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Commonwealth of Massachusetts
Title 5 O ficial Inspection Form
Subsurface Sewage, Disposal System Form - Not for Voluntary Assessments
131 Pondview Circle _
Property Address
Suzanne Jaxtimer R Bvocable Living Trust _
Owner Owner's Name
information is required for Centerville MA 02632 August 27, 2009
—
every page. City/rows State Zip Code Date of Inspection
Inspection results Must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General In ormation
When filling out
forms the `�I
computer,
r,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell _
cursor-do not Name of Inspector
use the return
key. Septic Inspectioii Services Co. _
Company Name
189 Cammett Road _
Company Address
Marstons Mills MA 02648
reran Cityr town State Zip Code
508-428-1779 SI 12855 _
Telephone Number License Number
B. Certification
I certify!that I have p rsonally 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 base on my training and experience in the proper function and maintenance of on site
c c•. sewage,.disposal sys ems. I am a DEP approved system inspector pursuant to Section 15.340 of
aL �(Title 531,0 CMR 15 000).The system:
®'Passes ElConditionally Passes ❑ Fails
Q
(r"J
❑ Needs Furth r Evaluation by the Local Approving Authority
August 27, 2009
Ins ctor's SigAturi Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DE 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 app opriate regional office of the DEP. The original should be sent to the system owner
and copies sent o the buyer, if applicable, and the approving authority.
****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 dill Brent conditions of use.
09-179 Jaxtimer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
TOWN OF BARNSTABLE
LOCATION c�(1(,Q J +� �(�` -sitym # _ ,�CF
VILLAGE �-.�{'���h SESSOR'S MAPyy,&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 00
LEACHING FACILITY:(type) -'N�t���t a (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COIPEhhde&DATE7-_r,50 V3
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
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Commonwealth of Massachusetts
D.
Title 5 O ficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
131 Pondview Circle
Property Address
Suzanne Jaxtimer R Dvocable Living Trust
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes
® 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 be ow.
Comments:
Tank is not in need of pumping at this time, leaching system had no standing water or evidence of
surcharge.
B) System Conditi pally Passes:
❑ One or morE system components as described in the"Conditional Pass"section need to be
replaced or iepaired. 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 L nsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will ass 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 f 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 inspect on if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obst uction is removed
09-179 Jaxtimer.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 o!15
f
Commonwealth of Massachusetts
Title 5 O ficial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Pondview Circle —
Property Address
Suzanne Jaxtimer Revocable Living Trust —
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for —
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ dist ibution box is leveled or replaced
ND Explain:
❑ The system equired 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:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.3O3(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Ces pool or privy is within 50 feet of a surface water
❑ Ces pool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System ill 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 c nvironment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 `eet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supp ly.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supr ly well.
09-179 Jaxtimer.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 15
i
Commonwealth of Massachusetts
4 Title 5 O ficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
131 Pondview Circle —
Property Address
Suzanne Jaxtimer R avocable Living Trust _
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for —
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system as 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 p sses if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicate 5 absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "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_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.
09-179 Jextimer.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 15
Commonwealt of Massachusetts
w Title 5 O ficial Inspection Form
Subsurface Sewag a Disposal System Form -Not for Voluntary Assessments
wM 131 Pondview Circl _
Property Address
Suzanne Jaxtimer Revocable Living Trust _
Owner Owner's Name
information is required for Centerville MA 02632 August 27, 2009
-
every page. Cityrrown State Zip Code Date of Inspection
B. Certificati n (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent 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 co of the anal siis
p 9g PY Y
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
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 accord nce with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
09-179 Jaxtimer.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
i
Commonwealth of Massachusetts
Title 5 O ficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 131 Pondview Circle
Property Address
Suzanne Jaxtimer Revocable Living Trust _
Owner Owner's Name
information is required for Centerville MA 02632 August 27, 2009
-
every page. CityrTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 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(5)]
09-179 Jaxtimer.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 131 Pondview Circle
Property Address
Suzanne Jaxtimer Revocable Living Trust
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Unknown
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
09-179 Jaxtimer.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealt of Massachusetts
p Title 5 O ficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
131 Pondview Circle _
Property Address
Suzanne Jaxtimer Revocable Living Trust _
Owner Owner's Name
information is required for Centerville MA 02632 August 27, 2009
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Reco ds:
Source of information: None
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume p mped: gallons
How was quanti y pumped determined?
Reason for pumping: —
Type of System:
® Septic tank, distribution box, soil absorption system
❑ ingle cesspool
❑ verflow cesspool
❑ rivy
❑ 3hared system (yes or no) (if yes, attach previous inspection records, if any)
❑ nnovative/Alternative technology. Attach a copy of the current operation and
aintenance contract(to be obtained from system owner)
❑ right tank. Attach a copy of the DEP approval.
❑ ther(describe):
Approximate age of all components, date installed (if known) and source of information:
Compliance date: 3/3/95
Were sewage odors detected when arriving at the site? ❑ Yes ® No
09-179 Jaxtimer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
i
Commonwealt of Massachusetts
W Title 5 O ficial Inspection Form
Subsurface Sewag Disposal System Form - Not for Voluntary Assessments
131 Pondview Circl —
Property Address
Suzanne Jaxtimer Revocable Living Trust —
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for —
every page. City7Town State Zip Code Date of Inspection
D. System Information (cont)
Building Sewer (locate on site plan):
1' _
Depth below grade. feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from p ivate water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(Iodate on site plan):
6" _
Depth below grade: feet
Material of cons ruction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, I st age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
----------------------- ------------------------------------------- ------------------------------------------------- ---
Dimensions: 10.5' long x 5.8'wide- 1500 gal._
0"
Sludge depth: —
Distance from to of sludge to bottom of outlet tee or baffle —
0"
Scum thickness —
Distance from to of scum to top of outlet tee or baffle —
Distance from b ttom of scum to bottom of outlet tee or baffle —
How were dimensions determined? Measured _
09-179 Jaxtimer.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealt of Massachusetts
. Title 5 O ficial Inspection Form
Subsurface Sewag Disposal System Form -Not for Voluntary Assessments
131 Pondview Circle _
Property Address
Suzanne Jaxtimer Revocable Living Trust _
Owner Owner's Name
information is required for Centerville MA 02632 August 27, 2009
—
every page. Cityfrown State Zip Code Date of Inspection
D. System Inf rmation (cont.)
Comments (on p umping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank had liquid only, no solids. Liquid level was found at bottom of outlet invert and tees were intact
and clear. Tank s not in need of pumping at this time.
Grease Trap (lo ate on site plan):
Depth below grade: feet
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: Date
Comments (on pimping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
i� Material of const uction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
09-179 Jaxtimer.doc•08r06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
i
Commonwealt of Massachusetts
Title 5 O ficial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Pondview Circle
Property Address
Suzanne Jaxtimer Revocable Living Trust
Owner Owner's Name
information is required for Centerville MA 02632 August 27, 2009
-
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Bo (if present must be opened) (locate on site plan):
Depth of liquid I vel above outlet invert 0 —
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.):
Observed a trace of solids carryover with no high stains. Liquid level at bototm of single outlet pipe.
Pump Chambe (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
09-179 Jaxtimer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
131 Pondview Circle
Property Address
Suzanne Jaxtimer Revocable Living Trust _
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for —
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ IE aching pits number:
® IE aching chambers number: 5 Infiltrators.
❑ leaching galleries number: —
❑ leaching trenches number, length: —
❑ leaching fields number, dimensions: —
❑ overflow cesspool number: —
❑ innovative/alternative system
T pe/name of technology: —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Interior of infiltrat rs were video inspected, no standing water or signs of surcharge were found. Soils
were probed and found no evidence of saturation. Leaching system is in good condition and
functioning ro rl .
09-179 Jaxtimer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface SewaC a Disposal System Form -Not for Voluntary Assessments
131 Pondview Circl _
Property Address
Suzanne Jaxtimer Revocable Living Trust
Owner Owner's Name
information is Centerville MA 02632 August 27 2009
required for 9
every page. Citylrown State Zip Code Date of Inspection
D. System In ormation (cont.)
Cesspools (ceE spool must be pumped as part of inspection) (locate on site plan):
Number and co figuration —
Depth—top of liquid to inlet invert —
Depth of solids I yer —
Depth of scum layer —
Dimensions of c sspool —
Materials of construction —
Indication of groundwater inflow ❑ Yes ❑ No
Comments (notE condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of conc truction: —
Dimensions —
Depth of solids —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
09-179 Jaxtimecdoc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealt of Massachusetts
Title 5 O ficial Inspection Form
Subsurface Sewag D Disposal System Form - Not for Voluntary Assessments
131 Pondview Circl —
Property Address
Suzanne Jaxtimer Revocable Living Trust —
Owner Owner's Name
information is Centerville MA 02632 August 27, 2009
required for — — —
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 PL blic water supply enters the building.
/
/ / /`J . / / / . / /
%
\ \ \ ♦ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
21 000000
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
/
33
\ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \
20
\ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \
I 1
Commonwealt i of Massachusetts
Title 5 Cfficial Inspection Form
Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments
131 Pondview Circl
Property Address
Suzanne Jaxtimer Revocable Living Trust
Owner Owner's Name
information is g
required for Centerville MA 02632 August 27, 2009
every page. Cit drown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slop
® Surface water
® Check cells
® Shallow we Is
_
Estimated depth15+to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If cliecked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ ChE cked with local excavators, installers- (attach documentation)
❑ Acc ssed USGS database-explain:
You must descr be how you established the high ground water elevation:
Pond at end of circle is considerably lower than SAS.
09-179 Jaxtimer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 115
TOWN OF BARNSTABLE
LOCATION ��/ eN��i�t� C�2G�Lo SEWAGE #9,5--
VILLAGE C,c^/TE2 Gs/! /P ASSESSOR'S MAP & LOT�'1, Dr'
INSTALLER'S NAME & PHONE NO.171 # 6oi/57- Ca
SEPTIC TANK CAPACITY /J O D 6A-1
LEACHING FACILITY:(type) ZC,Zr rO (size)
NO. OF BEDROOMS S PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERSd z n�NE J fC rl �?G✓L
DATE PERMIT ISSUED: �l rAs-
DATE COMPLIANCE ISSUED: � �
VARIANCE GRANTED: Yes No /'
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THE COMMONWEALTH OF MASSACHUSETTS I/FiRu3.3t5.)...............
BOAR® OF HEALTH
TOWN OF BARNSTABL.E
Apphration for Ali-nVniiul War1w Towitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( . an Individual Sewage Disposal
System at: if ,
-----------------------------------------------------------------------•-•••-•-......----------•-. ---••--•-•----------•••--•---------•-----•--••----•------••-------•-----.......---••---.......----
Location- Address or Lot No.
�t Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
44 Other—Type of Building ............................ No. of persons---------..---.------------- Showers ( ) — Cafeteria ( )
114 Other fixtures ---------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter--- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No..--..--_---........ Diameter----------------_-- Depth below inlet---..--............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------ ............................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.....-.------------- Depth to ground water..............--........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.......--...--...... Depth to ground water........................
P4 -------------------------------------------------------------------------------------------•------------------------------------------•---------------------
0 Description of Soil...........................................................................-------------------------------------------------------------------------------•-•----------
x
U •-------------- .................................................................................................................................................................................
UNature of RepBrs or Alter ions—Answer when applicable..... s '5 7---.-.... -S_--?y ............
-------------------------•--------...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued b he bo , Of health.
Sign rG -- - -- - .......
Application,Approved By ----------C ------------------- ---------.------------------------.................... 9,..1..
Application Disapproved for the following reasons: -------------------------------------------------------------------------------------------------
----------------------
-------------- ------------------------- ------- ------ ---- ---- ---------------------.....----- --------------....-------------..-...__--.-.....----------_---------------..-.-.-.--........ ------------------------------
C� Dace
Permit No. - F � - f.�..�............ ........ Issued .--. ....................
...--- .......................................Dace I
L_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gertifirate of ContlaIianre
THIS IS TO CER IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
/2 .....----�-�. c�5 T
by ---------------------------- ---- v
_r hsca��er
� - -- ----
at ----------------------�..3..�._......... _-..on'�`.......- ` to�r/ 12........... C—........... -
has been installed in accordance with the provisions of TITLE 5 ooff The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...../-�5 .�_1.d L/.--...--.... dated _-..._............_.. ---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR!U#R AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATIS.E_.ACTORY. /
�• —
DATE ....... - -- .... ......._ ..- ......_.......... Inspec ---------------- ---- ---------------------------- ------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No..../�S. �Z. FEs.�_ �...........
G/sz � i�
Permissionis hereby granted-------------------...........................................................................................................................
to Construc _ ) or Repair ( �,an Individual Sewage Disposal System
••..........
-----------------`i-.=- ......- -------------------•----------------------------•--•---•--..........---
Street /r+ / I _ C
as shown on the application for Disposal Works Construction Permit No._.,__..,.._..,..__ Dated...... �..�- /�......
Board of Health
DATE..............------------------------..----......------...--......................
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
�1 b
I THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dhaip ial Wnrk,i Toustrurtiuu Frrinit
Application is hereby made for a Permit to Construct ( ) or Repair (--<an Individual Sewage Disposal
System at: - /f/
�vL,q�w� JAy-T, ! 3/ ���-v !/lecve2 �E •�
.. ------- ------------ ..•...•...•--...•• •---•---•-•-•------•--•-•••••--•--•---...---••-------•-----------....-..........-..----•-•-•••----
Location-Address or Lot No.
......................—.......................................................................... '--••--•-------------•----------------•--•-------..•...•----•---•••----•---•-------.........-•---
Wi✓1"T r Address
Ins tatter Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ _ _
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity..____..____gallons Length---------------- Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. ........:........... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) . - , Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water__.__.___.__________._..
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a .........................................................•---•--.....--•------•--------.-.-...•--••-.........................................................
0 Description of Soil............................................----------------------------------------------------------------------------------------------------------••-•--------•-_..
x
U
W ---•---------------------------------------•---_.. __...-•---•--•---••......._.....------•--------•-------------•-----------------------------------•_..-.•--•------_.f__..._.-----------------........
U Nature of Repa rs or Alter
/aj'ons—Answer when applicable.. T _ ... S-,.v r%r11.47-v-e 5-
----•-•---•----------------------•--.....__..•-••-••••-•-•--..--.-......_._.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by-the boakd of health:
npd'Siga_474�_. ............
�: -...
Dace
Application.Approved By ........... 1.. --�--,: t0-..-.....__Date
.�......,�.... i
. 1 .
Application Disapproved for the following reasons: . . . ........................... ............................ .........................
......... ----------------------------------------------------------------------------- ----- ----------------------------------------------- ----- ------------------------------ -------------------------- ........
Daw
PermitNo. ......c..�.. � .i7- ............ ........ Issued _............................ ............................ .......
Date