HomeMy WebLinkAbout0066 OVERLOOK DRIVE - Health 66 Overlook Drive
Centerville P
A 188 082 ��
No. 42101/3 ORA
7 _ .
� ESSELTE
10%
0 0 0 0
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TOWN OF BARNSTABLE
`0Cp T1ON hy0k SEWAGE #
VI)t AGE ASSESS R'S MAP & LOTI`3% "L
NAME&PHONE N
SEPTIC TANK CAPACITY V nn,,���
LEACHING FACILITY: (type) Y/,c t ✓t C6,n Q o (size)
NO. OF BEDROOMS
BUILDER OR OWNER
C�0 Jo 6" ,//"
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 .
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COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�1
P 'fib
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 6 C 1 1-
e a✓4 j
Owner's Name: �, �'/ L el, ✓l.�.f�1X-��`�. t�x. '�"
Owner's Add resX7 - ap 9
Date of Inspection:
Name of Inspect lease rint)
Company Name:
Mailing Address:
Cr t r-
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper,function and maintenance of on site sewage 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
Needs Further Evaluation by the Local Approving Authority
Fails in
Inspector's Signature: .-' Date: �rJ
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to-ffie 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 I
I
Page 2 of I 1" .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
a
Property Address:
-�
Owner-
D
ate
of DpLec-tion: 0
.1411)
Inspection.Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D
A.�ystem Passes:
I have not found any informationwhich.indicates that any of the.fail ure-criteria.:deseribPd-in-31;0 CMR-
15.303 or in 10 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,vyill pass:
Answer yes,no or not determined(Y,N IUD)in the for the following statements. If"not determined'.'please
explain.
The septic tank is metal.and:over'2O.years old* or the septic tank(Whether metal or not)is structurally.
unsound, exhibits substantial infiltratiorr.cir.exfi ltratiori or tank failure
is imminent:System will pass inspection if the
existing.tank is replaced with a complying septic taril: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
ob-struction is,removed
distribution box is leveled or replaced
ND explain:
The system required pumping morn 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):
brok--n 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)
1
Property Address: 4ne 14'/0 VILAY21, 191 A 10
Owner: f
Date spection:
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 :Hill 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
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is withir_a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is withir_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 DEEP certified.laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free fi-orn pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to Dr Tess 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 1
OFFICIAL.INSPECTION FORM—.NOT'FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address-/ (is
Owner: _4
Date of pection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes. N
_ Backup of sewage into facili- or system component due to overloaded:or clogged SAS or cesspool
Discharge or ponding of of luent to the surface of the ground or surface waters due to an overloaded or
1 clogged SAS or cesspool.
tf Static liquid level in the distribution box above outlet invert due to an overloaded or.clog ged SAS or
/ cesspool, .
f/ Liquid depth in cesspool is less than.6"below invert or available volume is less than.'/2 day flow
. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)-.Number
l of times pumped
_ ✓ Any portion of the SAS, ces_=pool 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
Jl water supply.
Any portion of a cesspool.er privy is within a Zone 1 of a,public well. _
_ U Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a.cesspool cr 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 fa6lity-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).1he system fails. I have determined that one-or more of the above failure criteria.exist as
described in 310 CMR 15.303,therefore the system fails. The system:owner should contact the Board of
Health.to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large.system the system must serve a-facility with a.design.flow of 10,000-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 o=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 nitrDgen 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 faded 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
4
Pate 5 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner
Date of I ection: I
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes —
Pumping information was provided by the owner, occupant,or Board of Health
4ZWere any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two wetik 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?(Ifthey were not available note as N/A)
Was the facility or dwelling inspected for,signs of sewage bajk up
A/� — 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 ir:erior 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
_V Was the facility owner(and'occupants if different from owne-)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 tz-•Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
i y
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION
Property Address:'
�".Owner:
Date of, pection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): �,_,,.�--�
DESIGN flow based on 310 CMR 15.203 (for example: 1:0 gpd x#of bedrooms),`
Number of current residents: _
Does residence have,a garbage grinder,(Yes or no): ~
Is laundry on a separate sewage system( or no
[if yes separate.inspection required]
Laundry system inspected(ye r no)./
Seasonal use: (yes or no): O
Water meter readings, if avai tible(last 2 years usage (gpd)): a��3. f?��`IV/00
Sump pump(yes or no):
Last date of occupancy: 9e"
J
COMMERCIAL/INDUSTRIA1k
Type.of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgfE,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Tit:e 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records \ A
Source of information:
Was system pumped as part of the insp-2ctics yes or no):
If yes, volume pumped: gallons--Ilow was quantity pumped determined?
Reason for pumping:
TYPPI 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):
hA roximate age of all components,date installed(if known)and source of information:
Were.sewage odors detected when arriving at the site(yes or no)/L�ld
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cortinued)
Property Address:
Owner:
Date of I s ection:
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:
Material of construction: concrete_metal_fiberglass_polyeth°]ene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate), ,
Dimensios: 2's x
Sludge depth:
Distance from top of sludge to bottom of outlet tee.or baffle: 3 L
Scum thickness: b
Distance from to of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottomyf outlet tee or baffle:
How were dimensions determined: 1 �
Comments(on pumping recomme ations, ' let and outlet tee or baffle condition,structural integrity, liquid levels
s related to outlet invert,evidence of leakage, etc.):
C P
GREASE TRAP (locate on site plan) 1
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
Page 8 of I 1
OFFICIAL INSPECTION, FORM-NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:66
Date of spection: "Q009
TIGHT or HOLDING TANK: rtank 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 floEt switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan) .
Depth of liquid level above outlet invert:
Comments(note if box is level and disir_bution to outlets equal, any evidence of solids carryover,-any evidence of
leakage into or out of box, etc.):
PUMP CHAMBER: locate on sire plan).
( P )
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)
BB ,
Property Address: ,sue
Owner:
Date of spection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
2 Typ
leaching pits,number:
leaching chambers,number:
leaching galleries, number:
china trenches, number, length: _
leaching fields,number,dimensions: °k
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,
JL d g.
CESSPOOL(cesspool must be pumped as part of inspection)(lacate 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.):
PRIV�(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of por.�iin-,condition of vegetation, etc.):
T ° � ,�rxe 6
&yWC/ kO"%4e)9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress: .
Owner: ��((( -N
Date of pection: �00C
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 )CO feet.Locate where public_ water supply enters the building.
�161
a
1 �
1 '
U
� a
--_-_ - y
. -�
Ll �*-'ne. 1wc) (31101)
10
Page I I of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
O
Property Add44'/"Owner:Date of ec ��
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water /5-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:
Checked with,local excavators, installers-(attach documentation)
Z Accessed USGS database-explain:
You must describe how g you established the high round water elevation:
Y g
, -� gf JV
5 s10c� � c
1]
Permit Number: Date:
Completed by: �
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot No.
Owner: Tort es C4c11,-2 Address:
Contractor: t4 90r70 A CO Address: J` lYcS7Vfp5
I. Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. .................. ................ .Date
......................................_. . month/day/Year
�F
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
e
site and determine:
G a i
O Appropriate index-well....................... -
OWater-level range zone ..................................................:..
STEP 3 Using monthly report"Current
Water Resources.Conditions"
determine current depth to
water level for index well...........................
month/ye--r
STEP 4 Using Table of Water-evel Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and.water-level zone (STEP 2B)
determine water-level adjustment ........................... ................................... ....
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to,water
level at site (STEP 1) .......................................................... Z a
l
t � ,
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Figure 13.--Reproducible computation form.
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15 4 I J it
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a
1 4 /18 01
DAT, E: — ------
PROPERTY ADDRESS:fi_Overlggk..p�.j,y�,_____
Centerville,,
--D2632-----------------
on the above data, I Inspeoted the septfo ,aysteM at the above. address.
This system consists of the following:
1 . 1 -1000 gallon septic tank. 4 . 2-40 ' leaching trenches.
2. 1 -Distribution box. 4V X2'X4 '
3 . 1 -1000 gallon, precast leaching pit.
eased on my Inapectlon, I certify the following oondltlonu
5. This is a title five septic system. ( 78 Code ) p
6 . The septic system in proper working order at '� �S 0 �vZ
the present time.
7. Trenches are dry. Leaching pit has 13" of waster water.
waste is 59" below the invert pipe.
SIGNATURE
Name:_ j_E .K9SSttottr_ U�_-----
Company; Jo••�h_P � Necomb.r_b Son , Inc ,
Address :_ Box-66______-------
__Cent: eryi11eL Ha__02632-0066
Phone :_
THIS CERTIFICATION OOES N07 CONSTITUTE A GUARANTY OR WARRANTY
J6SEPH P, MACOMBER & SON, INC,
T+nki-091I'pooli-LeichikIdt
Pumped 4, Initslled
Town bow#r Conneotlonai
P.O. Box 6775•�3J8�'I Is 641z26J2-0066
RECEIVED
APR 202001
TOWN OF BARNSTABLE
HEALTH D PT.
6.\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
3
s
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 66 Overlook Drive
Centerville,Mags_
Owner's Name:James E_ Caula
Owner's Address: 411 A 101
Same
Date of Inspection: 4/18/01
Name of Inspector: please print) Joseph P.Macomber Jr.
Company Name: J P.Macom e.r & Son Inc.
Mailing Address: ox
en erville,Mass.02632
Telephone Number: 508-775-3338
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:
. asses
—/PConditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails j
Inspector's Signature• Date: l�'��
The system inspector sha Vubmit
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 I
Nee 2of1I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 66 Overlook Drive
Centerville,Mass.
Owner: James E. Caulo
Date of Inspection: 4/1 8/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S stem Pa
.A&_ 1 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:
NONE
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:
k4 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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 Overlook Drive
Centervi e,Mass.
Owner: James E. Caulo
Date of Inspection: 4 1 8 01
C. Further Evaluation is Required by the Board of Health:
X 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(I)(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
V3 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:
4D 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.
.D The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
&1Q 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 supple 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 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 Overlook Drive
Centerville,Mass.
Owner: James E. Caulo
Date of Inspection: 4/1 8/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes ?�ischarge
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
/clogged SAS or cesspool
t/ Static liquid level in the distribution box-above outlet invert due to an overloaded or clogged SAS or
-2cesspool , 14 tpt) A-40-E'rt dw&
,Liquid depth in.cessp"! is less than 6"below invert or available volume is less than '/,day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
4 Any portion of the SAS,cesspool or privy is below high ground water elevation.
VV Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
_Y Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
_ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 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
'Y the system is within 200 feet of a tributary to a surface drinking water supply
1✓ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
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 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:66 Overlook Drive
Centerville,Mass.
Owner. James E. Caulo
Date of Inspection: 4/1 8/01
Check if the followine have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
umping information was provided by the owner. occupant,or Board of Health
— ZWere 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 eluding the SAS, located on site ?
Z_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
thbaffles 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 I5.302(3)(b))
5
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address,66 Overlook Drive
en ervi e, .
ONner: James E. Cauio
Date of Inspection:
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design):—1— Nwnber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: v4
Does residence have a garbage grinder(yes or no):AS
Is laundry on a separate sewage system es or no IV (if yes separate inspection required)
Laundry system inspected(yes or no)
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage(gpd)):
v0
Sump pump(yes or no): /
Last date of occupancy: —�f
COMMER CIA UINDUSTR.IAL
Type of establishment:
Design now(based on 310 CMR 15.203):
Basis of design now(seats/persons/sgft,etc.): 4,14
Grease trap present (yes or no): 49
Industrial waste holding tank present (yes or no):
Non-sanitary waste discharged to the Title S system(yes or no):
Water meter readings, if available: - .(W
Last date of occupancy/use:
OTHER (describe):
Pumping Records GENERAL INFORMATION
Soacc of information: Not available
Was system pumped as pan of the inspection (yes or no):
ReT-
!!*des. volume pumped: gallons •• How was quantity pumped determined? -
Reason for pumping:
TYP 0F SYSTEM
Septic tank, distribution box, soil absorption system
,4�2 Suigle cesspool
,W Overflow cesspool
/Vy2 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)
/1Jld Tight tank N,�f Anach a copy of the DEP approval
Other(describe): 40
'10proxima aee of all components, dat installed�if�nown and source of i formation:O .
Were sewage odors detected when arriving at the site (yes or no):,a
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propene Address: 66 Overlook Drive
Centervi e,Mass.
Owner: James E. Caulo
Date of Inspection: 4/1 8/01
BUILDING SEWER (locate on site plan)
Depth beloµ grade: Af/I
,Materials of construction:AJhcast iron _Z40 PVC&�4ther(explain): A1,4
Distance from private water supply well or suction line: /d*
Comments(on condition ofjoints, venting, evidence of leakage, etc.):
Joints vented
/U6o 4'S through the house vent.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: loef
Material of construction: �concreteVd meta l,/Lpfiberglass4,Vpolyethylene
,,140other(explain) AJ4
cant is metal list age:�0 Is age confirmed by a Certificate of Compliance (yes or no):4 (attach a copy of
cen�ficate)
Dimensions:
Sludge depth: �ett�e—
Distance from top ofsludge to bosom of outlet tee or baffle: B.
Scum thickness: _(
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee or baffle.
Hoµ were dimensions determined: AaeI42 �/
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 septic tank annually Garbage disposal is present Inlet
& outlet.-tees are in place Liquid level at' the outlet invert '
' is fifty one inches.Tank is structurally sound and shows no
evidence of leakage.
GREASE TRAP (locate on site plan)
Depth below grade:
Material of construction:A/A concretely meta IV fiberglass�A po lye thylenedOother
Dimensions: ,d/p
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle:40
Distance from bottom of scum to bottom of outlet tee or baffle: eoffl
Date of last pumping: 414
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present -
7
Page 8 of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Overlook Drive
CentPrville,Mass.
Owner: James E. Caulo
Date of Inspection: 4/1 8/01
TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:Aconcrete AlA metal fiberglass&4 Polyethylene yAother(explain):
AO
Dimensions: 414
Capacity: A gallons
Design Flow: W11 gallons/day
Alarm present(yes or no): _,V,44
Alarm level: _A Alarm in working order(yes or no):
Date of last pumping: AO
Comments(condition of alarm and float switches,etc.):
Tight or hnl rli nq tankG art- nnt- present
DISTRIBUTION BOX: Zif 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 three la rala No' evidence of solids
carry over.No evidence of leakage into or out 'of the box.
PUMP CHAMBERA"(locate on site plan)
Pumps in working order(yes or no): V�
Alarms in working order(yes or no):�J
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not crPRAnt -
8
Paee 9 of 11 i
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Overlook Drive
Centerville,Mass.
Owner: James E. Caulo
Date of Inspection: 4/1 8/01
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located
Type l •
leaching pits,number:
_A,Q leaching chambers, number: 0
_A20leaching galleries, number: _
I;sleaching trenches,number, length: �D
leaching fields,number, dimensions: D
_"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.):
No signs of hydraulic failure
or p n ing;Soi s are dry.Vegetation is normal.Waste water is
59 below the invert pipe.
CESSPOOL"(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: A,14
Depth of solids layer: /gyp
Depth of scum laver: ijJjQ
Dimensions of cesspool:
Materials of construction: /�
Indication of groundwater inflow(yes or no):,A,$—
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
Cesspools are not present_
PRIVYdjf&_(locate on site plan)
Materials of construction:
Dimensions: /
Depth of solids: 1,114
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Privy i s nnt- present.
9
. Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Overlook Drive
en ervi e,Mass.
Owner: James E. Cau o
Date of Inspection: 1 8 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.
aG pvG✓16k C�- '(*,enkrv,11e
Jv,
%�
10
• - ` Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propern• Address: 66 Overlook Drive
Centervil e,Mass.
Owner: James E. Caulo
Date of Inspection: 4/1 8/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Esumated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
rained from s stem design plans on record - If checked,date of design plan reviewed: �`�Fdz
bserved site(abuttE
erty bservation hole within 150 feet of SAS)
ecked wtt oca ealth•explain:
Checked with local ors, installers• (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:
Water Contour- Mapy
nAhrr-f-v & M; i i er Modal
11
1•r/-•\T•-..i l'IT T�\T\I. J.A AIT/TT\f.Tt.fRRt•.T• RRrItIfTI'RFl TflAL 1�1I1�1.11� rTTT►•a�•r- - _
TOWN OF Barnstable DOARD OF IIEALTII
SUDSU11FACF SEWAGE DiSI'OSAL SYSTF,M INSPECTION FORM - PART D •- CERTIFICATION
,.T.••..•r�T.I G��ITIA1 rw1'.1.7T.TR!lT1IZTTr\'r\'1 rlVPr\iR7r1'Tf7A�IR.�'t�7Rt ewnn —.r r.— r—._. _.
-TYPC OR PRINT CI.EAAL1'-
PROPERTY INSPECTED
STREET ADDRESS 66 Overlook Drive CEnterville,Mass.
ASSESSORS MAP , DLOCK AND PARCEL #
OWNER' s NAME James E. Caulo
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or City state tip
COMPANY TELEPNONC ( 508 ) 775 - 3338 FAX (508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system nt
this nddress and that the information reported is true , accurate ) and
omplete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper, function and maintenance of on-
site sewage disposal systems ,
Check
one :
~ Y� Systevi PASSE .
D
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILEU#
The inspection which I have con acted has found that -the system fails to
Protect the i)ttblic health and the environment in accordance with Title
5 , 310 CMR 16 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature Date
ecopy of this cert.tfication must be provided to the OWNER, the BUYER
On
where applicable ) and the BOARD OF HEAL'I'll.
If the inspection FAILED, the owner or"ho` r oator shall upgrade 'pgrado ' tho eyetcm
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 15 . 306 .
partd . doc
TOWN OF BA.RNSTA.BLE
�v
I,OCATION 09 di j 0- v SEWAGE # ZOO-ZS-1
VILLAG V 4,6 ASSESSOR'S MAP & LOT_ Z --0,Z
INSTALLER'S NAME&PHONE NO. JA-� C.1V Lkf 1�01-, 49_ -b l
,SEPTIC TANK CAPACITY _aor> IrX
( :
size)
LEACHIN� FACILITY: (type) � l
z"NO. OF'BEDROOMS� be
Ibs 'BUILDER OR OWNER
4:
PERMIT DATE:.--. , COMPLIANCE DATE: Ll -3 0-D�
Separation Distance Between the:
':•Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
,..Private Water Supply Welland Leaching Facility (If any wells exist
on site or withiWM feet of leaching facility) Feet
y` Age of Wetland and Leaching Facility(If any wetlands exist
within 300 feet4of leaching facility);- , Feet
.Furtushed by
..
J
i .
Z
j T
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE � .tB�! i . .����� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. V
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMrLDATE: 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 fee o leac 'ng fac' 'ty) Feet
Furnished b
1
Over/ocl)kj r �Cenicrwlle
Ole
rs
I'�
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for 30igpozar 6p.5tem Conaruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( andon( ) 0 Complete System ❑Individual Components
Location Address or Lot No. (' 0 0 e K— O v Owner's Name,Address and Tel.No.
7T w► C )&U l 0
Assessor's Map/Parcel ,
to cp,
(® U U eta ci(AC
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
70W 1 t y-Cl4U14A I OA
U t-�j to (Z. MA fh9-0-e
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) YM U C)�
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 bee 'ss u by thi B d of Health. /
Sign r Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. "r Date Issued
,� �� "' �E..z�r�,�jx�3�,}' *a' �+�t��„,,�t ^�l'���:r7 ��as� �r�£ ;,�r�a �se.�-�.� � �' a a f ' as � r •,: ,�, n T 7;,e
I •.
". TOWN OF BA:RNSTABLE.
LOCATION �� r�Ue-iAoot SEWAGE # ZC'0/-Z'5
ASSESSOR'S MAP & LOT 7 -U,7 Z
f INSTALLER'S NAME&PHONE NO. 4J;�.V�'(ay a� O y,
I SEPTIC TANK CAPACITY
LEACHDO ACILITY: (typo) size)
NO. OF`O'EDROOM& be
L.. BUILDER OR OWNER... ,
is
PERMITDATE:' COMPLIANCE DATE: —3 U-y/
" Separation Distance Between the:
x. .
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 ofJeaching facrli'ty) Feet`
� _ Furnished by
E t a ,
tT li^.l.T`
41
h
-
No. Fee O^
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
•t �.. I
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS I
Yes
ZippIiration for ntgoar *p5tem Construction Verna
Application for a Permit to Construct( )Repair( )Upgrade( andon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 45,GIU UP It /)v Owner's Name,Address and Tel.No.
PlU�PitU � ( l`e 7TIWI C )&Q O
Assessor's Map/Parcel A U U
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�o-A 1 r"c1
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
"Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets e, Revision Date
Title
Size of Septic Tank Type of S.A.S.
,
Description of Soil d 1 I ){
q_� wa'+f V 3 W
Nature of Repairs or Alterations(Answer when applicable) PO U S 12 C- ` AAj�C
v
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 be/en-is tphi�B d of Health.
Signeds o ia7C , /1 r Date
Application Approved by 01 ® � X_ Date akllo
Application Disapproved for the following reasons 6_1
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compitance
THIS IS TO CE FY,tat the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( L_�
Abandoned( )by e
at OV Pr leek ; has bpp constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N . dated `� 17-U
Installer Designer
The issuance of this e t s all not be construed as a guarantee that the s ste 1 func i . 4des i,•nDate ��r' g Inspector y �_ /L�
———— ————————————————————————————
No. _ / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
'W" igpozar *pgtem Congtructton Vermtt
Permission is hereby grante to�onstru ( / R� �(6)Up de �System located at ( )
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.
Provided:Cons con t be ompleted within three years of the date of t S ertn�d.
Date: ` e Approved b l
� PP Y y �
TOWN OF BARNSTABLE
LOCATION 6K 0(16Q/-001� M SEWAGE
VILLAGE_� —��ac.�iT— ASSESSOR'S MAP & LOT 092
INSTALLER'S NAME 6z PHONE NO. � oCLl-- ��
SEPTIC TANK CAPACITY Arno
i � s
LEACHING FACILITY:(type) T ES (size) 2 5�61-tg
NO. OF BEDROOMS "Y PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER J1IryIL8
DATE PERMIT ISSUED: ' _ 7 '
DATE COMPLIANCE ISSUED: 9 7
VARIANCE GRANTED: Yes No
r
0
Q
PIT
r
r
i
LOCATION ��,i !s SE 0,64E PERMIT MO.
VILLAGE
IWS-TALLER 5 I &ME ADDRESS
Za-
BUILDER 5' Q &ME ADDRE_SS__
_—.D�►TE. _PERMIT _ LSSUED_=-5�'—%�-_.— — .� — _ _
DATE COMPLI &MCE ISSUED,:
4 � " 4
III � ��
No. �,.aa Mr Fee J v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppricatton for Mgozal *pgtem Conetructfon Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 66 006gtxk4912 , Owner's Name,Address and Tel.No.
Assessor's Map/Parcel C�ILIC i6m`Ic �e7U� 6 _
Installer's Name,Address,and Tel.No. G� �75 � Designer's Name,Address and Tel.No.
B✓L-42 0. 14.16)lVe
ae Tr ee-y-off
Type of Building:
Dwelling No.of Bedrooms Ll Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Rl_q< No. of Persons _ Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /006> a Type of S.A.S.
Description of Soil 0�-'6 arl00 61 — 3, r_L_/P y 3
Nature f Repairs or Alterations(Answer when applicable)' / K �7
IT
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 iron ental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by ' Bo d f
Signed _ Date-
Application Approved by At! 2 Date — 4 9,?
Application Disapproved for the following reasons
Permit No. — 1219 Date Issued 59
Le= L
N Fee
THE COMMONWEALTH OF MASSACHUSETTS" Entered in computer:
�— Yes
PUBLIC HEALTH DIVISION -TOWN-OF BARNSTABLE, MASSACHUSETTS
01pprication for Migozal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 6G 006AL000 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel C/, �n t,rl�!C JAM
Installer's Name,Address,and Tel.No. , /C�! If�'/' '[Lye .Designer's Name,Address and Tel.No. �f `
Type of Building:
Dwelling No.of Bedrooms_ L Lot Size sq. ft. Garbage Grinder( )
Other Type of Building R6, No. of Persons _1Z Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons perday. Calculated daily flow gallons.
Plan Date Number of sheets F " Revision Date
Title
" Size of Septic Tank IQQQ Type of S.A.S.
Description of Soil 0-'6��� ? Q � 3 . [Ll7y 3z �•�� e�gill) 57'Q/Y�
R
Nature of Repairs or Alterations(Answer t when applicable) �/S7A/LO 716/L��
IT
Date last inspected:
r
Agreement:
i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with theµ.provisions of Title.5 of the iron ental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by Bo/ard f H i
t Signed �l Date ~
i r
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 7_ 9 Date Issued — S— 9
———————————————I———————————_—_—————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandoned( )by
at t1 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. g 7 dated Lf--/- r— S' 7 .
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date 7 Inspector
h
I ----�^-7 ---- ----- --------------- ----- .
No. 9 / — 1 7 / Fee
THE COMMONWEALTHtOF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mfi6pont 6potem Cbt%truction Permit
Permission is hereby granted to Construct( )Repair( ),Upgrade( )Abandon
System located at ZIze_v�QOGl
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.
Provided:Construction must be completed within three years of the date of this permit.
Date: 9 ? Approved by
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAN 1
1 � ��N �Gf(f j�� , hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at r)f� I a� �� �/�`Ce— 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 14 feet or greater below the bottom of the leaching facility
1 . • There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
A�SYSTEM
SIGNED : DATE:
LICENSED SESTALLER IN PTHE 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].
jxert
l
'000
\ 1006
`/+ TOWN OF BARNSTABLE
LOCATION 6 OC/ 1-001s- Dq, SEWAGE # z_� _
VILLAGE C244� ASSESSOR'S MAP & LOT�,�. 0S2
INSTALLER'S NAME & PHONE NO. �Q
SEPTIC TANK CAPACITY 16700
LEACHING FACILITY:(type) 5 (size)
NO: OF BEDROOMS K PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �JlrlGCa
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: L/ - 17 - 77
VARIANCE GRANTED: Yes No ✓
l
10
ono/ `
i
Commonwedth Of MOSSQChuSetts .John Grad
ExecuWe OMCe of ErMronTtr ental Affdrs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Envlro�nmental Protection Te 508)t, -6 13
D (508) 5G4-6f{13
e
536
1 �( e9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
n U 1 PART A e!
V 0 (1` /--CER,�TIFICATION /AAA VFW
66 Overlook Dr.Centerville S stem One ��7r0 2 1 19 T
Property Address: Y Address of Owner: � TO)yh,0F
Date of Inspection:3119197 `�._ w•-•-'' (If different) Hpg1 BAA�,-
Name of Inspector:Johncracl caulo
Company Name,Address and Telephone Number:
r
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My flndinps are of how the system is
_ NeedsFu erEvaluationB theLocalA Approving Authority performing at the time of the Inspection.My Inspection does
y PP 9 ty not Imply any warranty or guarantee of the longevlty of the
Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 3119197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B.C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
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,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.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 9 Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Go overlook Dr.Centerville System one
Owner: caulo
Date of Inspection:3119197
_ Sewage backup or breakout or high static water level observed in the distribution box is 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 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 we
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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply. .
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water.
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ 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 determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 66 overlook Dr.Centerville System one
Owner: Caulo
Date of Inspection:3119197
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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 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. 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:
The following criteria apply to large systems in addition to the criteria:
_ 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:
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.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 66 Overlook Dr.Centerville System One
Owner: Caulo
Date of Inspection:3119197
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
Na 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.
_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.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 66 Overlook Dr.Centerville System One
Owner: Cauto
Date of Inspection:3119197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 gallons
Number of bedrooms: 4
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n►a
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: Iva
Design flow:0 gallons/day
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: Na
Last date of occupancy: nla I
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: nla
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1978
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Overlook Dr.Centerville System One
Owner: Caulo
Date of Inspectlon:3119197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10-
Sludge depth:2'
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:e
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: Is"
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 system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:Na
Distance from bottom of scum to bottom of outlet tee or baffle:n1a
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.)
n1a
(revised 11115195)
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 Overlook Dr.Centerville System One
Owner: Caulo
Date of Inspection:3119197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of con struction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n/a gallons
Design flow: n1a gallons/day
Alarm level: n1a
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: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Na
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Overlook Dr.Centerville System One
Owner: Caulo
Date of Inspection:3119197
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible;.excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: 1,000 gallon leach p1ts
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: n1a
leaching fields,number,dimensions:n1a
overflow cesspool,number:nla
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit is structurally sound and functioning property.It was 112 full at the time of the inspection.
CESSPOOLS:
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: nla
inflow(cesspool must be pumped as part of inspection)
nla
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: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nla
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 66 Overlook Dr.Centerville System One
Owner. Caulo
Date of Inspection:3119197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
A 3� A 0I
gg 31 Ng 4�
9
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c
CO
. A
B� 3°
�� 59
Qg CA 21
eC yy
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
No......//-�'--------- Fim.................-..C?�)
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
......OF............./ lL,� /�g���
Appliratinn -for 43i,i ufitti Works Towitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
---------Location-Address ---- --- Lot No------------------------------------------
Ow er �T _,d�dr,
a
Installer Address
d Type of Buildin.g Size Lot....c _`_ _....Sq. feet
U Dwelling No. of Bedrooms__._________________ __ _-_-Expansion Attic (� Garb'age Grinder (fir
g p Showers ( — Cafeteria ( )
Other—Type of Building ---------------------------- No. of ersons-.-------------•-------___-•
Q' Other fixtures ------------------------------------------------------
W Design Flow............. �_o......................gallons per person per day. Total daily flow..._._...�.,�-0- ------------.........gallons.
04 W Septic Tanl.�Liquid capacitvj __gallons Length---------------- Width.----.------.--- Diameter---------------- Depth----------------
x Disposal Trench—No- ____________________ Width.................... Total Length..................... Total leaching area-------------.------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below ' let__________ _______ Total leaching area.---._-..--------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) d P` c—
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.----------------------
1:14 Test Pit No. 2.................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_---.---_-___-----_-.
Ix --------------------------------------------------------------------------••-•--•-----••--•-••--•-•.........................................................
Description of Soil ------ -
x
-------------- T" � --��-�:s .�.. ......-------------••••-- ----------- ----------------------------------------------------------
i _
— rc�T
UNature of Repairs or Alterations—Answer when applicable..----------------------------------------------------------------------------------------------
--------------------------- -----
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
4
Signed.............- ---- ------ =----- ._�. --------------7----- --------------------------------
Date
Application Approved By ithe
=/6----...----••-•----•-•--••-•-•-•-•-••------•-••.__..-•------•-••----••--•-•--
Date
Application Disapproved f ofollowing reasons---------------------------••------------------------------------------------------------------------------------
.....•--•-'-••----••--•-•--•-...--•--•-----------------------•-•-•--•----••-•---•-•••-•••---•--=••'- ••---•-----------•----•--•-••--•---••-----•--------••••-•-•-----------.......-----••--••-
Date
PermitNo._1//............................................ Issued........................................................
Date
--------- ---
��„ -
r ; ,. � r
No.----f, ----- Fps....:.. l
....:.. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appiirtt$ion -for ]i,ipo al WorhD Tonstrurtion Vrrniit .
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.............................................
Location-Address f t or Lot No.
�.+t...,•.� CS.............. .__.b_I--F-..��....._....................•...-
.� Owner Addr
Installer Address
UType of Buiin ld• g Size Lot... - _!Y3�L....Sq. feet
Dwelling No. of Bedrooms.__-.___ _____________________________:Expansion Attic Y Yoj Garbage Grinder
04 Other—Type of Building _______________________ ... No. of persons----____-_----_-._._.-_-_.:_ Showers (��,) — Cafeteria ( )
a' Other fixtures '
W Design Flow____._._.._.._______________________gallons per person per day. Total daily flow____-_-��J.....................gallons.
WSeptic T trtitt'—"liquid capacitvjr _.gallons Length---------------- Width----------------- Diameter---------------- Deptlf.._--_.__-._....
xDisposal 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-..-_____------.--.--.-.
G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------.--------.--
tx .................•----------•------•----•-•----•----------••----•--•--------------......-••--••--•---•=....................................................--
O Description of Soil----------------------------................................................... -------------------------------------------------------------------------------------
-------------- ----- --------•--•----------------------------•-------------------------------------------------------------------------------
x --• ----•------•-----------------------------------------------•-•-•-------------- -
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
••-- •---------------•••------•--•-----------------•---------------•- ------------------•--------•-----------------------------------•-•-- ...........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place,the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...........` "� ,-''A -a
Date
Application Approved By................I/------.._..-•--•---•----------------------•••••.
f/ Date
Application Disapproved for the following reasons:................................................................................................................
Date
PermitNo._/.1/*�--------------------•----------------•--..... Issued............. ------------------------•-•--•---•----•--'
Date
leiUU j/-e r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH fGd �'
r ✓ s
...kr '.1 -
....................................................................
Trr#if irtt of Tflutpliaurr
THIS IS TO CERTIFY, That t ndiv' 1 Sewage Disposal System constructed ( ) or Repaired ( )
by--- r� •---------�= `�= .. .-•--- ---------- --
- - - -----------------------------------------------
Installer r•---•---------Y---•--------------•-
at...----•-•-!t-/......... .?---•-------- �r�t f (�
.............-
has been installed in accordance with the provisions of Artic e XI of The S.tate Sanitary Code as described the
application for Disposal Works Construction Permit No.___-____1_�1........................ dated_._...0.:l_ -..._ 4..
T IE ISSUANCE OF THIS (CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- S -------------------------------•-- Inspector-•--d eol��
--- ................
..........................................
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEALTH
No........ ...-------- FEE----- . ..P••--1 .. .--
��--- �i��o�ttl�•. ork� �ou��rttrtioat �rrtutf
Permission is hereby granted_._.. j--------------------- ------------------ --------------------------------------------•--------------------------....--------
to Construct O or Repair ( ) an Individual Sewage Disposal System r s
f" ; 1 " st t it`r r( f r % r�
at No - _
=:_..-•-----------•----------------------=-----------------.....-------------------------------------------------------- ............................
Street - '°^-
as shown on the application for Disposal Works Construction Permit No......KZ1....____ Dated.....__`..........._..._..................
� / Board of Health
---------f.._DATE----- ../../-fq-------------.........................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
t.
PLOT PLAN SHOWING INLOCATION OF BUILDING
CENTERVILLE BARN STABLE MASS,
FOR
IYANOUGH HILLS REAL ESTATE
SCALE: I "= 80' DATE' APRIL 24 1975
CHARLES N. SAVERY INC. REG. C.E.a L.S 712 MAIN ST HYANNIS , MASS.
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1 hereby ccrlity ih,it fh. bull Inl c;,isk
in the �rount, is sho�.tin on this ol:,n n(i r
is In ��•r� 3�Ic' w[T,i the zcnlll.Barnstable.. �Kis N
HIS LOT IS NOT LOCATED IN A FEDERALLY DESIGNATED FLOOD PLA114 ZONE
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