HomeMy WebLinkAbout0351 LAKE ELIZABETH DRIVE - Health 35%1 Lake Elizabeth Drive
Cent rve P
A = 227 014 � � � �
s_)9L4 l 4-
TROY WILLIAMS
L - 5-
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660 EAIRW
�-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI.AFDEPARTMENTOF ENVIRONMENTAL PROT
.J
'TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 1
ProperIN Address: 351 Lake Elizabeth Road
Centerville,MA
Owner's Name: Diane Bergeron
Owner's Addres,: 8025 W. Russell Road,Apt. 1004
Las Vegas,NV 89113
Date of Inspection: October 3,2002
Name of Inspector: Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (50S)385-1300
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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svltem•
Passes
Conditionally Panes
Needs Further Evaluation by the Local Approving Authorir)
Fails
Inspector's Signature: S:; Date: /- /3/o 2-
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 `
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification Is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. i his 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 pace 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of Inspection: Diane Bergeron
October 3,2002
Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the B d of Health, will pass.
Answer yes. no of not determined(Y,N,ND)in the---for for the following Staten nts. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tan• whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failur s imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approve y the Board of Health.
•A metal septic tank will pass inspection if it is structurally so d,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available
ND explain:
Observation of sewage backup or bre out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settl or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
roken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syst required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspect if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of(rt3ptction: Diane Bergeron
October 3,2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health ui order to determine if the system
is failing to protect public health, safety or the environment.
1. Sy stem Hill pass unless Board of Health determines in accordance with 310 CMR 15.3030 )that the
system is not functioning in a manner which will protect public health,safet} and the en ronment:
_ 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 sh
2. System will fail unless the Board of Health(and Public Wat Supplier, if any)determines that the
system is functioning in a manner that protects the public he ,safety and environment:
_ The system has a septic tank and soil absorption tem(SAS)and the SAS is within 100 feet of a
surface %s ater supply or tributary to a surface water pply.
— The system has a septic tank and SAS d the SAS is within a Gone 1 of a public water supply.
_ The system has a septic tank an AS and the SAS is within 50 feet of a private water supple well.
_ The system has a septic t - and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". ethod used to determine distance
"This system pass if the well water analysis, performed at a DEP certified laboratory, for colifotm
bacteria and vol a organic compounds indicates that the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure c ' ria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3 s<
Page 4 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 351 Lake Elizabeth Road
Centerville,MA
Owner: Diane Bergeron
Date of Inspection: October 3,2002
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_jk 61 Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
14119 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. v
Any portion of a cesspool or privy is within a Zone 1 of a public well.
„L Any portion of a cesspool or privy is within 50 feet of a private water supply well.
C(/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.
N o (Yes/No)The system ails. I have determined that one or more of the above failure criteria exist as
described in 3)0 CMR 15.303. therefore the s\,stem 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 esign 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 cr' ria above)
yes no
the system is within 400 feet of a surface drink' g water supply
_ the system is within 200 feet of a tribu to a surface drinking water supply
_ the system is located in a nitrogen nsitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supp well
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes"in Sectlpn D above the 1, e system has failed.The owner or operator of any large system considered a
signifcant that under Sect' E or failtrd under Section D shall upgrade the system in accordance with 310 CMR ,.
15.304.The Oystem owne ould contact the#ppropriate regional office of the Department.
4
i
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of Inspection: Diane Bergeron
October 3,2002
Check if the following have been done.You must indicate"yes"or"no"as to each of the following
Yes No
information was provided by the owner. occupant,or Buaid of llealti.
__. __✓ 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?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out
Were all system components,excluding the SAS, located on site
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from 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)]
5
Page 6 of l 1
OFFICIAL INSPECTION.FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of inspection: Diane Bergeron
October 3,204LOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):_d
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x ti of bedrooms): 3 3 0
Number of current residents: o
Does residence have a garbage grinder(yes or no): No
Is laundn on a separate sewage system(yes or no):.Cfy [if yes separate inspection required)
Laundry system inspected(yes or no): /9
Seasonal use:(yes or no): ye S
Water meter readings;if available(last 2 yearsltsage(gpd)): 01
Sump pump(yes or no): No
Last date of occupancy: L-, rb.7 a 0 0- 57
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,eic.):_
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 syste (yes or no): _
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: ✓ , ,+� -0...4_...1_, _-�_T�..�w,�.,h p►. ,,f;
Was system pumped as part of the inspection(yes or no): .v-
If yes, volume pumped: gallons-- flow was quantity pumped determined?
Reason for pumping: --
TYKE OF SYSTEM
y/Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):.
Approximate age of all components. date installed(if known)and source of information:
7 `j-7 Sys- 1
Were sewage odors detected when arriving at the site(yes or no): .Vo
6
Page 7 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of Inspection: Diane Bergeron
October 3,2002
BUILDING SEWER(locate on site plan)
Depth belu%� grade: IS '4-
Materials of construction: .,-cast iron ✓40 PVC__other(explain):
Dkiancr iron, pirate water supply well or suction line: ,.,t4
Comments(Ion condition of joints, venting, evidence of leakage,etc.):
�I v s(,",t I_ r L-s 4.n..� T�✓ti� � /.0 u L.. 1 f
SEPTIC TANK: v/ locate on site
—( plan)
Depth below grade: I "
Material of construction: ,/concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no)'_(attach a copy of
certificate)
Dimensions: __C `�c/a .s 'K � •o ' /Sao C -1/o h
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle:2
Scum thickness: A/o/y,E
Distance from top of scum to top of outlet tee or baffle: ,Avo_S
Distance from bottom of scum to bottom of outlet tee or baffle: A
flu"-were dimensions determined: ra„z t,
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.): /
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass olyethylene_other
(explain): _ _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or b e:
Distance from bottom of scum to bottom of ou tee or baffle:
Date of last pumping:
Comments(on pumping recommendati s,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence eakage,etc.):
Page 8 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of Inspection: Diane Bergeron
October 3,2002
TIGHT or HOLDING TANK: (tank must be pumped at time of spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fibergl s_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo": gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working o er(yes or no):
Date of last pumping:
Comments(condition of alarm and at switches, etc.):
DISTRIBUTION BOX: v' (if present must be opened)(locate on site plan) '
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
ri-.�.off. _...a✓ ..._.S]
1 T�
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,con ' on of pumps and appurtenances,etc.):
8
Page 9 of 1 l
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of Inspection: Diane Bergeron
October 3,2002
SOIL ABSORPTION SYSTEM(SAS):-Z(locate on site plan,excavation not required)
If SAS not located explain wh):
Type
leaching pits, number:_
✓ leaching chambers,number:-S 14' ✓,f*14 s It, (g /kz5-IX a /
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions: _
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,Zondition of vegetation,
' et�+c�> pp
NJ Gy, /roc Jrat ., ! c `
CESSPOOLS: (cesspool must be pumped/olinspecli (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(yes or
Comments(note condition of soil,sig of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:.
Comments(note condition of soil,signs of hydr lic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 351 Lake Elizabeth Road
Centerville,MA
Owner: Diane Bergeron
Date of Inspection: October 3,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the buildino.
r
A-
A 4-
F-•.r Sram,:rs
to
Page I 1 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
351 Lake Elizabeth Road
Owner: Centerville,MA
Date of Inspection: Diane Bergeron
October 3,2002
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water.3Y 8 "feet
- Adjuslcd high ground water clevalion2y•2 feel
Please indicate(check)all methods used to determine the high gruund %kater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed
site abu( tang property/observation hole within ISO feet of SAS)
Checked with local Board of Health-explain: any
Checked with local excavators, installers-(attach do umetttationc
���
✓ Accessed USGS database-ex lain:
You must describe)how_you established the high ground water elevation:/
w+
1
- 01-�•.-Z�� . �4_.f-t_v-�o_.r�' /c._ v � �` Lli.�s�sV'�_ u/�
a 5
u
Bey]-• � . f' l«.-(,�..�' .
Z' 3Y e
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system voll function properly in the future. There have been no warranties or
Guarantees,either expressed,written or Implied,relating to the system,the inspection and/or this report.
Il
° TOWN OF BARNSTABLE
1,G'ATION SEWAGE :,;! ,7_
V
ASSESSOR'S MAP& LOT�. 7-- 0 t Y
INSTALLER'S NAME&PHONE NO. A-(Lf—S -r t
SEPTIC TANK CAPACTI'Y I S LTZS
LEACHING FACELITY: (type) --Vw iz 14-:r^-C 1 c,(7 S (size)
NO.OF BEDROOMS vC
BUILDER OR OWNER ,ten
PERMITDATE: ��_� COMPLIANCE DATE: l-1 —/ 7 7
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
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
6 ' n
p o 0 3
3
37
ID
--3 ` 15-3
v�
W
x
No. ! v - ® � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
. . Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Zigpo.5al *p5tem Construction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. (,.t%-i�zLlb� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel •���_o`�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms=? Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 7X�6) gallons per day. Calculated daily flow —1338 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank_1 y1/ Type of S.A.S.
Description of Soil 6NL S�
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Cod and not to place the system in operation until a Certifi-
cate of Compliance has been is s B
tgned Date _
Application Approved by Date 7
Application Disapproved for the llowin reasons
Permit No. - Date Issued
i
TOWN OF BARNSTABLE
LOCATION 1-7c11 \.L
SEWAGE #
VII-CAGE_ L-e,L-� s � �P ASSESSOR'S MAP do LOT
INSTALLER'S NAME 8c PHONE NO. —
SEPTIC TANK CAPACITY _L�QZS
LEACHING FACILITY: (type) �w�C1 LT iL.:cRs (size) �S
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: ci �`j U
COMPLIANCE DATE:_ -/ 7 9
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
on site.or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within.300 feet of leaching facility)
Furnished by Feet
1-
d
J
0
No. � �V � / - � � L' -�,.. Fee �� I
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �I
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEi MASSACHUSETTS Yes
1
ZIpprication for Migpool OpMem Construction Permit
Fh
Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. 35 I („2 biyh�� Owner's Name,Address and Tel.No.
C cv.� � � c�•r e_' r ¢v oVIJ F.
Assessor's Map/Parcel S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 7336D gallons per day. Calculated daily flow 3 30 gallons.
Plan Date Number of sheets Revision Date
Title
j Size of Septic Tank y'x pe of S.A.S. J2vr 4-7- u te,O C
Description of Soil 04
Nature of Repairs or Alterations(Answer when applicable) _'3__µ--SV'4AA \ k S 0-V SP(Et
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of he afore described on-site sewage disposal system
in accordance with the provisions-of Title 5 of the Environmental Cod and not to place the system in operation until a Certifi-
cate of Compliance has been issu is B o 7
S gned Date 4/ C,/ J
Application Approved by Date �7
Application Disapproved for the llowin reasons
ai
Permit No. - / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS '.
Certificate of Compliance
THIS IS TO CER IFY that e On-s' wage Disposal System Constructed( )Repaired( )Upgraded
Abandoned( )bya �
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _ 141 dated
Installer Designer r
The issuance of this permit shall not be construed as a guarantee that the system ill_ff`t6*on as designed.
Date ! / - `7 -2 Inspector JJ..
No. t/ 1 Feer
l
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE., MASSACHUSETTS
lwigpoar bpgtem Construction Permit
Permission is hereby granted to Construct( Repair(,_�Pgrade( )Abandon( )
System located at : �� �ri�.�-
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
4
Provided: Construction must be completed within three years of the date of this permit. i
Date: u -- N 7 Approved by
I
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 4 --57 , concerning the
property located at '?vim( C_ V-a- meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
jxert
�1 V�� i
oa a
i
No....... 7__../... F��,.....�.% ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OJF HEALTH
--._.....-....-`.'� ..........e
Appliration -for Uiipusat Works Tomilrur#ivit Vantil
Applicatio /-hereby de r a P -mit to uct ( ) or Repai*r ( I<a-n Individual Sewage Disposal
System t
. d .
l
�or .---
. t No.ocati dress
ner Address
Installer Address
Q Type of Building Size Lot04?-----Sq. feet
U Dwelling—No. of Bedrooms. _---.Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) Cafeteria ( )
Q' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity-------------gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No--- ----------_-. Width-------------------- Total Length.................... Total leaching area--------------.-----sq. ft.
Seepage Pit No.................... Diameter.................... Depth below inlet.-.---.-----------.- Total leaching area-----._.-..-.--_sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by=------------------------------------------------------------------------- Date---.-....-------------------------------
,� Test Pit No. 1----------------minutes per inch Depth .of 'Pest Pit.................... Depth to ground water........----------.._..-
- f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------.-.------
�' ....----•-----•-----------------•----•---•-•--------------•-•-•--•----•---------•---------•----•--- .........................................................
0 Description of Soil.......................................................................................
U ------------ ------- ----------------------------•----....--•----•--•----------------•---------•-------------------------- ------- Y
x ----------- --------------------------------------------------------------------------------------------------- ----------- ------ -- --- - --•-•----
U Nature of Repairs or Alterations—Answer when applicab e....... L' ---.
............................................. -------------------------------------------------- . ..............
Agreement: rj ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article\I of the State Sanitary Code-T de ned further agrees not to place the system in
operation until a Certificate of Compliance su o health.
igned / � ----------------------------- ..........------•---------------
Date
ApplicationApproved By------------------ ---------- • ...................................................... --------- - ----------
Date
Application Disapproved for the following asons-----------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
No............ .. .... Fss..........?....=...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l ~s_
-Allpfiration~for i A tt1 park Cnuat� r�tr�i�� rr i#
_ Application is hereby for a Permit to'Cons uct ( ) or Repair�( do Individual Sewage Disposal
System at• sf
7r0'-"
/ may$ J�{�" ��',j//•' ,,� ,ram/`j �'`
Locat' n=!Address' yr..a°�
'a! ✓�Tr= -; - lw-----------*;---------------------• --•---------------------•— -'-= ^` o
Lot N o
...........................................
caner' .
Address
Installer Address ,.
d Type of Building Size Lot_; ----._*� ---_
--- feet
Dwelling—No. of Bedrooms_(� --------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------------------------------------------------------------------------------------------•---•----
Design Flow............................................
W ggallons 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....-:-_.______--..-
Test Pit No. 2................minutes per inch Depth of Test Pit.-.--_-__-_______- De it" to round
P P P g water.---•-------------------
---------------_--- -------•--------=----....-----------•---•---------•-•--••-•--------------------•-•-•-•-••--------•---.;,.---_--------------•------
DDescription of Soil -----------•----------------------------------------------= `_ '•----- -----.-.------------------------------------
x .....••-• - ✓......r r% .. ..
V
W ------- '----- ------------------------ .......... ---------------------------------------------- _
10
U Nature of Repairs or Alteratdns Answer when applicable-._._ ,�<_ �' - eA_,14'. " , , ,
-
_ _______________________________ --------------------------------------------- __._.. -------
`r w
Agreement: _ ,
The undersigned agrees td,install the aforedescribed .Individual Sewage•Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been;issued by thebf health.,
g
A lication A roved B ..-_--- .-• Date�t
e 4
PPPP Y ------•-••--•-•---•------•--•-•--- ............................... .
VDate
Application Disapproved for the following reasons: ....................................................................................................................
--•-•-.....--•-----=---•-•--•-•-•-----------------------------•-•-•-•--...-------•--•------------•-------'•---•---•-•---------------•-•-•---•-•-•-•-•------•-----•-----------•---........••----•.•..-----
Date
Permit No......................................................... Issued....... / ------Z: .
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r'
':O F..............................:.. ......
w1rdifiratr of f Ikomp atta
THIS IS TO CERTIFY,.That.the Individual Sewage Disposal System constructed ( ) or Repaired ( i'
by....... %:�... . .� 1 ----•-------------------------------------- --------
=r-----.....................................
- � •''tom •� ,, `� Installer -.�''-
� r r.
at "--------'---••------- -••--•---•----•----==•--------••------• ••--------•-------- ---- --
.............................................................
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 CONST D AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .............................................................. Inspector......... --------•------ ...................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/� - — ftfirtf 0F /7t .,
......... ..................................................
>
No. -•---...f............ FEE-- ..........
• t.4voiitt1.Norko Qlamitrurtion Prrmit
Permission is h'e 'granted__..,..: _ ..._................................
? �y -
----------------- ---------------------------------••.
to Construct ( ) or Repair_(�an Individual Sewage Disposal System
Y !.rY ,
at rr�
. -� u ' I Street
as shown on the application for Disposal Works Construction Permit No-------------:�...... Dated...................h,
....................
- --- -- -.............................
Board of Health
DATE................................................................................
L/
.FORM' 1255 HOBBS & WARREN. INC_ PUBLISHERS
LOC 10N ' SEW lJ,C,E PERMIT MO.
IPIST R IJ�NIE � ADDRESS
BUILDERS, 1.1 E A DRESS
D , E E R MIT 1 SSU ED
fl =�=�✓��= ����%
cit
D ATE COMPLI &&ICE ISSUED
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