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HomeMy WebLinkAbout0176 PLEASANT PINES AVE - Health (2) 176 Pleasant Pines Ave. (Centerville) A=234-072 i I �J�0.ECYC(FOrO yz, UPC 10259 No.H163OR HASTINGS.MN TOWN OF BARNSTABLE �Q LOCATION PIC,4,$4,+ Pinks SEWAGE # �S 57a VILLAGE (lykr✓-4 ASSESSOR'S MAP & LOT a3y *7 INSTALLER'S NAME&PHONE NO. 9 . O or, co SEPTIC TANK CAPACITY C1CsO GAL LEACHING FACILITY: (type) (size) Sra✓lk NO.OF BEDROOMS S BUILDER OR OWNER 1Alr Gt �1 J PERMITDATE: 1/3 5 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of eaching facility) r Feet Furnished by Stiff it a on r �� $ Qp A1- 39'�" 8i 3y. 30 (o �A3- a3 Kati- af' all- -)C �(o s a , -46 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 176 Pleasant Pines Avenue Centerville. MA 02632 Owner's Name: Claire Gillis Owner's Address: One Constitution Road Hingham MA 02043 RECEIVED Date of Inspection: May 7 2001 Name of Inspector: (Please Print) James M. Ford MAY 16 2001 Company Name: James M. Ford M_rma .,v Mailing,Address: P.O. Box 49 TOWN OF BARW. ...E, "OsteMlle.MA 02655-0049 "r HEALT. �T Telephone Number: (508) 862-9400 Parcel. 072 Lot: 3 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 experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP training and p p P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Con"' nally Passes. N s ther Evaluation by the Local Approving Authority Fail Inspectors Signature: Date: May 8, 2001 The system inspector shall sub 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 This inspection does°not addiess.how.the system will.perform in the future under the same or different conditions of use. = I Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION (continued) Property Address: 176 Pleasant Pines Avenue Centerville, AM , Owner: Claire Gillis Date of Inspection: May 7, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR,15.304 exist. Any failure criteria not evaluated are indicated below. Comments- B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or .repaired::The system,-.upon,completion-ofthe 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 The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: - -- -The system required pumping more.than.4-times a ear,due to broken or obstructedpipe(s). The s stem will .. _._ Y �l P P g . Y- _. . . _ . _. _ . .--- Y ----- ---------pass.inspection_if(with.approval.of the.Board of Health): -. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 176 Pleasant Pines Avenue- ...... Centerville, 1M Owner: Claire Gillis Date of Inspection: May 7, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMER 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the envii onment: 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 unless-the Board of Health(afid'Publie W:ter'Supplier,,-if any)determines'.that the 2. 'Systemwilffail''66lis: a system is functioning in a emsanner 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.-fe.et:.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.Lof a public.water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at,a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate'nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 1 is Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ;CERTIFICATION (continued) Property Address: 176 Pleasant Pines Avenue ; Centerville, MA Owner: Claire Gillis Date of Inspection: May 7, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution-box above-outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100.feet of a surface,water;supply or tributary to a surface water supply. ✓ Any portion of a cesspool:or.privy.is.within.a.Zone I of a,public welly;:: .;,., ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. - ✓ Any portion of a cesspool or privy is.-less-than 100.feet but.greater:than,50.feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performedat"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 Aitrogen and uitr"ate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. F. Large Systems r. To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B i :., . . .. CHECKLIST Property Address: 176 Pleasant Pines Avenue F Centerville. MA Owner: Claire Gillis Date of Inspection: May 7, 2001 Check if the following have been done: You'must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in'the previous two weeks? Has the system received normal-flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined.?(If they were not available note as N/A) ✓ Was thefacility-'or.dwelling.�irispected.for,signs,ofsewage:back,up:2 Was'the!site inspected,for.signs of break out,? - Were.all..system,components,excluding:the SAS,-located on site? ✓ Weie the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and.location of the Soil.Absorption.System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. . ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 176 Pleasant Pines Avenue Centerville. MA Owner: Claire Gillis Date of Inspection: May 7, 2001 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: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no):_No [if yes separate inspection required] Laundry system inspected(yes or nb):" No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000-260,000 gals.; 1999- 162,000 gals. Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR-15.203):-- apd Basis of,design'flow(seats/petsoris/sgff,efc) Grease trap present(yes or no): _ Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no)-'-- Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Not pumped-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank distribution box,soil absorption system ep � rp Y Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of.the current operation and maintenance contract(to'be obtained from system owner) _ Tight Tank Attach a copy of the DEP approval .Other-(describe)• . . ....._. .. .. Approximate age of all components,date installed(if known)and source of information: Jul. 20 1995-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 i Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -SYSTEM-INFORMATION (continued) Property Address: 176 Pleasant Pines Avenue,", - --- Centerville, MA Owner: Claire Gillis Date of Inspection: May 7, 2001 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: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age:----- - -Is-age confirmed by-a Certificate of Compliance(yes&no):' ' L (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee-or baffle: Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:' Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping.recommendations,inlet and outlet tee or.baffle.condition,_structural integrity;-liquid'levels as related to outlet invert,evidence of leakage,etc.): 7 , f• lG • • Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 176 Pleasant Pines Avenue Centerville. AM Owner: Claire Gillis Date of Inspection: May 7, 2001 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass olyethylene other(explain): g —P Dimensions: Capacity: Qallons Design Flow: aallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): _._.._..__ _DISTRIBUTION"=BOX::'` ✓ esentmust:be'operied).(locate:on site ,plan)' Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box;etc.) The D-box was level. There were no signs of solids. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): .�_•__ Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM-INFORMATION (continued) Property Address: 176 Pleasant Pines Avenue Centerville, MA Owner: Claire Gillis Date of Inspection: May 7, 2001 ; SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: ----------------- T'pe ✓ leaching pits,number: 4'x 6'with 3'stone(per desiQ•n plans) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: _. -. . . ...__.overflow_cesspool,number: _......._Innovative/alternative system__-_Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit was located, but not dug up..s There,were.n6 signs offailure--in the D-box:.The.bottom•tograde,was-approximately 8. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 ,_ ; Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 176 Pleasant Pines Avenue Centerville, MA y Owner: Claire Gillis _._.... .. . . __ -. i Map: 234 _ Date of Inspection: May 7, 2001 - - Parcel:- 072 . Lot:.3 . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A -3 a 1 Aa_ 30 c� pa- 3o1' Aq- aa, 10 f Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "SYSTEM INFORMATION (continued) Property Address: 176 Pleasant Pines Avenue` - __.-_ _. Centerville, MA Owner: Claire Gillis Date of Inspection:" May 7, 2001 r SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: 3122195 Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You,must describe how you established the high ground water elevation: The b"ottom-of the pit to grade was approximately 8. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 17'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 ws 107(a TOWN OF BARNSTABLE LOCATION L�r �,o 5-gaAi �iL�dfaeSE WAG E # - 5 VILLAGECe: �Jkac U! ���_ ASSESSOR'S MAP & LOT, 3'-/` �- INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) i (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER t,�J ",4(C DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r3ticIC 53 4� ASSESSORS MAP NO: �S- 5?off PARCEL N0: '7 Z No..... --•-•-....... Fis.............................. THE COMMONWEALTH OF MASSACHUSETTS f; BOARD OF HEALTH TOWN OF BARNSTABLE liratio or,��� it Dig a %a f � ,� 1 3o,vrkii Tomitrurt>Iou Puma Application is hereby made for a Permit to Construct (✓S or Repair ( ) an Individual Sewage Disposal System at: ..................S ...T....!...�....t...... �t.� ��.'��.P�Z.�..-C 3 r... .......................................... Location-ilddress or Lot No. -- .....<<-:u�... F= '�'t��`�`' �� ---- =13 Pt4'lzert.s..Q... o_-----®, ►`tom[�K� !�'' W «. /\ �,y . � /_`�✓l W I r—1W Address a - - - - -- -- --- -------------V---v-------._._..----•- •--•--......'_......_....--•---•---._...`.......----..._...--•------- nstaller Address U Type of Building Size Lot_.. 1 z?cA......Sq. feet Dwelling—No. of Bedrooms.__-----__-5_-----------------------------Expansion Attic (wA) Garbage Grinder (No) 0., Other—Type of Building ---• G_.._ ..... No. of persons_____� Q -------------- Showers (Wf.) — Cafeteria (►+/A) Otherfixtures ......"IA--------------------------------------------- ------------------------- ----------------------------------•-----.................... W Design Flow......115P!-----------------------------gallons per person per day. Total daily flow--------- ......................gallons. WSeptic Tank—Liquid capacity_! gallons Length__` "__. Width. '! '.'_. Diameter."/A___.__ Depth_�-7'_.... x Disposal Trench—No. ._!-:i_/_A.......... Width....b"- .lA-------- Total Length._i.---/A......... Total leaching area____HIA......sq. ft. Seepage Pit No......i'.............. Diameter------1'7-_'.-__.__ Depth below inlet----- . ......... Total leaching area.!!�!3_:.!.....sq. ft. Z Other Distribution box (✓1 Dosing tank (N/A) Percolation Test Results Performed by ---------------------- Date.... ............ Test Pit No. 1-_-.''........minutes per inch Depth of Test Pit----- Depth to ground water...11-'0"..___._. 44 Test Pit No. 2...Hl_A------minutes per inch Depth of Test Pit---k/A----------- Depth to ground water....64_ln....___.___. a ----••-•-•••-----------------••---•••••--•-•--•-••-••••••-••--------•--••--•••......•---------....-•......................................................... 0 Description of Soil----•`•'••f-3- = t� = 1—f6-.41 � %e` : r►+4c Ss�a ta' - %�' . ------ ---- U A.. .....�-�r!1 S!tw+.0 �i t!.??}._.C�Q�4�IE i. ' G�0-c�v.-,D f cSE G. 12'c o t-----•----•••-•--- . --•--..._.. W M. -------------- -------------------------------------------------------- --------------------------------------•........................................................................................ U Nature of Repairs or Alterations—Answer when applicable----'-"� rA........................................................:........................ •------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' by t board of health.. Signed ...........-_4,/ -7' ................ - " Dam Application.Approved By ............� �G �..........Jv.%. �--.......... ....... 7f. Dace Application Disapproved for the following reasons: .....------------------------------------------------------------..............------------------------------------------- ...................................................................................... ........................................................................ .............. ........................................ 57- 5-2� Dace Permit No. — ........__................... Issued - - 135------------ .................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certif rate of Graptiance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� ) or Repaired ( ) ------- -- ------_..-------- -- -- ---- ---------------------...---------------------------...----.--- at ..--._�_ .3........ P�-f� �/.------ P_I----- .. -C �-�-�ii6�-------------------------------_---------------._ --------- --------- has been installed in accordance with the provisions of fITI.E 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. g5...- S72-�--.. .__._.... dated ..��._e23-_-. 3'_.-..._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------7 ....�--a� __ ......... .. ..__. Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c� TOWN OF BARNSTABLE / oU No.----/S►. a FEE.....l. v........ �innl nrbi Tunitrutinn rrntit Permissionis hereby granted.............................................................................................................................................. to Construct ) or Repair ( ) .an Individual Sewage Disposal System at No......e.[i.k.a...-----P.aGStreet �fC..n.f f .J � dr��.l�l f. - 2 as shown on the application for Disposal Works Construction Permit No� ----��2Dated---.-.�_ ..................................... -----... --------------------------------------- DATE.................. C ---------------------------------- Board of Health --'-�-J----l-� FORM 36508 HOBBS&WARREN.INC..PUBLISHERS No................_....... r t Fps.............................. F THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphrativit for Di-nipw3ul Wor1w Tomitrurtion remit Application is hereby made for a Permit to Construct (✓�or Repair ( ) an Individual Sewage Disposal System at: PLEA'S T P 1,1ES A\i C . G�l�,E': 1 t_l.(_.. LIST' A—5 2 /�� 2 ...........•••....L:. ..................•---....•---•r-••--•--•••----•--•.....•............... ............------......-....:-�`:..........Q...1:�4.Y._...� 7. Location-Address or Lot No. �N l t_L.(A Nl F. M A.R-r-a=w = , Q �Z 3 P t ,!<.t<<e s c ,off So. �1 T1GK AAA .... . ..a . . ....--- ----••------•--•---------•--•...-- . ...........................••-.,.............. wn ( /Address CA ess Type of Building =�stau«.......•• Size 1?-1 Sq. feet U ►.., Dwelling—No. of Bedrooms.-....-.-.�------------------------------Expansion Attic (N/A) Garbage Grinder (No) Other—Type of Building ....'y l+.-......... No. of persons.--._i-+1-A_------------- Showers (N/^) — Cafeteria Otherfixtures ------"/A--•------•------•------------------•------------------------ ----------- ----------------............................................. W Design Flow......1.1a.............................gallons per person per day. Total daily flow.......... ..................--gallons. WSeptic Tank—Liquid capacity-!QOU.gallons Length-.$'. ::-.- Width.4'.!!:'._ Diameter-�.M----.-. Depth.'--'-7 ... x Disposal Trench— No. ..".LA......... Width...j,jA-------- Total Length...�-ftJ�-........ Total leaching area....t JJA-......sq. ft. 3 Seepage Pit No......1............... Diameter.-.--.1?-..'........ Depth below inlet---. .......... Total leaching area.��3.:9.....sq. ft. z Other Distribution box (� Dosing tank (w/A) `" Percolation Test Results Performed ...... ---------------------- Date....O3J.!�a. 5............ Test Pit No. 1...l :-.----..minutes per inch Depth of Test Pit----- 2- ::... Depth to ground water..+ .'.�?."........ r3 Test Pit No. 2..ALA.---..minutes per inch Depth of Test Pit---H1t?.......... Depth to ground water....-lr------------ 0 Description of MAPM SSoil.O...��=3 ' L 5.,r6�V) ` '— t o1'2! F"1, a SAtiO 10' - iZ' ; .. - ---�..... .---Y� T�1 � A�--Y— C�U )-v ...... tu =• --------•-----•-----•----•------------•--------•- ........................................ W V Nature of Repairs or Alterations—Answer when applicable..:-1�:J A.................................................. .............. -----------------------------------•........................................--......................--•-•----------•------------.....--•-------------.......---•-................................__..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ed by t board of health. /- Z� Signed ........................................ .............. . ........... ..... ........................ Dace Application.Approved By ........... -1 [�[ may' - /` - = ..—.i� \ Dace \K Application Disapproved for the following reasons- ----------------------- --------- --- ----------------------------------------------------------------------------------------- ................ .................................. -^� -- ...........__....... .......... ............................................................. ........................................ 9✓ '... /� Dare Permit No. ---- ---------------------------------- Issued -------------, --- .. .3...-:.7�. -------------- 1� ............... Dace -2ATA ' . -" 51N6LF- FAMIL-( ti o 6A273AtsE GRIIJDE� 'PAIL-( FLOW .: 3 x I l o - 33o c,P c) 5E?rl C TAME 3 3 o G P O x 1 5 o°7 e : 411 5 U P D V5� l oc� C--A LI�GnI 215Po5AL PIT SIDEN/ALL ISo.B -tF A 2.a s 3o2 G�'p, 5�� P�,� ow BOTTOM A2 - i 13. I s F L o-r 3 11 3. 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