HomeMy WebLinkAbout0001 LUMBERT MILL ROAD - Health -------------
1 Lumhert Mill Rd
Centerville
A= 168.= 013
N SMEAD
No. H163OR
UPC 10259
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A RECEIVED
CERTIFICATION
1 Lumbert Mill Road
Property Address:Marstons Mills,Ma AUG 1 .7 2000
Address of Owner:
(if different) TOWN OF BH NSTABLE
Date of Inspection: 16 June 2000
Inspected by: James Holler
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Holler& Son Construction LLC
Mailing Address: P.O. Box 702, °sgten9-,MiUs,Ma 02648
Telephone: (508)420-0280
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this a4dress and that the information f6i orted
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:
®Passes
❑Conditionally Passes
❑Needs Further Evaluation by the Local Approving Authority
❑Fails f/ `—_
Inspectors Signature Date: lv 4l
0T-
The system inspector shall sub ' copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system ice,&hared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall
submit the report to the a} 'ate 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 3 10 CMR 15.303. 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 Healtll,,
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 wd 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 tank 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (Continued)
Property Address:I Lumbert Mill Road,Marstons Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
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 leveled or replaced
❑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:
❑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.
❑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:
❑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 1 of
a public water supply well.
❑The system'has a septic tank and soil absorption system and the SAS is with 50 feet of a
private water supply well.
❑The system has a septic tank and soil absorption system and the SAS is less ttian 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 presence of ammonia nitrogen and nitrate nitrogen is
equal to or less than 5 ppm. Method used to determine distance
(approximation not valid).
3) OTHER
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: I Lumbert Mill Road,Marstons Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
D) SYSTEM FAILS
You must indicate either"Yes"or"No"as to each of the following:
❑I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR
15.303.The basis for this determination is identified below. The Board of Health should be contacted to
15.304.determine what will be necessary to correct the failure.
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%z 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 Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
❑ ❑ Any portion of a cesspool or privy is with 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 with 50 feet of a private water supply well.
❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,
attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen
and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
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
❑ ❑ 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.
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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address: Lumbert Mill Road,Marstons Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
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,excluding 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 or the Soil Absorption System on the site has been determined based on:
® ❑ The facility owner(and occupants,if different from owner)were provided with information on the proper
maintenance of Sub-Surface Disposal System.
® ❑ Existing information,Ex.Plan at BOH.
® ❑ 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)]
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property address: 1 Lumbert Mill Road,Marston Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 gpd/bedroom for SAS
Number of bedrooms 4
Number of current residents:2
Garbage Grinder:No
Laundry connected to system:Yes
Seasonal use:No
Water meter readings,if available (last 2 years usage in gpd):No
Sump pump:No
Last date of occupancy:Currently
COMMERCIAL /INDUSTRIAL
Type of establishment
Design flow: gpd
Grease trap present:
Industrial Waste holding tank present:
Non-sanitary waste discharged to the Title 5 system
Water meter readings,if available
Last date of occupancy t
OTHER:(describe)
GENERAL INFORMATION
PUMPING RECORDS and source Owner
System pumped as part of inspection No
Volume pumped:
Reason for pumping:
TYPE OF SYSTEM
®Septic tank/distribution box/soil absorption system Z S69T I C -7;tM4s
❑Single cesspool
❑Overflow cesspool
❑Privy
❑Shared system(y/n)(if yes,attach 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:20 Years,Owner
Sewer odors detected when arriving at the site:No
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (Continued)
Property Address: 1 Lumbert Mill Road,Marston Mills
Owner:B.Brown
Date of inspection: 16 June 2000
BUILDING SEWER
(Locate on site plan)
Depth below grade 22"
Material of construction❑Cast Iron®40 PVC❑other
Distance from private water supply well or suction lineN/A
Diameter 4"
Comments:(condition of joints,venting,evidence of leakage,etc.11
)
SEPTIC TANK
(locate on site plan)
Depth below grade 14"
Material of construction®concrete❑metal❑Fiberglass❑Polyethylene❑other
If metal list age is age confirmed by certificate of compliance
Dimensions: 1000 Gal � l
Sludge depth: 10" f�V
Distance from top of sludge to bottom of tee or baffle 20"
Scum thickness 2" 6� + 0 lv�
Distance from top of scum to top of outlet tee or baffle 3"
Comments:
ra
'`^� i ' C�r/�"-y Mom► " �.
GREASE TRAP
(locate on site plan) c PI/� T a5
Depth below grade
Material of construction❑concrete❑metal❑Fiberglass❑Polyethylene❑other
Dimensions
Scum thickness
Distance from top of scum to top 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 leak,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (Continued)
Property Address: 1 Lumbert Mill Road,Marston Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
TIGHT OR HOLDING TANK:❑(Tank must be pumped prior to,or 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: GPD
Alarm level: Alarm working?❑yes❑no
Date of previous pumping
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet inve Zero V 4-U-7—,
Comments(note if level,and distribution is equal,evidence of leaks or solids carryover,etc.)
PUMP CHAMBER:❑
(locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order:(yes or no)
Comments:(note condition of pump chamber,pumps,and appurtenances,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(Continued)
Property Address: 1 Lumbert Mill Road,Marstons Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
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 _ c
leaching chambers,numb Infiltrators,6 total
leaching galleries,number
leaching trenches,number&length
leaching fields,number&dimensions
overflow cesspool,number:
Alternative system: Name of technology
Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation,etc.)
CESSPOOLS:❑
(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
Material of construction
Indication of ground water inflow(must be pumped as part of inspection)
Comments:(note condition of soil,signs of hydraulic failure,ponding,and vegetation,etc.)
PRIVY❑
(locate on site plan)
Materials of construction: Dimensions
Depth of solids
Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(Continued)
Property Address: 1 Lumbert Mill Road,Marstons Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
SKETCH OF SEWAGE DISPOSAL SYSTEM
Include ties to at least two permanent references,or benchmarks,locate wells within 100'and where public water supply
enters house.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (Continued)
Property Address: 1 Lumbert Mill Road,Marston Mills
Owner:B.Brown
Date of Inspection: 16 June 2000
Depth to Groundwater feet
Please indicate all the methods used to determine High Groundwater Elevation:
❑ observed from design plans on record
❑ observation of site(abutting property,observation hole,basement sump)
❑ determine it from local conditions
® check with local Board of Health
® check FEMA maps
❑ check pumping records
❑ check local excavators,installers
® use USGS data
Describe in your own works how you established the High Groundwater Elevation. (Must be completed)
No. T6o 7 Fees 40.00 66
THE COMMONWEALTH OF MASSACHUSETTS
i
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppricatiou for Migonl *p5tem Comaructtou i3ermit
Application is hereby made for a Permit to Construct( )or Repair i$XXan On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 428-3 804
1 Lumbert Mill Raod Paul & Sandra Myrick
Centerville,Mass . 02632 1 Lumbert Mill Road Centerviille,M ss.
Installer's Name,Address,and Tel.No. 5 0 8-'7'7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5-3 3 3 8 632
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632
Box 66 CEnterv�ille,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 4 Garbage Grinder Ye o
Other Type of Building Res No. of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 gallons�er day. Calculated daily flow 2x1 10=220 gallons.
Plan Date 8/19/96 Number of sheets Revision Date
Title
Description of Soil Loamy sand to medium sand.
Nature of Repairs or Alterations(Answer when applicable)Omit cesspools. Install 1-1500
gallon septic tank 1-1000 gallon grease trap, 1-D-box 6-330 Rechargers
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed by thi B d of Health.
SignedDate 8 19496
Application Approved by 9
Application Disapproved for the following reasons
Permit No.
�� Date Issued W— C
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced Mon
by J.P.Macomber & Son Inc. for
as 1 Lum rt Mill Roaderi ervl e, ass. has been construciedin accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoVj<`" dated y ^�
Use of this system is conditioned on compliance with the provision et forth below:
No. �W "I 1 �} ' Fee$ 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lie;pooar *p5tem Construction Vermit
Permission is hereby granted to J.P.Macomber & Son Inc.
to construct( )repairM_ an On-site Sewage System located at
1�-Lumbert Mill Road Centerville,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All constructio'mus be/completed within two years of the date below. _
Date: 9t0 Approved bye—_
07 s 40.00 �{
No.
Fee �
THE COMMONWEALTH 9F MASSACHUSETTS
PUBLIC HEALTH DIVISION -_TOWN OF'BARNSTABLE MASSACHUSETTS
Yication for Miooal *r5tem Congtructiou Perron
Application is hereby made for a Permit to Construct({ )or Repair XXXan On-site Sewage Disposal System at: 9
Location Address or Lot No. ` Owner's Name,Address and Tel.No. 428-3 804
1 Lumbert Mill Raod Paul & Sandra Myrick
Centerville,Mass. 02632 1 Lumbert Mill Roark Centerviille,M ss.
Installer's Name,Address,and Tel.No. 5 0 8-77 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 B-77 5—3 3 3 8 632
J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632
Box 66 CEnterville,Mass. 02632
Type of Buildin
Dwelling XNo.of Bedrooms 4 Garbage Grinder Ye p
Other Type of Building Res No. of Persons 2 Showers( ) Cafeteria( )
Other Fixtures "
Desi Flow �r�i allons �erda . Calculateddail flow 2x110=220 gallons.
g Y� Y
Plan Date 8 19/96 Number of sheets Revision Date
Title
Description of Soil Loamy sand to medium sand.
Nature of Repairs or Alterations(Answer when applicable)Omit c e s s-pools. Install 1-1 5 0 0
gallon septic tank 1-1000 gallon grease traD.1-D-box 6-330 Rechargers
Date last inspected:
Agreement:
" The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system k
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has beViss�edB•and of Health.
Signe Date 8 19/9 6
Application Approved by
Application Disapproved for the following reasons
Permit No. 7L Date Issued c9
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, Joseph P. Macomber Jr„hereby certify that the application for disposal works
construction permit signed by me dated 8/19/96 , concerning the
property located at 1—Lumbert Mill Ros-d Centerville meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is ;4 feet or greater bclowtlic bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED :d- EPTIC
�. DATE:
LICENSE SYSTEM INSTALLER IN iE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
TOWN OF BARNSTABLE
LOCATION L U"Al ab e AT M /L L R/— SEWAGE # �^
VLL.AGE C 'eA� I 'e R V/ /-Z-e- ASSESSOR'S MAP & LOT, R�/
INSTALLER'S NAME&PHONE NO. —T P ,A C' o,41 //e K ? S G-,11
SEPTIC TANK CAPACITY C ?' Z,D O D `r A+ V h /Cd O
LEACHING FACILITY: (type) wl lie-C g & ,1 A G P R (size) $:-&.O
NO.OF BEDROOMS 4/
BUILDER OR OWNER
PERMITDATE: "/�j'�' �J`� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of eaching facility)/ Feet
1�
Furnished by 117rLQ'Gd'l�1
1
r®
0
3
f �
f
TOWN OF BARNSTABLE
LOCATION i SEWAGE# �� /0
VMLAGE . 5VA� F4, 4�319 ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. bX/j�
SEPTIC TANK CAPACITY /�C� /ODD iee�s�
LEACHING FACILITY: (type) /A' �6 (size)
NO.OF BEDROOMS
BUILDER OR OWNER �/"1
PERMIT DATE: 4r!1! %��'� COMPLIANCE DATE: fg—
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Y 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 achin fa� �''����`� Feet I
Furnished by l
�'
1
o
o �
0
I '
No...... 2/111
THE COMMONWEALTH OF M SSACH ET� S
BOARD OF H A
'OWN OF BARNS L.
Appliral�u for Diti-Viiiial Works nttstrurtion ramit
Application is hereby made for a Permit to Construct ( ) or I r it (,/�'an Individual Sewage Disposal
System at:
--......`-=,.................. -----
Lo ttion-:1ddr ss or Lot No.
------------------------- - C� �-..
Owner Address
al t' ---- -----------------•------------------------------ -------`�1�----ezvLc ...........................................................
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling— No. of Bedrooms....-. ..-_.-------_._Expansion Attic ( ) Garbage Grinder
aOther Other—Type of Building ......................_..._ No. of persons.-_---------.----.--..---- Showers ( ) — Cafeteria 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........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water....--............--....
(s. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a ------------------------------------------------------------------•••----•------•-••---------------------------------------------------------------•---•----'
0 Description of Soil....................................................................................... ------------------------------------------------ •---------------••-•----.......
x
V ............................................... ----••-•-------------------•--••••••------••••••----••-•-•--------•---- ••-•-••--•-••-•--•••-----•--•••-------••---•--•-•----•--------•-----••-•••--•----
W V
x -- -- -------
&OV
U Nature of Repairs or Alterations—Answer when applicable..cz2._-.7...-..--._-. �....................................................114< , �Ga'•••---_
_ ----
p.
----------------- -•-•--•--• k s `'`' a` ---- ....................................................
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 issued by�bboarddf health.
-
Signed ........ ..-......
'
Date _
Application.Approved By ----' ............. ' ' G M.. ........ ----- ----- .` ...'�' '
D to ...
Application Disapproved for the following rearons: ---...._..-----------------------------------------------------------------------------------------------.._.....'
............................................ ..............' ' ' ... ......---------------------------------------- -------...--------------------------------- ........................................
Permit No. .............. ..�.. F/------------------------------ Issued
----------
Dare-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BAR(�NSTABLE
Certifirate of Complinurr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
byC 'v/\/J - - .........._.................... .
at .... ...�' ±... Q { ...141.E J 1....t�l�- ---------- ---------.......... .......-....---_.........---.......-------------------------------------------------------
has been installed in accordance with the provisions of.TITLE 5 of The State nvironmental Code as described in
the application for Disposal Works Construction Permit No. _ 21 dated ...... ':- ....:SS-..
s
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
No......9 S_ ���1 TOWN OF BARNSTABLE FEE ...2U _
....... ..................
Rapotial Works �u��tr t#imrn rrntit
Permission is hereby granted.........V....... tr.rk------C&------------- ----------------------------------------------------------------------------
to Construct ( ) or Repair (,-j"-an Individual, Sewage Disposal System
atNo......1...... ................................. ---.................-------------------------------.....---------......---•--
Street /5 -7 U/
as shown on the application for Disposal Works Construction Per-t�tit No---------------------- Dated. -3� =�� .........
3 o -
r — Board of Health
DATE--------------------•--------------....---------------
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gerti ictt#e of Tumpliance
THIS IS TO CWTIFY� Tha the�ndiv'dual Sewage Disposal System constructed ( ) or Repaired (
by _..._..... _..... - - ----- p---___.._....-----..............-._-----_. .- ---- ------------------------------...... ---..._...................----------------------
Insrdler
at ...../...._.. .v..M....�,'..r..rn. .1.11......
has been installed in accordance with the provisions of TITLE 55 of The State nvironmental Code as described in
the application for Disposal Works Construction Permit No. - -..�----21-—-------- dated ----- 3----- _.:S_.S.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------.._------__..._--------------__---------------------.....---------- - Inspector ----------------- --_-- ------- -- ---.- ------------.........................
THE COMMONWEALTH OF M'ASSACHU ETTS
BOAR® OF H�'\IlA
TOWN OF BARNS BL
App trAon for Utopoial Warkii n,itrnr#ton Urrnttt
Application is hereby made for a Permit to Construct ( ) or I pi it an Individual Sewage Disposal
System at:
.......... ..----. ...V. '1.�1 pK_1...._.�.L.c l �2 1
• ------•------•--------•--•---------- ---------•-------`�--------------�-"or Lot No..-------......_...._..-_•---•------_..---
- I
.Lo pion-Addrss
----- -dress-....------•................................
Owner Address
------------------
Installer Address
UType of Building Size Lot___________________________Sq. feet
Dwelling— No. of Bedrooms._ ______________________________._Expansion Attic ( ) j Garbage Grinder ( &j
aOther—Type of Building -----------------_-._.--_-- No. of persons---------------------------. Showers ( ) — Cafeteria (�)
dOther fixtures .---.-.-----•-•---•------------•--•-----------•-•----------•---------••----------------
W
Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. i
WSeptic Tank—Liquid capacitv............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 ( )
W
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........................
a --------------------------- ........................................................................---•----••••......---•-----•------•-----...........--••-
0 Description of Soil........................................................................................................................................................................
x
U -----•------------------•----•-•---••••--•-•----------•---•--••--•-•---•-••---------•••-----------•----------------•-•-•••-•-----•----•----•••------...................................................
W
. -------- ---- ---- --- . ---- --------
It
U Nature of Repairs or Alterations—Answer when applicable.-R........��_``!�_...�_..... �� �~ .. .��x
.... ----------- ! ----
Agreement:
The undersigned ages 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 iss�thhbOardof health.
Signed --------------- ---- ...--------------------------
Da re
Application.Approved By .... .1i---M- ........ ... � .. 3'0�
Application Disapproved for the following reasons- ------ ----------------------------....._-------------------------------...........-----......----------------------------
--------------- ------------------------------------------------------------------------------------------------- ----- ----- ---------------------------------------- ------------------------- --- ------------ - ----------
QQ
Permit No- -------------/ .�... ..:. .._........ Issued ----------..... .': ��--
Dare