HomeMy WebLinkAbout0085 LONG BEACH ROAD - Health LONGBEACH RD.
CENTERVILLE
A = 206 022 /
TOWN OF BARNSTABLE
LOCATIO L&vl i 1f3eQ*lwTE.
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VILLAGE e (p� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.Z1 � P. Jr� Co,n � e r: - C J�
SEPTIC TANK CAPACITY 2- GG o 4 Li9
LEACHING FACILITY:(type �
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_JD
BUILDER OR OWNER,
DATE PERMIT`ISSUED: Sr 7
DATE COMPLIANCE ISSUED: _
VARIANCE GRANTED:. Yes No e/
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 4 Apt YASCE
DEPARTMENT OF ENVIRONMENTAL PROTECT16K J!A 26
53
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 85 Long Beach Road
Centerville,MA 02632
Owner's Name: Mike Hughes
Owner's Address:
Date of Inspection: June 21, 2005
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Nees urther Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: _ June 27. 2005
The system inspector shall sub t 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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Long Beach Road
Centerville, MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
Inspection Summary: Check 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 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.
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:
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:
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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Lonk Beach Road
Centerville, AM
Owner: Mike Hughes
Date of Inspection: June 21, 2005
C. Further Evaluation is Required by the Board of Health:
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:
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.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Long Beach Road
_ Centerville. MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h 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.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
No (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 System:
To be considered a large system the system must serve a facility with a design 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 criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
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 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 85 Long Beach Road
Centerville, MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
Check if the following.have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping 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?
✓ 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
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _ 85 Long Beach Road
Centerville. MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): Yes
Water meter readings,if available(last 2 years usage(gpd)): _2004-120.000 gals.:2003-87 000 Qals
Sump Pump(yes or no): No
Last date of occupancy: Summer use
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
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:
Date of installation unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 LonizBeach Road
Centerville, MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 4"
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: 2000.eal. (H-20)
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
_Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
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.):
7
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Lone Beach Road
Centerville, MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal ,_fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
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• Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Long Beach Road
_Centerville. MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: _5-flow diffusors(per as built card)
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.):
There did not appear to be any signs offailure
CESSPOOLS: None (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 layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic 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: _- 85 Long Beach Road
Centerville. MA
Owner: Mike Hughes
Date of Inspection: June 21, 2005
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 . FronT Q\
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10
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
f
Property Address: 85 Lone Beach Road
Centerville, MA
Owner: Mike Hutches
Date of Inspection: June 21, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 8+/- feet
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: topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours mans the maps were showing gRproximately 8'+/ to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will 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.
I
11
L _ /,
I t
0ATE : 8�7�01 ---- -
PROPERTY A O O R E S S: Joseph A. Dorgan------
85 Lonbeach Road
------------------------
-- Centervi11e�Mass`02632_
On Iho above data, I inapootod the oeptlo ,oyster at the aboye address.
This syslom conalsls of the following;
1 . 1 -2000 gallon septic tank.
2. 1 -Distribution box. RECEI;VP
3 . 5-Flow diffussors side to side. 26 'X14 '
eeied on my In3pectlon, I certify the following ov dltap 31 5 ZOUI
4 . This is a title five septic system. ( 78 Code ) Ullaa
5.. The septic system is in proper working order TOWN of BARNS)A8LE
at the present time. HEALTHDEPT.
6. The flow diffussors are holding slight puddles of
waste water.Sand is clean.
$10NATVRE; / _�J�
Name : 9-r-
Company: Joj !.ph_P_- N.cowb.r-b Son , Ync , � �� CJ� Od
Address :_ Box- 66
-- --------------- -
-_ConcerYIII@L H6 ,_02632-0066
PhonePhone 508 175; 3338
:--- - rw__w w_
THIS CERTIFICATION 00es NOT CONSTITVTC A OVARANTY OR WARRANTY
J6SEPH P. MACOMBER & SON, INC,
T+nk� 0r��pool� t,�+chll�idt
Pvmp#d 4 Init+llid
Town 3+wfr Conn+vtloni
P.O. Box 66 C+ntrrYlll+, ► A 0263Z-0066
77S SJJB 775611z
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL. PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 85 Longbeaeh Road
en ervi a Mass.
Owner's Name:JOsep A. Dorgan
Owner's Address: 8 7 01
Same
Date of Inspection: 817/01
Name of Inspector: (please print) J.P. MacombP,_r ?r
Company Name:Joseph P. macomber & Son Inc
Mailing Address: Box 66
_Centerville Ma 02632
Telephone Number: 508 775 13R
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. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_h/Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authoriry
Fa' s
Inspector's Signature: Date: F--7-d
The system inspector shall sjWmit a copy of this inspection r ort 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
, Y
conditions of use.
Title 5 Inspection Form 6/1 512 000 page I
Paee 3 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:85 Longbeaeh Road
en ervi e, ass.
Owner: Joseph A. Dorgan
Date of Inspection: 8 7 01
Inspection Summary: Check A,B,C,DorE/ALWAY complete all of Sectlon D
A. System Passes:
Al, I have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 In exis . ny failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order
at the present time.
B. System Conditionally Passes:
AIQ 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,NU) in the for the following statements. If"not determined"please
explain.
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 ii 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 sepric 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:
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, senled 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:
The system required pumping more than 4 times a year due to broken or obstructed pipe($). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_ obstruction is removed ,r•
ND explain:
2
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Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:85 Longbeaeh Road
en ervi e,Mass.
Owoer.Jose h A. Dorgan
Date of lospection: 8 7 01
C. Further Evaluation is Required by the Board of Health:
A16 Conditions exist which requ'u•e father evaluation by the Board of Health in order to determine if the system
is failing to protect public health,,safery or the environment.
I. S,N'stem 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 wbich will protect public bealtb,safety and the environment:
Cesspool or privy is within 50 fcet of a surface water
Cesspool or privy is witbin 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 bealth,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.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the-SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet ut 50 feet or more from a
private water supply well''. Method used to determine distance �15L1�
"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:
3
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Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Longbeaeh ;Road
Centerville,Mass.
Owner: Joseph A. Dorgan
Date of lospection: 8/7/01
D. System Failure Criteria applicable to all systems:
You must indicate 'yes"or"no" to each of the following for all inspections:
Yes No
_ 4ckup 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
�logged SAS or cesspool
Sutic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/cesspool 6- DJ f�WPS ..?6X "V/
_ d squid depth-in cesspoo is less than 6"below invert or available volume is less than h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
D d
_ �y 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
ater supply.
SL�i y portion of a cesspool or privy is within a Zone I of a public well.
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. [Tbls system passes If the well water analysis,
performed at a DEP certified laboratory, for collform 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 forma
/ (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 now 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 criteria above)
yes n9
_ (_I�/the system is within 400 feet of a surface drinking water supply
(//the system is within 200 feet of a tributary to a surface drinking water supply
Zthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well
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 l 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 85 Longbeach Road
en ervi e,Mass.
Owner: Joseph A. Dorgan
Date of Inspection: 7 01
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No/
_,/ Pumping 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?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
_1z 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)J
5
I
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 85 Longbeach _ Road
Centerville,Mass.
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): -5- Number of bedrooms(actual): S
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):6-mo c
Number of current residents: 4 �p_
Does residence have a garbage grinder(yes or no):�
Is laundry on a separate sewage system (yes or no):A. [if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use: (yes or no): 5
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
� �s
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: _ AIX
Design flow(based on 310 CMR 15.203): Ile gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):,M
Water meter readings, if available:
Last date of occupancy/use: 41)1¢
OTHER(describe): �J
GENERAL INFORMATION
Pumping Records
Source of information: keA no
Was system pumped as part of the'inspection(yes or no):
If yes, volume pumped: _gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
N¢Single cesspool
,126 Overflow cesspool
"Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
�JQ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank A�o Attach a copy of the DEP approval
Other(describe):
Apprcite age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
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: 85 Longbeach Road
en ervi e, ass.
Owner: Joseph A. Dorgan
Date of Inspection:
BUILDING SEWER(locate on site plan)
�Lf
Depth below grade:
Materials of construction: _cast iron _L,,eO PVC,461other(explain): lift
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage. The system is
vented throuZ(-Iocate
h the house vent.
SEPTIC TANK: on site plan)
Depth below grade: _/
Material of construction: concretex�dmetaW/ fiberglass�Qpolyethylene
.�other(explain)_
I f tanl: is metal list age:&e Is age confirmed by a Certificate of Compliance(yes or no):4�eattach a copy of
certificate) ��
Dimensions: A,124"
Sludge depth:
Distance from top of sJtidge to bottom of outlet tee or baffle:
Scum thickness:1
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee or baffle:
How were dimensions determined: �¢$�
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pump the spptic tank Garbage disposal present.
Inlet & outlet tees are in p ace The tank is structurally
sound and shows no evidence of leakage.The liquid level at
the outlet nvert is 5 ' 4"
GREASE TRAocate on site plan)
Depth below grade:/1*
Material of construction:AJ,4concrete,Ametal&fiberglass polyethylene,//other
(explain): XIA
Dimensions: A
Scum thickness: dl,4 _
Distance from top of scum to top of outlet tee or baffle: ✓�
Distance from bosom of scum to bottom of outlet tee or baffle: W,* _
Date of last pumping: V.4_
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
n Grease trap is not present-
7
• Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Longbeach Road
Cen ervi a Mass.
Owner. Joseph A. Dorgan
Date of Inspection: 61 /101
TIGHT or HOLDING TANK411 tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: Xhi
Material of construction:4�concretej�,9 metalfiberglass i/ Polyethylene other(explain):
A)A
Dimensions: wh
Capacity: Alh gallons
Desien Flow: AW gallons/day
Alarm present (yes or no):
Alarm level: _&A Alarm in working order(yes or no): 0
Date of last pumping: A_
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX: 2(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.):
Distribution box has one lateral.No evidence of solids
carry over.No evidence of leakage into or out of the box
PUMP CHAMBER 1G (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present.
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress:85 Shortbeach Road
en ervi e, ass.
Owner: Joseph A. Dorgan
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):Zlocate on site plan,excavation not required)
If SAS not located explain why:
Located. 5—Side laoders diffussors in series. 26 'X14 '
Type
(Jo leaching pits, number:_ o
leaching chambers,number: tiF dj 11u�*al.S S'+djO 01� Ah )A lV
,t& leaching galleries,number: D
Vj)leaching trenches,number, length: D
leaching fields,number,dimensions:
overflow cesspool, number: (�3 ,
innovative/alternative system Type/name oftechnology:%i�� yt;'
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loamy sand to. sand. No signs of hydraulic failure or
ponding.Soi s are dry.Vegetation is normal.
CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: ,yi¢
Depth of solids layer: Aow
Depth of scum layer: 14M
Dimensions of cesspool: y,+Q
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present
PRIVYq��L(locate on site plan)
Materials of construction: ill/4
Dimensions:
Depth of solids: ,l]
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 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Longbeaeh Road
C_enterville,Mass.
Owner: Joseph A. Dorgan
Date of Inspection: 8 7 01
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.
•
�5 Lc>n ac�
I ►�a�w r►�.�
I
I
1 '
I 0 I
10
I�
Page 11 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Lonbeach Road
Centerville,Mass.
Owner: Joseph A. Dorgan
Date of Inspection: 8/7/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
t
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
"V fined from s d Tans on record-If checked,date of design plan reviewed:
bserved site(abutting property observation hole within 150 feet of SAS)
ec a wtt oca oaz oHeahh-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water contours map.
Gahrety & Miller Model
1 2/1 6/94
11
L
.•r.nT+.-n1T+>-.'n- mrmr•r.,rswnr�+.r+�.rre*nn�.-.1Twrn�+rnm nsrR�u�n�sw•n rn-r►T-.�lr--:..<•.� •`
TOWN OF Barnstable BOARD OF HEALTH
SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION0 I
T!'1^T••-•.:1—T.1 I I.^.TTT n rll'I1.1ri Tf1►1R17I'TRT r_t•1 T'1 VR11�TTw�f IR�RIR\ tw11 .TI-T'ram.^1. ._..A
-TYPE OR PRINT CLEARLY-
P/IOPERTY INSPECTED
STREET ADDRESS 85 Longbeach Road Centerville,Mass,
ASSESSORS MAP, BLOCK AND PARCEL #
OWNERRIs NAME Joseph A.• Dorgan
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.,
COMPANY NAME Joseph P. Macomber &''ton Inc
COMPANY ADDRESS Box 66 Centerville Ma 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790- 1578
7R
TIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
®rlecoinmendations
his address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
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 :
iv/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 Lhe environment as defined in 310 CMR 150303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection wllicll I have con toted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
a( ne
copy of this certification must be provided to the OWNER, the BUYER
here applicable ) and the DOARD OF HEAL'I`lI,
* If the inspection FAILED, the owner or operatorshall upgrade ' the eyetem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 , 305 .
partd .doc
ASSESSORS MAP No. 6
�. PARCEL NO: — O
Fes$
No.� 75
THE COMMONWEALTH OF MASSACHUSETTS
SUBJECT TO APPROVAL OF BOARD OF HEALTH
BARNSTABLE CONSERVATION
COMMISSION -.Tb.a_n__ ._...................O F...B:ar n s t ab l e..--- -------------------------------------
Appliratiou for Uisvuiial Works Tnnitrnrtiun thrmit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
Systesn�t
i.............. :.Ro.�:d...Centez°.. ille
- - --------Lot-N--.----•-------------------------------------
Location-Address or o
Dr.....Dargam------------------------------------------------------------------- --------------------------------------------------------------------------------------------------
Owner Address
aJy P•MacO?np r-•----------................................................ -•----•--•----------......--•--.......-----------------•----------------------•-•-------..........
Installer Address
Type of Building Size Lot............................Sq. feet
U DwellingX--No. of Bedrooms........5.............. .._..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )—
P4 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-----------------..........---------....
,a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-___________-__-______.
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -------------------------------------------------••--•--------•-•--•------.....---••-------•-------....--•••---•------•---------•--•-......-•-••-...........
0 Description of Soil.....S.an.d................
x
W
U Nature of Repairs or Alterations—Answer when applicable.___5- 2000 ga�.TOY t aril -
5 Flodif fu.ssore•------------------------------------------------
--------------------------•------------------•--------------------...------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE j of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued y t bo d of health.
Signe %<.(/ . • ................. 5,29/W.
Date
Application Approved By--------•-- ------ "'4rr--'�------------------------------ ....................Da.--..............
Date
Application Disapproved for the following reasons:-----•------------------------------•-----------------•---•--•---------•-------•--•--•----------•-....-----•--
•-------------------•----•--•••--•-•-••-•••-------------••-••--------•-••-••-----------•....-•----•-••••-------------.................................................. ...............................
Date
Permit No.... 7= 3.` .......................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................OF..........c..::....�....r ....................................................
ApplirFatiun for Uhgpaii al Works Toustrnrtion ernti#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
-
Location-Address or Lot No.
.....Y.f._._.. r......................... ............................................... ............................................ . ..............................................
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building ............... No. of ersons...._............_...._.___. Showers — Cafeteria
0.1 YP g ------------- P ( ) ( )
a
d Other fixtures ..----•--•-•--...-------•------.....-•----------------.--•-------•--•--••----•---•-•-•------••------•-•-•-------------•-•------•-••---..........---•--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter................_--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY..................................................................•....... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_____._-_-_----__.
4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
N ...-.........................................................................................................................................................
0 Description of Soil------='-----------------------------------------------•-••--••-•--•---•---------•-----------•---------------------•--•--•-------------•--•----••--.........-•------
x
U -•--•--•--••-•---•---•-----•----------------------------•••-------------------------...........--•------••-------------------•-------•-------•-•----------•--.....-•-------------------...------------•.
w
----•--------------- ...............................................................................................................................
V Nature of Repairs or Alterations—Answer when applicable._..---_-_-------_,__-__:_`: ` -- -
= `'"
1.0. ii . JZ. _ -ir_.
------------••----------------------•---------------•---------------•------•--------•----------------------- -•-----------•--•-----------------...------•-----•--•----------•-•------••........_•-----.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of,L-i
p 5 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 -•--•-------------;-----------------•••.� ' ••. ......... (............
Dat
Application Approved BY----------- -�` --'=-"�-----�-�- -�"`^-'---�..............••----•---•---... ........
Date
Application Disapproved for the following reasons:......................
-•-------•-••------•------•-••--••--......---•....................... ......--•---
..--•--•------------------------------•-----------------------------------------.........------...........-----•-----------------------------------------------------------------------------------------
Date
PermitNo.-- _7:... .�.. ................•-------- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..:n.-a t 1, .t k_l '
Trrtifiratr of TampliFanre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired {- }
at. _ ` 1 1 -t Installer — ...
has been installed in accordance with the provisions of Ti T IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-----a._7_-._.3.3-5............. dated-__.._._.__________________________________•--.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... ')..... -: ................. Inspector..................... ............................................
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.OF ..w� EE...F t
O.. ............. ..:!.i ..........
Disposal Norkii Tunotrnrttun Uprutit
Permission is hereby granted.----:.t.a: '._`7_i =----------------------------------------------•-•----------------........---------....-•-•-••-•....._.
to Construct ( ) or Repair (X an Individual Sewage Disposal System
at No------------_---- ��Yi L r?� �1.i, r t J� .aF i. �v a y t •
Street
as shown on the application for Disposal Works Construction Permit Na l- 7 . ... Dated..........................................
•.............. ...-. _ ' --------------------------------
d Health -
DATE................................................................................. Boar of
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
TOWN OF BARNST LE
i J /on Boc� 'A a
LOCATION SEWAGE #
`VILLAGE C�i►-rarv�ll� ASSESSOR'S MAP & LOT oZ0(o as
` INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 'C' 10W >�'t'T�o�l (size)
NO. OF BEDROOMS
BUILDER OR OWNER !NI • NUCi�G1
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 le hing facility) Feet
Furnished by -;7AS t, ttY1 �• FD/�
0
a 31�0 to y.
3 �� OL
y
1 ,� a
LOCATION ,' �j�'� SEWAGE K
•s VILLAGE 1��1�� 1"��•'�i�f- ,ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO-
SEPTIC TANK CAPACITY �Y ,,��--77
LEACHING FACILITY: (rypc). / t) '` .5-�Z,��5 (size.)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any weUs 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
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