HomeMy WebLinkAbout0028 LIETRIM CIRCLE - Health 28 Lietrim Circle —,mom_,
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DATE: 7/1 5/97
- 8 g
PROPERTY ADDRESS: 28 Lie ;rim C'IrolP d®
A
Centerville,Mass. RECEEiVEO ✓�
02632 aD J U L. 21 1997
N
NFADLTN DEPT.ABLE
On the above date, I Inspected the septic system at the ab dress
This system consists of the following:
1 . 1-1000 gallon septic tank.
2. 1.—Distribution box.
3. 1-1000 gallon precast leaching pit.
4. 3-infiltrators.
Based on my In6c�actlon, I certify the following conditions:
1 . This is a title. five septic system.
2., The septic_ system is in proper working
order at the present time.
51GNATURF7: fo
Name : J . P . Macomber Jr... i
-------,---------------
Company; J . P_Macogber &- Son-Inc .
Address:_ 8aac-bb-----=�------
Centervill.eAM ss__02632 '
Phone:---508.�Z7-5-333a------- - I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
Nr
.OSEPH P. MACOMBER- & SON, INC.
Tank&,-C*sspools-Leschflelds
. Pumped & installed'
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
775-33M 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
C DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE HINTER STREET. BOSTON, MA 02108 617.292.5500
H ILLIANi F WELD TRL D1'COX
Govcmor
Sc:rcta.,
ARGEO PAUL CELLUCCI DAVID B STRUH
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission
PART A
CERTIFICATION
Property Address: Lynn Mahoney 28 Lietrim Circle Address of Owner:
Date of Inspection:7/12/97 Centerville,Mass. (If different)
Name of Inspector: Joseph P. Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P. Macomber & _Son,_ nc .
Mailing Address: : Centerville , Ma . 02632-0066
Telephone Number: / > J J
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_Zpasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails /
,Wll' Date:
Inspector's Signature:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15,303.
Any failure criteria not evaluated are indicated below,
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
40 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not
&)� The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or
the septic tank, whether or not metal, is cracked, structurally unsound,.shows substantial infiltration or exfiltration, or lank
failure is imminent. The system will pass inspection.if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:1twww.mapnel.state.ma us/dep
Printed on Recycied Paper
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Lietrim Circle Centerville Ma
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/9 7
B] SYSTEM CONDITIONALLY PASSES (continued)
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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
,tea The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
U Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Ld 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
�f The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
L' The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the pre se ce of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance _(approximation not valid).
3) OTHER
(rw1oed 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Lietrim Circle Centerville Ma
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/9 7
D) SYSTEM FAILS:
You must indicate ei;-.er "Yes" or "No" as to each of the following:
I have determined y that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bass
�O
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea
the failure.
Yes No ,
Backup of sewage into facility or system component due to an 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.
Liquid depth in cev;pQral is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($).
Number of times pumped w,/
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
An cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Y portion of a
Any portion of a cesspool or privy is within a Zone I of a public well.
L� 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.
Q LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
�ICCr the system is within 400 feet of a surface drinking water supply
�i - the system is within 200 feet of a tributary to a surface drinking water supply
IfA the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
)revised 04/]5/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 Lietrim i C rcle
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/9 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and'the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
- '
All system components,AlAluding the-Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
— The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.Ci.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Lietrim Circle Centerville Ma
Owner: Lynn Mahoney
Date of Inspection: 7/12/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow.�.p•d./bedroom for S.A.S.
Number of bedrooms: IV
Number of current residents&2&
Garbage grinder (yes or no):A?61
Laundry connected to system (yes or no). lE?S
Seasonal use (yes or no): 4)0 / G
water meter readings, if available (last two (2) year usage (gpo): �Q1 ,�{�C1d0 z ��`y! �"
Sump Pump (yes or no):Z_)L 4M 7
r
Last date of occupancy.
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:._Jhl�gal Ion s/day
Crease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)Az� �1
Non sanitary waste discharged to the Title 5 system: (yes or no). 14
Vv'ater meter readings, if available Z)/
14
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and s4 r e fjinformation:
System pumped as pan of inspection: (yes or no),�o
If yes, volume pumped: gallons
Reason for pumping:
TYPE O SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
�Q Privy
Shared system (yes or no) (if yes, anach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: /J/Q
Sewage odors detected when arriving at the site: (yes or no) /10
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Lietrim Circle
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/97
BUILDING SEWER:
(Locate on site plan)
A
Depth below grader
Material of construction: _ cast iron Z0 PVC — other (explain)
Distance from 9rivate water supply well or suction line
11
Diameter 4T
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:.Leod(l'/ A.5
(locate on site plan)
t)
Depth below grader
Material of construction: Zoncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age ZZ,�q Is age confirmed by Certificate of1Compliance�,�(Yes/No)
Dimensions:
Sludge depth:
Distance from top of s�Ydge to bottom of outlet tee or baffle:
Scum thickness: � r/
Distance from top of scum to top of outlet tee or baffle:_ �r
Distance from bottom of scum to bottom f outlet tee orlbaffle:�C�
How dimensions were determined:
Comments:
(recommendation for pumping, condit}pn of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) .t/ ti r i-�.V /'
IN t • 7'' 7 Y2A2 '41 "Y7WIL i 5 /J Y .4.! S o d
do zTJz-C
GREASE TRAP:�i e
(locate on site plan)
Depth below grade:-,d&
Material of construction;(2!�concrete.(AmetaLoFiberglass '6/4Po[yet hyleneoAther(explain)
Dimensions: 14W
Scum thickness:
Distance from top of scum to'top of outlet tee or baffle:
Distance from bottom of scym to bottom of outlet tee or baffle:�/�
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
i
(revised 04/25/97) Paq• 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Lietrim Circle Centerville Ma
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/9 7
TIGHT OR HOLDING TANK:A&,:�(Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:.64
Material of construaion:,,t)4concret&V,9 metal V41'iberglass4_),4PolyethyleneA'. other(explain)
Dimensions: A4
Capacity: AA gallons
Design flow: /114 gallons/day
.Alarm level: /t)g Alarm in working order VVYes;4),j No
Date of previous pumping: V—
Comments.
(condition of inlet tee, condition of alarm and float switches, etc.)
U r ah a 2,y� 713WIR � 2r
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(no a if level and distribut on is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
L/L i i
i e-zii 0 1
�¢ if je- /,v D!^ du T d 7- D K
PUMP CHAMBER:A/4210e
(locate on site plan)
Pumps in working order: (Yes or No) AM
Alarms in working order (Yes or No)-424
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
2 jr IC AAT
(reviz•d 04/25/97) Pa90 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Lietrim Circle Centerville
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/9 7
SOIL ABSORPTION SYSTEM (SAS):
;locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: .
leaching pits, number:t
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:(9 7L
Alternative system: J tti�t Gi'�47 _
Name of Technology: 1,Uo /t�Y
Comments:
(note condition of soil, signs of hydraulic failure, level of (jnding, condition of veg cation, etc.)
l,. fr r.
{ i ,
CESSPOOLS: A 1 e
(locate on site plan)
Number and configuration: w>r4
Depth-top of liquid to inlet invert: Alit
Depth of solids layer: A114
Depth of scum layer: 414
Dimensions of cesspool:
Materials of construction: 144
Indication of groundwater:
inflow (cesspool must be pumped as pan of inspection)
Ag
tyi
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
SipDD S T Ore se�yT
PRIVY:
(locate on site plan)
Materials of construction: /l�/9 Dimensions: yi5�
Depth of solids:_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
r�r/Y 1 JLv B
(revised 04/35/91) D&g• 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Lietrim Circle Centerville
Owner. Lynn Mahoney
Date of Inspection: 7/1 2/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
-
a
7
(s.vi..0 0i/75/97) ➢age 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Lietrim Circle Centerville
Owner: Lynn Mahoney
Date of Inspection: 7/1 2/9 7
Depth to Groundwater&rFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
-Observation of Site (Abuning prop&rrL observation hole, basement sump etc.)
_ZDetermine it from local conditions
heck with local Board of health
Check FEMA Maps
heck pumping records
�eclk local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Septic systems installed in the areaof Lierim Circle and Taramac Road.
These are all title five septic systems 78 Code. No water encounterd at 121±
Existing leaching pit is dry. The pit shows no signs of water intrusion.
(revised 04/25/97) Page 10 of 10
1
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� Barnstable �-
'1.W0 OF WARD OF HEALTH �
SUIISURFACE SEFIAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIF1CATIO�;
� F...-....�.....•--il'.����.T.�I•rt:TTT.`RT..TT1',r•.1^ ITTtRTAT'T1.11'11�1.'•'R�TTT ITn.nT.i"rr.TT+�.+- -�r•� r. - _ 1
-TYPE OR PRINT CLEARLY-
PHOPERTY INSPECTED
STREET ADDRESS 28 lietrim Circle Centerville,Mass.
ASSESSORS MAP , DLOCK AND PARCEL #
O w N E R ' s NAME Lynn Mahofiey
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr .
COMPANY NAHE Joseph P. Macomber & " n , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
5tra9t TOvn or C1ty St,t. tIP
COMPANY TELEPHONE 1508 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
this nddress and that the information reported is true , accurate , and
complete as of the time of .-inspection . The inspection was performed and any
recornrnendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance o ;site sewage disposal systems .
Check one :
�ysteui PASSED
The inspection 1ihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
I,ealLh or Lhe environment as defined in 310 CMR 15 . 303 , Any fail �, re
criteria not evaluated are as stated in the FAILURE CRITERIA sectie.:, o :
this form .
System FAILED \
The inspection which I have con ilcted has found that the system fn '. ls to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILUR-
CRITERIA of this inspection form .
Inspector Signature
Date —1
.�..-.!�'����-Tom.•...-. �.
')ne copy of this certification must be provided to the owNER , the DUYER
( where a p p I icabl e ) and the DOARD OF HZALI'11 ,
IC the inspection FAILED , the owner or 'oporator shall upgrade
one year oC the dote of the inspection , unless allowed ortrequirecj
otherwise as provided in 310 CmR 15 . 305 .
pa, t+ • ,�c..
U
7 �
y
- SSbjV 3/�l�
THE COMMONVVEALTH OF MA.SSACHUSETTS
DEPARTMENT OF E ONMENTAL PROTECTION
BE IT KNOVVN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
Junc 8, 1995
Acung Dircctor of the ion of Watcr Pollution Control
LOCATION:
VILLAGE:
LOT#: PERMIT#:
INSTALLER'S NAME:
INSTALLER'S PHONE#:
LEACHING FACILITY. (type) �f �j,yp� ,�T���,� (size)
/
NO. OF BEDROOMS:
BUILDER OR OWNER:
PERMIT DATE:
COMPLIANCE DATE:
DRAW DIAGRAM ON BACK
V 5
l
TOWN OF BARNSTABLE
J
LOCATION ��,e SEWAGE #
VILLAGE*I!fA" /.g r 02//e ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. '7'7
SEPTIC TANK CAPACITYf61Z iSa, , 4 /J &X
LEACHING FACILITY (type) 3,L-fa, ize)
' NO. OF BEDROOMS �, PRIVATE WELL OR PU�'LIC WATERA4CiC
BUILDER OR OWNER ,//. Raf'1 -4%
DATE PERMIT ISSUED: s�� �g
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
v
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ASSESSORS MAP NO- t
hh PARCEL N0:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AFl ® TOWN OF BARNSTABLE
K�Dv
lirtt#" i� ntti nrlt� C�a��t �rrinnprutit
A. a
n
nion—ishereby-7rdEff. a Permit to Construct ( ) or Repair (V�an Individual Sewage Disposal
System At:
tion-Address or Lot No.
.....
Owner ddre �
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.........a------------------------------Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building No. of persons............................ Showers
a g ----••---•••---•-•--•------- P ( ) — Cafeteria ( )
04 Other fixtures ---------------------- ---------------------------------------------------------------- ---------•••-----•-••-------•--••••--••••--•---...........---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity---iogallons 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........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................
W ----•••-••-•-----------------•-•••--•••••••....-••-••-•••-•-•--------••......-•-••••._...------•-•--........................................................
0 Description of Soil........................................................................................................................................................................
W
x -------- --- -------- ------ - y,
U Nature of Repairs or Alterations— nswer when applicable......._ ��.. .._...._(_. (}� ._`........ ... ......
L
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian has been ' sub t e oard of health.
Signed ------- _..._ ---- --- ----------- --------------------------------------
Dare
Application Approved By ............ ..
,. ^ ..7...� 9.Yf...
-- Dare
Application Disapproved for the following rearonr- --------------------- -------------------------------------------------------------------------------------------------------------
................ ................. ...._................. . ....................... ... ... . ....._............................... ----------------------------------------
Da'
PermitNo. -----q- _ `- .. ................... Issued ---------------------------------------------------------...._.----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
I�tral- it 'unpwial Wnrk,i C�omitrurftntt rrruttt
A lication is hereby made for a ermit to Construct r Repair p y t ( ) o p (L/�an Individual Sewage Disposal
System( t:
a _
------------- Y...Ue_kc'sue..•.....` �.a.--••-•-•-------........... ------------------------------��.....--------...---------...--------•---....---•••------•-
hon-:address or Lot No.
...... .Gt.! ... _----------••..................... •----- � ........................................................
.... ddre
------------
A.
Installer Address j
UType of Building Size Lot............................Sq. feet
.-I Dwelling— No. of Bedrooms.___----- -----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures ------------------- ----------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity---10CIgallons 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. I................minutes per inch Depth of Test Pit______-______----_ Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 --•-•------------------------------•---------------•--- .....................................................................................................
ODescription of Soil.....................................................................................•..................................................................................
U .....•---------------------•--------•-----------••-••-•-•----------•------•---•••••---•••---•------••-••-•-------•-••-••••--•---•---•-----•-•----•--•---•---••---.......................................
W
x •------------------------------ ------------------------------ -----------------------------------------------
Nature of Repairs
or Alterations—,Answer when applicable-.-._._ I ,L L
ar—I.nX.........Cc�cn }i^ .-.•-• -. .. •-�-. Q `� . ..._. .C- ---- W
-.1 1• r 'Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been ' sue- y t e board of health.
Signed (-a.-../� ...
Dare
Application Approved B -
Date
Application Disapproved for the following reasons- --------------------- --------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------
Dace
PermitNo. ..----q--1/------..- -. -------- --------- Issued .......--------------------------------------....
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
TerttifiratE of Tompliance
THIS IS TO CFRUFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by -------------------- .......... ............. - ........
C � Installer
at ------------------ -----------l...C.. rc.. .------ U
-------------------- -......... --------------------------------------------------------
has been installed in accordance with the provisions of TITLE 51Qf The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..... ----------- dated .....__----------------........._--------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED. AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. -�~---- .�' . ---- -- ----------- Inspecto . . -
� �/
------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No... FEE... ...............
�i���a� l �rk� �utt�#rtuan �rrnti�
Permission is hereby grante -••-•----- ..c:s?. 0 CC ! ,----------------------------------------------
to Construct ( or (repair ) an Individual Sewage Disposal System
atNo. C_ -f.................................. ------------------------------------------------------------------•-----.----•----
Street
as shown on the application for Disposal Works Construction Permit NoA—W2_._. Dated...... ��^•���°-.
Board of Health
DATE................ '. ...................................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS