HomeMy WebLinkAbout0367 LAKE ELIZABETH DRIVE - Health 167 Lake Elizabeth ®rive
Centerville P
227 016
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F- COMMONWEALTH OF MASSACHuSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
-,RA-RCEL
TITLE S
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: , RECEIVED
Owner's Name:
Owner's Address: AUG 3 0 2004
Date of Inspection: - T(wvN OF tsHhNSTABLE
HEALTH DEPT.
Name of Inspector: leWprint)
Company Name•
Mailing Address:
Telephone Number:.
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 dis000 . The posal systems.I am a DEP
310 CMR 15.
approved system inspector pursuant to Section 15.340 of Title 5
( ) system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 0 2 L
The system inspector-shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15l2000 page I
Page 2 of t t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address: _
Owner. 'r.
Date of Inspecti D:
Inspection Summary: Check A,B,C,D or E/ALWA complete all of Section D
A.7stem Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15303 or in:3IgCMR 15,304 exist.Any failure criteria not evaluated are indicated below.
Comments: C�
System Conditionally Passes:
sr section need to
replaced or
One or more system components as described in the
el on of the replacement or repair,as approved by the Board oHealth,will S.
repaire . e system,upon compl
Answer yes,no or n determined(Y,N,ND)in the for the following statements.If"not determ' ed"please
explain.
The septic tank is meta d over 20 years old* or thseptic urenk imminent her metal or t is will pass structurally
inspection if the
lion or
' infil ion or exfiltra
unsound,exhibits substantial
existing tank is replaced with a comp g septic tank as approved by the Board of th.
xi metal septic tank will pass inspection 't is structurally sound,not leaking an f a Certificate of Compliance .
indicating that the tank is less than 20 years o is available.
ND explain:
observation of sewage backup or break out or high is ter level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distrib box.System will pass inspection if(with
approval of Board of Health): laced
broken pipes)are p
obstruction is oved
distribution x is leveled or replaced
ND explain:
'required pumpi more than 4 times a year due to broken or obstructed p s).The system will
The system
pass inspection if(with approv of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND ex in:
2
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ASSESSMENTS
PART A
CERTIFICATION(continued)
Property Address: �p� �Q
Owner:
Date of Inspection:
Further Evaluation is Required by the Board of I3ealth:
Conditions exist which require further evaluation by the Board of Health in order to determine i
is failing protect public health,safety or the environment. f the syst
1. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303( that the
system is n functioning in a manner which will protect public health,safety and thee ironment:~
_ Cesspool or 'vy is within 50 feet of a surface water
Cesspool or pri 's within 50 feet of a bordering vegetated wetland or a salt
h
2. System will fail unless the Board of Ith(and Public Water
system is functioning in a manner that Prot the public healt safetylier and environment:mines that the
The system has a septic tank and soil abso 'on ste surface water supply or tributary to a surface water (SAS)and the SAS is within 100 feet of a
P
_ The system has a septic tank and SAS and the AS ' within a Zone I of a public water supply.
The system has a septic tank and SAS an a SAS is wi 'n 50 feet of a private water supply well.
The system has a septic tank and SA and the SAS is less than 00 feet but 50 feet or more from a
Private water supply well**.Method d to determine distance
"This system passes if the well w er analysis,performed at a DEP certifi laboratory,
bacteria and volatile genic or co pounds indicates that the well is free from po tion from that facility and
the presence of ammonia nitr gen and nitrate nitrogen is equal to or less than 5 p ,provided that no other
failure criteria are t iggere .A copy of the analysis must be attached to this form.
3. Other.
3
Page 4 of 1 l .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL ASYSTEM INSPECTION
RM
PA
CERTIFICATION(continued)
property Address:
Owner.
Date of Inspection.
D. System Failure Criteria applicable to all systems:
You mast indicate`fires"or"no"to each of the following for all inspections:
Yes No nent due to overloaded or clogged SAS or cesspool
tbD Backup of sewage into facility or system com im and or surface waters due to an overloaded or
Discharge or ponding of effluent to the surface of the gro
clogged SAS or cesspool
rL Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
� is less than 6"below invert or available volume is less than'A day ow
Liquid depth in cesspool
1D� Required pumping more than 4 tunes in last year_NOT to clogged or obstructed pipe(s).Number
of times pumped 6
l or Privy is below high ground water elevation.
i]S) Any portion of the SAS,cesspoo
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
j10water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
�p Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_11D 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 facilityand that presence other failof ure criteria
onia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
are triggered.A copy of the analysis must be attached to this form.]
e of the
ve failure criteria
as
(Ye described
The in 31 system
15.303,therefore the syst m faiined that one or ls rThe system oowner should ontact the Board of
described m 310 to correct the failure.
Health to determine what will be necessary
Large Systems:
To onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 1
gpd•
You must indic either"yes"or"no"to each of the following:
(The following criten ly to large systems in addition to the criteria above)
yes no su 1
_ the system is within 400 feet surface drinking water PP y
_ _ the system is within 200 feet of a tribu a s drinking water supply
_ _ the system is located in a nitrogen s rve area(Irate ellhead Protection Area—IWPA)or a mapped
Zone II of a public water su well
" o any question in Section E the system is considered a sign t threat,or answered
if you have answered
"fires"in Sectio ve the large system has failed.The owner or operator of any large syste sidered a
all upgrade
signifi eat under Section E or failed under Soecthe system in tioon D shonal office of the Department accordance wi 0 CMR
I .The system owner should contact the tipper p [P
4
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Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ate, ei Dr.
Owner.
Date of Inspection: 4
Check if the following have.been done.You must indicate"Yes"or"no"as to each of the followine:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
T tY� 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?
_ MO Have large volumes of water been introduced to the system recently or as part of this inspection?
,AA _ 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?
146& _ 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
�df 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
nYaintenance 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
0 _ 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
t unacceptable)[310 CMR 15.302(3)(b)]
S
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: or
Owner. -j
Date of Inspectio
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2) Number of bedrooms(actual).3
DESIGN flow based on 310 Clv)+R 15103(for example: 110 gpd x#of bedrooms):
Number of current residents: ll
Does residence have a garbage grinder(yes or no
Is laundry on a separate sewage system(yes or no):In [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
Water meter readings,if avPilable(last 2 years usage(gpd)): tJ [A-
Sump pump(yes or no):tO
Last date of occupancy.P&S91c"
CB EERCIAL/INDUSTRIAL
Type of es anent•
Design flow(base 10 CMR 15.203): _gpd
Basis of design flow(sea ons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes
Non-sanitary waste discharged to the Title a es or no):_
Water meter readings,if availab
Last date of occupanc
OTH escr'be)•
GENERAL INFORMATION
Pumping Records `
Source of information: V Db d� (,;P�T
Was system pumped as part of the inspection(yes or no): kAg
S
If yes,volume pumped:jr allons—How was quantity pumped dete fined?
Reason for pumping: .i N-e Acj r 41-f- Mty\ G'�t'�
TYPE OF SYSTEM
Septic tank, utien bow,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): n -�36y_ j j O b �Ctr_ k ''�MNL_� W C)C��1 L.P.
Approximate age of all components,dat installed if known)and source of information:
col- t
Were sewage odors detected when arriving at the site(yes or no):{�
6
Page 7 of I I
OFFICIAL INSPECTION FORM P S�SYSTEM INSPECTION FORMOR VOLUNTY
SUBSURFACE SEWAGE PART
SYSTEM INFORMMATION(continued)
Property Address:*, & Or.
Owner.
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: I LA V6 YJ
40 PVC
Materials of construction• cast iron other(explain):
Distance from private water supply well or suction line: -
Comments(on cbndi 'on of j ' ts,venting,evidence of leakageljili,etc.): 1/e��"
111)
SEPTIC TANK:_(locate on site plan)
tt tt
Depth below grade: ej
Material of construction: concrete metal_fiberglass__polyethylene
_other(explain) p attach a copy of
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or ro): (_
certificate) I
Dimensions:
Sludge depth: < <
Distance from top of slydge to bottom of outlet tee or baffle:. 1l�
Scum thickness:�_ t`
Distance from top of scum to top of outlet tee or baffle: �.�r I I
Distance from bottom of scum to bottom of outlet up or e:�=5
How were dimensions determined:
Comments(on pumping recommendations,Wet let and outlet tee or baffle condition,structural integrity,liquid levels
as related to utlet invert,ev'lence of leakage,et `. ec,6 /
tJ
C !'-r_.(C)A4Mi
EASE TRAP: (locate on site plan)
Depth be de:y
Material of cons n:_concrete metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness-
Distance from top of scum to top of outlet tee or
Distance from bottom of scum to bottom of outlet tee or _
Date of last pumping: gr , q
let outlet tee or baffle co "on,structural integrity,liquid levels
Comments(on pumping recommendations,in
as related to outlet invert,evidence of I e,etc.):
7
Page 8 of l l
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:A
e
#&
Owner: R
Date of Inspectio : to
GHT or HOLDING TANK: (tank must be pumped at time of inspectionxlocate on site plan)
Depth low grade:
Material o onstruction: concrete metal fiberglass____polyethylene other(e
Dimensions:
Capacit): Ions
Design Flow: llons/day
Alarm present(yes or no
Alarm level: Alarm i orking order(yes or no):
Date of last pumping:
Comments(condition of alarm and flo switches,etc.):
DISTRIBUTION BOX: (if present must be o d)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distrib 'on to out
equal, evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
IZ
PUMP CHAMBER: (locate on site plan)
Pumps in workin rder(�efs
s or no):
Alarms in wor 'ng order or no):
Comments ote conditio pump chamber,condition of pumps and appurtenances,etc.):
S
r
rage 7 of i i
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1N"e r1 N �r
owner. 2�N
Date of InspectioCr,/0 LL_
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,,excavation not required)
If SAS not located explain why:
Type1
leaching pits,number: t L o vo ic'
leaching chambers,number
leaching galleries,number
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): �
SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number a configuration:
Depth—top o ' uid to inlet invert:
Depth of solids la
Depth of scum layer:
Dimensions of cesspool:_
Materials of construction:
Indication of groundwater inflow(yes no
Comments(note condition of soil,signs o draulic fail evel of ponding,condition of vegetation,etc.):
PRIVY: (locate on site pl
Materials of construc
Dimensions:
Depth of s ' s:
Comm (note condition of soil,signs of hydraulic failure,level of ponding,condition egetation,etc.):
9
v
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Address: 1 LAe Z�
e �
Owner. ll
Date of lnspectio : '
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
A
2�
10
w
r
Page l l of i 1
OFFICIAL INSPECTION FORM—NOT FOR
SYST M INSPECT ON FORM ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL
R C
SYSTEM INFORMATION(continued)
property Address:
Owner.
Date of Inspectio
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water Lelleet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: Iry L —7A Zn J
Yo must describe how you establishe the high ou d water elevv ion: S
t�v
o � Q
00
6� o� 6
y\o fmv�
,t
> r ;.
e
PROPERTY ADDRESS; 367 Lake Elizabeth Drive
__,�sai.gville------------
02636
------------------------
on the above date, I Inspected the eeptlo ,uysteM, at the above address.
Thls system consists of the following;
1 . 1 -1000 gallon septic tank.
2 . 1 -1000 gallon precast leaching pit.
eased on my Inapectlon, I certify the following oondltlonat
3 . This is a title five septic system. ( 78 Code )
4 . The septic system is in proper working order 9 f O
at the present time. ,
5 . The leaching pit is •-piesently dry at this time.
$IGNATURE:./
Name :_ .P.,,lt9ssm2a.c. LL---
Company: Joa.,Qh_P _ Hacomb�r_b Son , Inc .
Address :_ Box-66---
Cenceryi Ile L He--_02632-0066
Phone: -------
THIS CERTIFICATION 00es NOT CONSTITUTE A QVARANTY OR WARRANTY
J6SEPH P, MACOMBER & SON, INC,
T+nkr•C�+spool+•l Iichfl�lds
Pumped 4 .1nr<tillid
Town sow#r Conneotlons
P,O. Box 6775.33J8e�775.6{1Z26J2-0066
r___RECEIVED
APR 2 0 2001
TOWN OF BARNSTABLE
M<H DEPT.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 367 Lake Elizabeth Drive
Craigvi le,Mass.
Owner's Name:Steve Pillsbury
Owner's Address: 26 Stonebridge Lane
Avon Conn. 06001
Date of Inspection: 411 0 I01
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address:Box 66
C'antarui 1 1 ' Macc 02632
Telephone Number: rr n u_u5-33o2-
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system:
t/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail /J 1
Inspector's Signature: Date:
The system inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 367 Lake Elizabeth Drive
Craigville,Mass.
Owner: Steve Pillsbury
Date of Inspection:4/10/01
Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D
iA. Syst;have
Passes: L
I 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:
None. :The leaching pit is presently dry.
B. System Conditionally Passes:
AJ� One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
,60 The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
>✓6 Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
4,�� The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 367 Lake Elizabeth Drive
Craigville,Mass.
Owner: Steve Pillsbury
Date of Inspection: 4/10/01
C. Further Evaluation is Required by the Board of Health:
5 Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
,VO Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
A6 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
�11 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/1) The system has a septic tank and SAS and the SAS is less than 100 feet byt 50 feet or more from a
private water supply well". Method used to determine distance Zl1,YGa✓z
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
None
3
Page 4 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 367 Lake Elizabeth Drive
Craigville,Mass.
Owner: Steve Pillsbury
Date of Inspection: 4 10 01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes
NoZBackup 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
_A10Wg :Static liquid level in the distribution.box.above outlet invert due to an overloaded or clogged SAS or
cesspool 1..4,,0-1600 ( 10rY -2
Liquid depth in�eeaspo -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�.
!ky portion of the SAS, cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/water supply.
_ d y 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. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10 000 d to 15,000
g Y Y Y g � gP
gPd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes now
d the system is within 400 feet of a surface drinking water supply
z/the system is within 200 feet of a tributary to a surface drinking water supply
/the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well 4.
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:367 Lake Elizabeth Drive
Craigville,Mass.
Owner: Steve Pillsbury
Date of Inspection: 4/1 0/01
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_ZPumping information was provided by the owner, occupant, or Board of Health
/Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period?
ZHave 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 ?
Z_ Were all system components;44eluding 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 ?
.1G 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
l/ 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 1 I '
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 367 Lake Elizabeth Drive
Craigvi . e, ass. /
OMner: Steve Pillsbury
Date of Inspection: 4 1 0 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_:L Number of bedrooms(actual):
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x q of bedrooms): IX?P=,A9e ,V
Number of current residents: () _
Does residence have a garbage grinder(yes or no):m
Is laundry on a separate sewage system (yes or no):.f& [if yes separate inspection required)
Laundry system inspected (yes or no):/&
Seasonal use: (yes or no):Zf 4C n /�
Water meter readings, if available (last 2 years usage(gpd)):
Sump pump(yes or no):.S,1Q
Last date of occupancy: ZaAr d1�
COMM ERCLAUINDUSTRIAL
Type of establishment: Alh
Design now(based on 310 CMR 15.203): t—V gpd
Bans of design (low(seats/persons/sgft,etc.): 4,14
Grease trap present(yes or no): A2
Industrial waste holding tank present(yes or no):A14
Non sanitary waste discharged to the Title 5 system (yes or no):
eater meter readings, if available:
Last date of occupancy/use:
OTHER (describe): ,rl
Pumping Records GENERAL INFORMATION
Source of information: /1/ j
',k'as system pumped as pan of the inspection (yes or no):
Ii yes. volume pumped: gallons — How was quantiry pumped determined?
Reason for pumping:
TYPR OF SYSTEM
Septic tank, , soil absorption system
d2Q Single cesspool
42 Overflow cesspool
Vcl Privy
► Shared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative/Allemative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
APj Tight tank ," Attach a copy of the DEP approval
d' Other(describe):
Approximate age of all com o ents, date installed (if known)and source of information:
/0./s��/-c1q/r 7
I ere sewage odors detected when arriving at the site (yes or no):.lJJ
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 367 Lake Elizabeth Drive
Craigville,Mass.
Owner: Steve Pillsbury
Date of Inspection: 4/1 0/01
BUILDINC SEWER (locate on site plan)
Depth below grade:
Materials of construction: cast iron 2, 40 PVC mother(explain): AlA
Distance from private water supply well or suction line: lGV-
Comments (on condition ofjoinis, venting, evidence of leakage, etc.):
Joints appear tight No evidence of 1aaka P g m is
4 y�?
'coo vented through the house vent.
SEPTIC TANK: (locate on site plan)
Depth below pade: yI
Material of construction: concrete/0 metal•al fiberglass4,Lpolyethylene
�other(explain)_ 4114
!i tank is metal list age: _4.W Is age confirmed by a Certificate of Compliance(yes or no):41of (attach a copy of
cenificate)
Dimensions: ,� 'iyG •�%j��iQSG S'9� {
Sludee depth:
l
Distance from top of sludgeto bottom of outlet tee or baffle:
Scum thickness:
D!s:ance from top of scum to top of outlet tee or baffle:
D stance from bosom of scum to bottom of outlet tog or baffle:
Hoµ mere dimensions determined: / Sil
Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
:Septic tank should- be gumpeci annual' ly A__garbaga disposal
is present Inlet & outlett eG arP in 1AnP Tha' tank ig
..—is
sound and shows no evidence of leakage.
GREASE TRAP44 (locate on site plan)
Depth below grade: V,4
Material of conswction:NgconcreteA�&metal4j&fiberglass 1!__PolyethyleneN�other
(e\plain): AA
Dimensions: AM
Scum thickness: A)fi
Distance from top of scum to top of outlet tee or baffle:—AM
Distance from bottom of scum to bottom of outlet tee or baffle: d11
Date of last pumping: _ ),
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not prPGent
I
7
• Page 8 of 1 I '
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 367 Lake Elizabeth Drive
C'rai qvi l l P,Mas
Owner: St-PvP Pi 1 1 c;Lry _
Date of Inspection: 41 1:/n i
TIGHT or HOLDING TAN}44we. (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: 41
Material of construction:&concrete414 metal 414 fiberglass -t14 Polyethylene V,4 other(explain):
A4
Dimensions: AM
Capaciry: X114 gallons
Desien Flow: Vh" gallons/day
Alarm present(yes or no):
Alarm level: AIA Alarm in working order(yes or no):
Date of last pumping: �i
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks art-_ not present
DISTRIBUTION BOXtk (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Wh
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.):
Distribution. box is n,ol- rezeni-
PUMP CHAMBERd/� (locate on site plan)
Pumps in working order(yes or no): 41,4
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Pump chamber is not present.
8
" Page 9 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 367 Lake Elizabeth Drive
Craigville,Mass.
Owner: Steve Pillsbury
Date of Inspection: 4 10/01 /
SOIL ABSORPTION SYSTEM (SAS): I/ (locate on site plan,excavation not required)
If SAS not located explain why:
.oaA Tic T .g ' &&v czd e
Type
I/ leaching pits, number:
Vj,� leaching chambers, number: 47
D leaching galleries,number: 6
,11d leaching trenches,number, length:
leaching fields,number,dimensions: Q
overflow cesspool, number:
4,6 innovative/alternative system Type/name of technology: j',�
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic failure
or ponding.Soils are dry-Vegetation is normal
CESSPOOLS Ge /L (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):.4
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present.
PRIVYt✓�(locate on site plan)
Materials of construction:
Dimensions: ar
Depth of solids:
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Privy is not present
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 367 Lake Elizabeth Drive
Cra1gv1iie,Mass.
Owner: Steve Piiisbury
Date of Inspection: 1
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the,bUilding.
i �
fy
F-F
,
36' 7 ZAA -e ClIZAbery oof .
10
Page I 1 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem Address: 367 Lake Elizabeth Drive
Craigville,Mass.
Owner: ySteve Pillsbury
Date of Inspection: 4/1 0/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
_ Obt om s stem design plans on record - If checked, date of design plan reviewed:
Observed site(abunin ro erty bservation hole within ISO feet of SAS)
het a With oca! Board of Health-explain:
_
Checked with local excavators, installers- (anach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water contours Map_
Gahrety & Miller Model
12/1hf94
II
`• r+.n r+ -n.rr�•'tern-srn•nr.w�-�.n+t.rmr•.�+�.►r�nn•+ r�nnu�'w'.n wt+ Tn-r�--.•- r—.- -
'I'UWN OF Barnstable GUARD OF HEALTH
0. � -r•....,-_ r_SUI)SURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
r - I
-TYPE OR PRINT CLEARLY- 1
PROPERTY INSPECTED
STREET ADDRESS 367 Lake Elizabeth Drive Craigville,Mass.
ASSESSORS MAP , BLOCK AND PARCEL I
OWNER' s NAME Steve PillSbury
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inc':`
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Strevt Town or C.Ity St ty tIp
COMPANY TELEPHONE ( 508 ) 775-3338 FAX (508 1 790 _ 1 578
.t
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
this address and that the inrorrnation reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
recommendations 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 : .
f� System 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 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have conducted has found that the system fails to
protect the E)ublic 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 Date0
ne copy of this c rtification must be provided to the OWNER, the BUYER
where applicable ) and the BOARD OF KRAL'Ilt,
If the inspection FAILED , the owner orhoperator shall up
grade pgrade ' the ayotem
w ; l.hin one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 16 . 305 ,
partd . doc
LOCL.TION SE t�. t= PERMIT 1.10.
VILLAGE
— _ —�G.�..►-t-�'+:-v t l j�s /��f S �'6. o r�i !fir /7�a�
IMSTQLLER5 U&NlE ADDRESS
BUILDER 5 N I MF- ADDRESS
Do►TE PERKA T 15SUED
O ATE COKAPL1 1. MCE ISSUED ;
r
n v
77--•� .r. L D t�d
i
No..... -7 / —�/ FR$...2..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_... __... ... ......._...... OF..................................... ...................................................
Appliratiao n -fur Uiiipwial Works Tonfitrurtion Prruiff
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
ystem at: _
Location'-Addre�ss y or Lot No.
Ow er Address
1------`---5-------------- ------•----- .......................` ° a'' �' '^ `�
Installer Address
Type of Building Size Lot............................Sq. feet r
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 ( )
Percolation Test Results Performed by-------------:............................................................ Date----------------------------------------
aTeAPit,;No. 1_---------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-..-----
CAL/, Test Pit;No. 2________________minutes per inch Depth of Test Pit.___.__._..____.____ Depth to ground water__.__.______-__-__-___..
. t t�.r; ..............________________ ____ ___---------____
Description of Soil:_______________
-------------------
r• J'
U
W _________________________________________________________________________________________________________________ .__.-..______._____.____.__-_._._._...-___ _____-_.
2.
U Nature of Repairs or Alterations—Answer when,a plea `" -.
- --
---------------------
Agreement:
The undersigned agrees to 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 the board of health. �
/'r Lf �°--------•-----------------•---------------------------
Date
A lication A roved BAsigne-
.. ...... ... :.. • ------------------------ —•--•-- --.-.- � ----------------
Date
J®-----
PP PP Y
,. Date
Application Disapproved for the following reasons:__________________•____.._.-___________________...._...._._._.___.__..-___._.._....___.___________....._._______
__...-•--------------------•---------...----------------..._..-•---.._....----•--------------------------...------------------------.._-----•----- . -------------------------------------------_-----
;��ya ate
Permit No....................................=-=---------------- Issued---- -- ...
�........ ....................
Date
�.
No..... l....�` F>za. ... :....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
__...._..... _. _.... ........OF....................................
.... -
Applirttffint -for 11-spuiitt1 Works C owitrurtion Pumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
,L -Z kE r/i Z a b c- 41 Z�?_,Ile
------------•--------------------------------•-...--------------------------•-•••-•-•-..._..------ --•----••••••--•--•---•------•-•-----•••--•------••......-•----•---•----------••-•.........--•-•-
v G d Location� a address S L or Lot No.
...^_--- - .........................^_....-........--'--•------------ -•--'---' .........
O-wper Address
a t`vc7 1 y �.l e o � L C_---V. -o-I, ..'1-------•--.. -•.
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a
d Other fixtures -----------------------------------------------------------------------------------------------------------------------------------------------------
W
Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width--------------.. Diameter-----.---------- Depth................
x Disposal Trench—No_ ____________________ Width-------------------- Total Length-------------------- Total leaching area.-___-__---_._.---_sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area____--.----_-._..-sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----------------------------------------------------------------r------- Date----•------------------------------- ..
a
W 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.-_--_._--__•__-__-- Depth to ground water-_.---..-_-._---__---_-
--------•------------------•---------------•' -- I
DDescriptionof Soil -C '-''� --•--------------------------------------------------------------------------------------------
x
WA .
------- - ------ --------
-Answer when Nature of Repairs or Alterations—Answer when applica ----------
Agreement: -
/ ------ -
The undersigned agrees to 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 the board of health.
Signed -- - -�t,---,,.y-- ��`f
------------ -- - ----------------------------------------------------------- ................................
��,,� ` Date
Application Approved BY ... -- ------ - /r �
Date - - - ------
Application Disapproved for the following reasons: -••-------------••-----•-•--------.....---------..........---...._--••••-•----...
.......•--•-•---•---••----------••-----•-•-----------------------------•---•••-••-•••--•-------------•---•-----•-----•-•---.............._.._.._..-•----•---•••---------._........--•-------.._....••...
Date
PermitNo......................................................... Issued.........................:........................•---•-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�1..0...'. .............O F....�.....
....................................................................
'W"ertifiratr of f TUMpliattrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by.........
-- tall
��, l Installer _- — -- - - •------'------•-�----------
at D !r'C .:-.'1��—� -q l-') - !' . ...
.`
. .........
has been installed in accordance with the provisions of . i XI of The State Sanitary Co Ae as described in the
application for Disposal Works Construction Permit No..-_---__...2::�/�I............. dated...._ - ' '..7 __............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---•---------------•-----------------------------...._._........._........-----• Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O F.
No......................... FEE.'02.-................
Dispg!ii t1 Workii Tomitrurtion Prrmit
Permission is hereby granted l -------- .... �..
to Construct ( ) or Repair (,w- 'an Individua ewage Disposal System
at No---- --- ... ••.-f-
Street '�-
as shown on the application for Disposal Works Constructio rmity' 7s
-0- K _
-- Board of
DATE-----. .� �-------- `f...................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
_ p rF_
Assessor s ma and lot number :... r " ,`—-'
..............
r p�� SEPTIC sY sTl : 1 RE !�
�� INSTALLED IN PLIAI�C'E
t Sewage Permit number �� E 1 I'r.'......d!%-:4�:..-..... ?yr MW
' ' ` 1 R-f ,ART 9 LE
�...
/ /a� ' ,�� � ,�- ;� > , SAI41TAIZY C II- ATE
Q�o TOWN
�E T ) V ®1. R
r4 .�
Is 13.UX3TAML
°ga639- B U IL 1 G I W S TO
Constrkct addition
APPLICATIONFOR PERMIT TO .............................................................................................................................
q Woodframe
TYPEOF CONSTRUCTION .....................................................................................................................................
25 April 75
..................... .:.....................19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit accotding to the following information:
Lake Elizabeth Drive,Cr.aigyille
Location ....................................................................................................................................................................:.
Family room
ProposedUse ........................................................................................................................................ ..................................
Centerville
Zoning, District ............ ...........................:...................... .......Fire District ...........................................:
ke%rAL onard- F11lsbu2y_P`-" I ke: Elizabeth
Nameof Owner ......................................................................Address ..................................... ......... . .............................
Carl Brian Olander 258 .Winter, Hyannis
Nameof Builder ........... ........................................................Address ......................................................
Nameof Architect .....SaffiL ...Address.......................................................... ........................................................:.............................
Number of Rooms 011ie
.............Foundation COriCret.. B10Ck
Exterior .......Viny. l....clap. b. ....................
oard Roofing ......, Asphalt
..... ....... .... ....... .......... ................. .................................................................
i Floors Carpet .Interior Drywalled ............................ . ..
Heating Forced hot. air Plumbing :..None
Fireplace .....1�1031C'.....:............ ................................................, Approximate Cost ...... ..r.C®...................................................
Definitive Plan Approved by Planning Board ___________ __-__------------19_______. Area 224 SGg ft
v
Diagram of Lot and Building with Dimensions ,' Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
N � -
�6c
N`?
0 iv
0
1.1-O
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ......................................... .................