif hair of Tuntplinnrr THTS_IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( } V Install has been installed in accordance with the provisions of T i T LE j of The State Sanitary Cod ass desc i to the __ -. 1� J application for Disposal Works Construction Permit No =cam-_.. �--..... dated-_. __�..__�`='.`......___... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................5-.-...I_. ............................... Inspector Inspector......--------------- ............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1-' f....c_7. ?3 ! ....OF......... ..i..!:�. �Y ..... -- `... FEE I_ ..... Permission is hereby granted.. ..... '4-=..I............. ---•---------••---•-•--------------------------------------------------•---.... to Construct ( or Re air ( an Individual Sewage isposal System r at No--------L-.. �.......t._�_.._._.�_..,.: �-��;� .�-�,-�1�� �..�'� {�__• �- as shown on the application for Disposal Works Construction Permit N�:__S5='.........._ Dated........... ........`.. `.. Board of Health DATE --------- ---•--•---- �1.I.C............---•---- FORM 1255 HOBBS & WARREN. INC.. 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TH11J T'f}E Llt) R.�nl 1-5R07 3A5tp aNl� _. a P SuRYC� T ANC HE 0FF5ET5 5HOtiyN 5HOU 14 L-D 1� T �~ %t" T3E usEz,> TLC E•ST&T3 L15 H Lz::,-f' L 1 N l;S. I�E LINE 10 X 10'f0 TmE IN-, � I i CI I i r D Q�1 TOWN OF BARNSTABLE T',OCATIONL(fl7l y 70.E © 75' SEWAGE VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.elFL eCIAC (?Z, '65__�O UoSEPTIC TANK CAPACITY 1 5,A / LEACHING FACILITY:(type) '�/t� (size) f W< 1 ' NO.-OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 4LA f�J S"A� / DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: —7 VARIANCE GRANTED: Yes No �o�es o-r'ts " QAc K N` 3 q