HomeMy WebLinkAbout0345 OLD CRAIGVILLE ROAD - Health 345 Old Craigville Road
Centerville P
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RECEIVED
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COMMONWEAL
TH OF MASSACHUSET PS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS TOWN OF BARNs TABLE
I HEALTH DEPT.
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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�'M 5a0
,.._ TITLE 5
OFFICIAL INSPECTION^FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE;SEWAGE DISPOSAL SYSTEM FORM 24�
PART A MAP
CERTIFICATION PARCEL
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE, MA 02632 LOT
Owner's Name: MYERS
Owner's Address: 16 STONE'.CROSSING WAY HOPKINGTON,MA 01748
Date of Inspection: 10/21/02 opy
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Name of Inspector: (please prin't)'�, JQI;N) GRACI ,
Company Name: SEPTIC INSPECTIONS �I��•
Mailing Address: SRO. 130X`2119 TEATICKET, MA.02536
Telephone Number: 508-564-6813,FAX 508-564-7270
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:
X Passes
_ Conditionally vasses
_ Needs Furth Evaluation by the Local Approving Authority
_ Fails
Inspector's Signature: Date: 10/21/02
The system inspector shall submit copy of this inspection report to the Approving Authority(Board.of Health or DEP)within
30 days of completing this inspecti n. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner,'shallsubmit 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
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use al that lime.'Phis
inspection does not address how theesystem will perform in the future under the same or different conditions of use.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 345 OLD'CRAIGVILLE�RD CENTERVILLE,MA 02632
Owner: MYERS "
Date of Inspection: 10/21/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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(' ;NXND) in`the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20.years`bid* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is inuninent. 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`oid is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
li—Ipipe(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: n/a
n/a 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: n/a
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
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tCERTIFICATION(continued)
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE, MA 02632
Owner: MYERS
Date of Inspection: 10/21/02
C. Further Evaluation is Required`b'y 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.
I. 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
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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 tsoil 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 but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"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.
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3. Other:
n/a
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
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Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE,MA 02632
Owner: MYERS I .`
Date of Inspection: 10/21/02;A,
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"-to eac`h of the following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to,the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in tM'distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NO PUMPING,' INFORMATION,
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool of priv'y`is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or-,privy is•within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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,,Nr`coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,;provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.]
(Yes/No)The system failss. 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 system must serve a facility with a design flow of 10 000 d to 15 000 d.
g Y .Y Y g � gP � gP
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
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogeii`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 Ihe.large sy`stein Ito�failedL The owner or operator of any large system consi(lei a siE�11ificant threat
11 0.
under Section E or failed und'er,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.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE,MA 02632
Owner: MYERS
Date of Inspection: 10/21/02
Check if the following have been done. You'must indicate "yes"or"no"as to each of the following:
Yes No 4 `
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks"
X Has the system received norinal flows in the previous two week period`?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwellling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site'?
X _ 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 ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems.'?
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The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no 4
X _ Existing information. For example,a plan at the Board of Health.
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X _ Determined in the.field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15302(3)(b)]
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE,MA 02632
Owner: MYERS ,
Date of Inspection: 10/21/02 i
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3: . Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: n/a
Does residence have a garbage grinder(yes oeno): NO
Is laundry on a separate sewage,system.(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or-no) NO
Seasonal use: (yes or no): NO f �
Water meter readings, if available,(last 2 years usage(gpd)): nha- (� - _I ZI ®Oo
Sump pump(yes or no): NO 00 - 10�t 060
Last date of occupancy: 10/20/02 f„, 1
COMMERCIAL/INDUSTRIAL
of establishment: n/a
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Type ,,.
Design flow(based on 310 CMR 15.203):�Wagpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO '
Industrial waste holding tank present(yes or no):.NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available:,n/a
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Last date of occupancy/use: n/a i
OTHER(describe): n/a $ ,
3 GENERAL INFORMATION
Pumping Records
Source of information: NO PUMPING INFORMATION
Was system pumped as part of the,.inspection(yes or no): NO
If yes,volume pumped: n/agallons;`j How was.quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components„date installed(if known)and source of information:
APPROX 1970 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE, MA 02632
Owner: MYERS
Date of Inspection: 10/21/02
BUILDING SEWER(locate on site.plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well,or suction line: n/a
Comments(on condition of joints,venting;evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is"age Con r"med by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS'\t
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: 1"
Distance from top of scum to top of outlet,tee or baffle: 24"
Distance from bottom of scum to bottomof outlet tee or baffle:-1"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)'
Depth below grade: n/a '
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a,, k,
Comments(Oilpumping recomnEen(ati'ons,.inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.,):
n/a
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE,MA 02632
Owner: MYERS
Date of inspection: 10/21/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float sw trhes,etc.):
n/a
DISTRIBUTION BOX: X(if present-must be.opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX WAS VIDEO INSPECTED ANG APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plain)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Al
n/a
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE,MA 02632
Owner:-MYERS
Date of Inspection: 10/21/02
SOIL ABSORPTION SYSTEM (SAS): % (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' ,leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a ;a ` innovative/alternative system
Type/name of technology: n/a
' l
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. PIT WAS EMPTY AT TIME OF INSPECTION. PIT HAS 1' OF LEACHING LEFT IN IT. BOTTOM IS
AT 10 FT.
CESSPOOLS: (cesspool must betpunped a.'s'part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a '
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
o ,;
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE, MA 02632
Owner: MYERS
Date of Inspection: 10/21/02
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 wherepublic water supply enters the building.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD CENTERVILLE, MA 02632
Owner: MYERS
Date of Inspection: 10/21/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 124 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain': n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+ FT. .
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Town of Barnstable
• snxtvsrnat�. •
Department of Health, Safety, and Environmental Services
`""SS.
039• Public
,0 lc Health Division
� b P.O. Box 534, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
January 4, 2000
Lawrence Smith
2 Dustin CT.
Mansfield, MA 02048
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY
CODE II,MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE BOARD OF HEALTH'S NUISANCE
CONTROL REGULATION NUMBER ONE
The property owned by you located at 345 Old Craigville Rd., Centerville was inspected
on January 3, 2000, by Jerry Dunning, Health Inspector for the Town of Barnstable,
because of a complaint. The following violations of the Nuisance Control Regulation
Number One Regulation and the Sanitary Code II were observed:
• 410 . 602 Large pile of garbage and rubbish observed at
rear of the house.
You are directed to correct these violations within 48 hours of receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven(7) days after the date order is received. However, this violation
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and$15.00
for each additional violation. Tickets will be issued daily until the violations are
corrected.
PER ORDER OF THE BOARD OF HEALTH
Pomas McKean
Director of Public Health
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y 6,
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00. STATE SANITARY
CODE II. MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE BOARD OF HEALTH NUISANCE
CONTROL REGULATION NUMBER ONE
The property owned by you located at
was inspected on _. 7d by
Health Inspector for the Town n Barnstabl , beR use of a comp faint. The following
' violations of the Nuisance Control Regulation Number One Regulation and the
Sanitary Code U were observed: 6 b M
You are directed to correct violations within
of receipt of this notice.
You may request a hearing if written petition requesting same is received by the Board of
Health within seven(7) days after the date order is received. However, this violation must
be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than S500. Each separate day's failure to comply with an order shall constitute a separate
violation.
You are also subject to non criminal citations of$40.00 for the first violation and S 15.00
for each additional violation. Tickets will be issued daily until the violations are corrected.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
Health Complaints
03-Jan-00
Time: 10:00:00 AM Date: 1/3/00 Complaint Number: 2192
Referred To: JEROME DUNNING Taken By: DONNA MIORANDI
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail:
Business Name:
Number: 345 Street: Old Craigville Road, Hyannis
Village: HYANNIS Assessors Map-Parcel: 247-096-002
Complaint Description: Trash all behind and beside house. The
Smedberg's look out their window at the piles.
Tenant has been arrested a couple of times.
Woman and child observed leaving house. Go
to Smedberg's if you like for a cup of coffee if
you need to see it from their house. Owner is
Lawrence Smith of Mansfield (see attached).
Actions Taken/Results:
Investigation Date: Investigation Time:
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Sargent Lynda
From: Giangregorio Robin
To: BMEA1
Subject: Meeting Notice
Date: Tuesday, January 04, 2000 9:33AM
All employees are encouraged to attend a very important meeting Weds. evening at the high school regarding
your future wages.
A brief presentation shall be made on behalf of ALL town unions concerning coalition and impact bargaining.
This session will afford you the opportunity to ask questions of professional representatives. Specifically, we
seek to identify the desire of all members and you will be asked to vote at a later date concerning this
presentation. We seek your opinion on the pursuit and amendment of health insurance costs(employee/town
split). Even if you do not currently participate in one of the insurance programs you are encouraged to attend.
Retirees are also welcome. Whether or not this issue is of immediate concern to you, it is also equally important
that we send a very clear and visual message of unity to Management. All union leaders agree that bargaining
will be difficult this time. Your attendance has the ability to directly effect the procedure and results of your labor
contract. The meeting shall commence at 4:35 at the Center for Performing Arts in the high school. Coffee and
cookies will be available.
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION r
Property Address: 345 OLD CRAIGVILLE RD. CENTERVILLE U
Name of Owner LARRY SMITH
Address of Owner: 2 DUSTIN COURT MANSFIELD MA.02048
Date of Inspection: 12/17/99
Name of Inspector:(Please Print)JOHN GRACI r'
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a g �-
Mailing Address: n/a DEC 2
WN�$ 199
Telephone Number: n/a
f OF BA m ABLE
•� TO ,�DEPT.
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CERTIFICATION STATEMENT +' \
I certify that I have personally inspected the sewage disposal system at this address and that the informationfreported below`�is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experi ce,in__tlie p operfunction and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:12/17/99
The System Inspector sh II submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND MAINTAINING EVERY YEAR.
I
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 345 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nLa 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.
nLa 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 tank
failure is imminent.The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n& 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).
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
n& 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
revised 912/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 345 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17199
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa_(approximation not valid).
3) OTHER
n&
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 345 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17199
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below Invert or available volume is less than 1/2 day Flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X 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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
I
revised 9/2/96 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 346 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)
11 5.302(3)(b)j
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 346 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:—M g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):1
Total DESIGN flow: IQ
Number of current residents:.
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): n/a
Sump Pump(yes or no): NO
Last date of occupancy: Wit
COMMERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): MS2
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings,if available:Wit
Last date of occupancy: n&
OTHER: (Describe)
n/a
Last date of occupancy: n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Wa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nla. gallons
Reason for pumping: Wa
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1967
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17199
BUILDING SEWER:
(Locate on site plan)
Depth below grade: i 6"
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nta
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: i
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nla
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
nLa
Dimensions: L H'S"H 5'7"W 4'10"
Sludge depth: r
Distance from top of sludge to bottom of outlet tee or baffle: 3J_'
Scum thickness:_r.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 1B_
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND EVERY ONE YEAR
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: nLa
Scum thickness: nta
Distance from top of scum to top of outlet tee or baffle:.nla
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
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.)
nLa
revised 9/2/98 Page 7 of 11 i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: Wa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
Wa
Dimensions: nta
Capacity: n1a gallons
Design flow: Wa gallonstday
Alarm present: NQ
Alarm level:jild_ Alarm In working order:Yes_No_: NQ
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n1a
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:nta
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
Wa
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 9/2/98 Page 8 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 345 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: ONE LEACH PIT
leaching chambers,number: ji&
leaching galleries,number: jjLa
leaching trenches,number,length: n&
leaching fields,number,dimensions: n&
overflow cesspool,number: nta
Alternative system: n(a
Name of Technology: 1ILa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,'condition of vegetation,etc.)
THE LEACH PIT STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE PIT HAD 1'OF LEACHING LEFT AT THE TIME OF THE
INSPECTION.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: nLa
Depth of scum layer. n&
Dimensions of cesspool: nLA
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:nLa Dimensions:n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 346 OLD CRAIGVILLE RD.CENTERVILLE
Owner: LARRY SMITH
Date of Inspection:12/17199
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
&%C
a
06
AA a•
AR%L
1p
revised 9/2/98 Page 10 of 11
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 346 OLD CRAIGVILLE RD.CENTERVILLE
Owner: TARRY SMITH
Date of Inspection:12/17199
NRCS Report name: Wa
Soil Type: n1a
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
um in Checked records
- pumping 9
_ Checked local excavators,installers
XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2198 Page 11 of 11
OF BARNSTABLE
LOCATIONSq5 00OWN SEW�A�GE #pc,
y VILL'AGE ASSESSOR'S MAP& LOI ! "®°Z'
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /60
LEACHING FACILITY: ( ) (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 wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
AB aL
�h
C ASSESSOR'S MAP N0. %' PARCEL 41
Ea CATION S Ea AGE P E Rl IJ N0.
VILLAGE
I N S T A LLER'S NAME ADDRESS
1O05 rvAgc�w
BUILDER OR Ow E
DATE PERMIT ISSUED � � ,.. jq
:DATE COMPLIANCE ISSUED . �. � �.��
T/A7
00"' '
......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
AVVIiratualt for Uhi- oiial Workii C omitrurtintt Puntit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at
----..&k.....0.1 ...... l.. �- , f._.•..-Location-i�dd�ss � ....
�S o't yr Lot ---- .... ��
....._' /1...._.—"" --- _n-------------------- -----------------------------------------------------`_,._ v..�'.Y.:'�4.............
Owner (� /� ddress
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms--_._..._____--------___-------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
0 Other fixtures -----------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity-__--_-_---gallons Length________________ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter--------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------ -------------•-------------................................. Date---------------...-----------.......---
Test Pit No. I................minutes per inch Depth of Test Pit-------__-----..-_-_ Depth to ground water........................
(T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ....................................................•-•--.....-----•----------------.....-----------.........................................................
xDescription of Soil------------------------------------ .-• --..... -----•-----....._...---•------------•-------------•-------------------•-----------....-----------•
U ----------------------------------------••------.....----------=-------------------------..... -----*...............................................................................................
W --------•----------------------------------------------------------------------------------------•--------------------------- -- --- ----------------------•-
x Nature of Re air or Alterations.—A sorer hen ica e- -------------- l C . _._.___. O 2
p � � P
S -`,- �-- -----------� ® Q ---�-- --.... s���
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Enviro ntal Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp anc ,has en issue y the oard of health.
Signed ........ .... - ....... ......... ........'. .. .�.:...
ce
Application Approved By .::....._-.. �._L� J 1�>�� kj
X........ .`` .."-----
............................
Dace
Application Disapproved for the following reasons: .... ........... .... ................................ . ............-..-
........................................................)...................................................................................................................................................... P /
Da
Permit No. .....�r ."............. .............. .. Issued 7-------�'-... . ....
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CPrtifirate of Compliana
THIS IS TO CERTIFY, That the Individual Swage Disposal System constructed ( ) or Repaired ( )
by ....�.:.....r .. '.�... .L--......... ..� .�.....'�..�.. .... -
-� -----------------------------------------------------------------=----------------------------------------
at . _. t...�-1�1_:.-......... --,
..
has been installed in accordance with the provisions of TITI.E,5�of The StatS Environmental Code as described in
the application for Disposal Works Construction Permit No. ....,. ...►'`'" _ dated _.._ A" .. . ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT t CONSTRUED AS A GUARANTEE THAT T,HE
SYSTEM WILL
FUNCTION SATISFACTORY.
-----------
DATE
...... - Inspector , `7 a ' � =-
l
THE COMMONWEALTH OF MASSA/CHUSETTS
BOARD OF HEAL?H
,�.�*, TOWN OF BARNSTABLE
Nof`�./ FEE........................
Biopmal �x� �u tUan rrnti�
Permissionis hereby granted.-CZ. ....... ..................................................sit_�......-••----------------•---•--------•--•--•---••--
to Construct ( ) or Repair O an Individual Sewage..;Disposal System
at No..---•-•-•---- •L f . f \ r e„ �.�- �--C 1�--��� �co,-
Street/'}
as shown on the application for Disposal Works Construction Permit No.............�'��Dated_._�.�".f�. ..........r.
--
f" Board of Health /
DATE..... ------•---•-----------------------------••
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
A/-- � - .
No.... _....... F�a. ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Divi-poottl Wor1w Tonitrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (, an Individual Sewage Disposal
System at +
q
s €
Location-Address � Vr Lot No
t� Vn
Ayddress �"V, ....
............. ..:......
Installer Address t
d Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms.............. _-____-__--___----.-_-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons--------..-__________-_--.-- Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------------------------------•-----------------•-----------..........--------.....--------•••-•----•-----------------•...
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. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
fT Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................
a •----•-••-••---•--------•-----------•---------•-------•-------------•-••......----------------...............................................................
0 Description of Soil..................................... `?
x �/.. ..
UW n -- -•------------------------------= ---=r=---_ ------
Nature�of Repairs or Alteratio'nns•—Answer when applicable+..................V,C�,..�y`��'v(-) ._.._._[\.�..}p I - S.,, .'`...._/_.. (1 `
................s^. .�'/k-' .:. A.......
.....�..*��.4._......_._...�-...____.__�..V��*!_..__!_.__...-.+•__...................�-!,/�Ll
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 Complanceh6��
bn isued b\\y��the board of health.
Signed ...._ ......\`Qm ........... .._l� .
Dace
Application Approved By ...... w�-+ :� ��... ..... .... ..*-�, .._._ "'.a.'....�� .(..
Dare
Application Disapproved for the following reasons: ......... .. ... . ........................................ . . .. ............... _ate......... ,..y
....................................................... ........... .................................... . .............................. ........ ......... .........
(! Date
Permit No. "," f Issued ....... ."'..r ....... .....................
`................----------- ----
Dare