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Home My WebLink About0245 PRINCE HINCKLEY ROAD - Health 245 Prince Hinckley Road Centerville P 171 115 i(J V COMMONWEALTH OF MASSACHUSEFTS ExrGuTfVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF•ENVIRONMENTAL PROTECTION RECEIVE® SEP 2 12004 TITLE S ��1 K ARNSTABLE OFFICLkL INSPECTION FORM—NOT FOR VOLUNTARY ASSE 9iYk # INH DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM YUKM PART A CERTMCATION Property Address: S Pr:11C k4cklekdIr MAP {)meer'sNsme: ffarhAraO r 'RCE ` Owner's Address: a �:Aa e r .. it -it .QT Date of Inspection.• -O - '..�`•� r Name of Inspector: prase print; Company Name-,-;!kt M. aosfe r r,3gj Mailing Address: wee SLFA/Lo4—goS"36 Telephone Number: CERTMCATION STATEMENTi I certify that I have personalty inspected the sewage disposal system at this address and that the i of nation reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and 0)Vdenee in the pmper Amcdon and maintenance of on site sewage disposal systems.I arm A DEP spprcwtx`a nys£e st insPee1IIaaat to 8"ea 15340 of Title 5(310 CMR 15.000), The system: �t=d5S2S Conditionally Passes Needs Furthdr Evaluation by the Local Approving Authority Fails Inspector's Signature.- Date: -0 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 ihould be and the system owner shaft submit the report to the appropriate regional"office of the DEP.The original snsI be sent to the system;owner anal copies sent to the buyer, authority. if applicable,and the approving 1 Notes and Commen TC �G �� it a i AC ca✓l a 3 '' L. ( " p re * eglAr& o G ICK t�r� p a, *r�ataT reportOng,desc ibe$tond'tions st tht time Of[WPOitiOn*ad under the coed f oft of Use At mat ^- timr.-rhis iuspectiOd does not addrew huw the systeus wiafl-perform in the future s conditions of use. Oder the same or different Ali cnnnrt Pace 2 of I OFFICIAL INSpECMN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• ,n Ce Ai All C� "CY 01' le.tfee vale Uwaer: Date of Inspection• Inspecfivn Summary:'Check A,B,C D or E 1 A€.WAyS eomplete all of Section D '4' Sy ste asses: I have not found any information which indicates that any of the failure criteria described ilr 310 OAR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicared below. Comments: B. System Couditiodaliy Passes: ; Ono o,r sears s}�arexr ao�npoaexeas sa deaon'bad is die'°Cauditio`aaf Pess"secfioa need to be ieplaced or repaired.The system,upon completion of the replacement or repair,as approved by the Boaad.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 2ayew old*or tire septic tank(whether metal or not)is structurally unsound,exhibits substantial fi f'1tration or exfilt-ataon 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 Ptealth. *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 Iess than 20 years old is available. ND explain: Observation ofsewage backup or break out orhigh static water level in the distribution box due to broken or obstructed pipe(s)or.dtre to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board ofHealsit): broken pipe(s)are replaced obsuuction is removed distribution box is leveled"replaced ND explain: The system rKl*ited pumping more th=,4 titum a ycarCduc to brokeiior obstructed pipe(s).,Tlu systma will Pass inspection if(with approval of the Hoard of Health): brokers pipe(s)are replaced obstruction is ieinoved ND explain: Page 3 of I t OFFICIAL INSPECUON FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A CERTIFICATION(continued) Property Address: A Ce _(eat ,erU:l le Owner: Date of inspection: - 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. Systems will pass unless Board of Health determines in accordance with 310 CIMR 15.303(1)(b)that the system is not functioning In a manner which wilt 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 : Z. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that thIe 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 a surface water supply or tributary to a surface water supply. T The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply weil. The system.has a septic tank and SAS and the SAS is less than 100 feet but-50 fixt7ormore from a private water supply well".Method used to determine distance. `�Ris system passes if the well crater analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indit-atm that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Iess than 5 Ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECT N FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SERFAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: agS"PV'41e RiA �eJrd! Gerifer r1�t J e Owner: Date of inspection: D. Systems Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each'of the following for sI inspections: Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge orponding of effluent to the surface of the ground or surface warers due to an overloaded or iclogged SAS or cesspool — ____ Static liquid level in the distribution box above outlet invert due to an overloaded or abed SAS or -//cesspool ' _ iquid depth in cesspool is less than b"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; 1/ ,cC„y pion of uie 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 , 14Fater supply. V_ Any portion of a cesspool or privy is within a Zone I of a public well. _ t/ y portion of a cesspool or privy is within 50 ket of a private water supply well. — my 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 anitysis, performed at a DEP certified laboratory,for conform bacteria and volatile organic compounds iwileates€hilt the well is free fi UeH poltutioet from that Imi iii£y 8skei flee presence#tf ammonia siiuvgea 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 forna.j t'YcmNF O)The system faits.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 awner 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 now,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 Iocated 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 shalt upgrade the system in accordance with 310 CMR 15.30+.The system owner sLvnld contact the appropriate regional office of the Department. Page 5 of H OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST Property Address: erys Pr.n et gm cklw Jr, Owner- Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes u 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?: V _ Has the system received normal flows in the previous two week period? _ V Bave Iarge volumes of water been introduced to the system recently or as part of this inspection? V Were as built plans of the system obtained and examined?(71f 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 bteak 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 b es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scutu? _ Was The facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size iad location of the Solt Absorption System(SAS)on the 4ite has.been•determined based on: Yes no/ _ &' Existing infOrtnatiom 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 unacceptable)[310 CMR I5.302(3)(b)J •4 r� Pace 6 of I I OFFICIAL INSPECT N FORM 'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addresr. n Owner- L?ate of insperteou: •D FLOW CONDITIONS RESWENTIAL Number of bedrooms(design):—a Number of bewvums(ac:tuai). DESIGN flow based on 31*0 CNM 15.203(for example: 1 i0 gpd x#ofbedtooins): 330 Number of current residents:_L_ - - Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system f Xus or no):TD[if yes separate inspection required] Laundry system inspected or no): Seasonal use:(yes Of no): ¢ Water meter readings,if a able(last 2 years usage(gpd)): Sump pump(yes or no): O Last dale of occupancy: 1-1-0 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15203): and Basis of design flow(seats/persons/sgft,etc.): 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 WFORMAT ION Pumping Records � Source of information:_6 wt�1.e -1,04144 IOE'd/ /0_ 63 Was system puinped as part offhe inspection(yes or no): If yes,volume pumped OOO ons—How was quantity pumped determined? G ot— Reason for pumping. A 6G T'YF OF SYSTEM _kASeptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if arty) _-__Innovative/Alternattve technology.Attach a cosy 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: /�fYo Were sewage odors detected when arriving at the site(yes or no):A0 Page 7 of 1 l OFFICIAL INSPEC' N FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART , SYSTEM INFORMATION(continued) Properly Address: c1led( ,. . . . ; Owner: Date of Inspection: -d BUU-DING SEWER(locate on site plan) Depth below grade: 1 a„ / Materials of construction:_cast iron ✓4{T 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 gmia: qr� � Material of constrtction: r/concrete—metal—fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: y'/Ory r Sludge depth:__311 Distance from top of edge to bottom of outlet tee or baffle: o "i Scum thickness: _ Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottgnt of outipt tee or baffle.-_ How were dimensions determined: +C*,L t I 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:(locate on site plan) Depth below Sndc: aterial 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,struchrral integrity,liquid levels as related to outlet invert,evidence of leakage,etc): Page 8ofii OFFICIAL INSPECN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r'�c �j` dt. Owner: Date of Inspection• TIGHT or HOLDING TANK: (tank mub"t 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: gallonsiday 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: i/ (if present must be opened)(locate on site plan)' Depth of liquid level above outlet invert Comments(note if box is level and distnbution to outlets equal,any evidence of solids carryover,any evidence of le ge into or out of etc-): Cox .`w —a ObrOby� PUMP CHAMBER: (locate on site plan) Pumps in working order(pas or no): Alarms in working order(yes orno): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 4 of I I OFFICIAL INSPECT11ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. FART C SYSTEM INFORMATION(continued) Property Address: QS'Ancca diviCkey r'e.1.fa•�,;t ice— . . , •�_ , _ • Owner: Dare of Inspection: —0 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)' If SAS not located explain why: Type Lof teaching pits,number. leaching chambers,number leaching ga}leaes,number: teaching trenches,number,length: leaching fields,itunibm dimensions: overflow cesspool,number, innovative/alieinative system Type/name of technology- Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.t CESSPOOLS: __ (cesspool must be pumped as part of inspectionl(Iocate on site plan) Number and configuration: Depth—tap of liquid to inlet invert: Depth of solids layer: Depth of sctun layer. Dimensions of cesspool: Materials of construction: Indication of grotmdwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation, PRIVY: _ (locate on site plea) Materials of construction: Dimensions: Depth of solids: Comments(mote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc,): Page 10 of 1 I OFFICIAL'&SPECT1bN FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: dK r;ll CL7 A-4 ekky Jr n emu: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTE]NI Provide a sketch of the sewage disposal system including ties to at least two permanent refstence landmarks or , bembmarlcs.Locate all wells within 100 feet.Locate where public water supply enters the building. �a g-c- c)q' c- 374 0 0 A-D- X 13-0- 31` a-F- sI Z�- 1 C• y6'6 fa A+ V W Pf:ACO W"kley dr Page I i of I I OFFICIAL MSPECT40N FORM—NOT FUR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ayf Pr;me 9 Ck 10 Cem feey Ll to Owner; Date of inspection: _ �O SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ac feet Please indicate(check)all methods used to determine the high ground water elevation: ____Obtained fmm system design plans on record-If checked,date of design plan reviewed _!!!!�Pbserved site(abutting property/observation hole within 150 feet of SAS) ____Aeeked with local Board of Health-explain: Checked with local,excavators,installers-(attach documentation) Y Accessed USGS database-explain: Yo must desgn how you establLftd the high ground water eleY tion: / 4ro, P.1ka a3" Title 5 Inspection Form 6/15/2000 i 1 +'tll l`0 C A T ION S}, SWAGE PERMIT NO. I N ST A ER'S NA E i ADDRESS -o e' I l DIE R R OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED / /�� f j J A 5 3 ` 3 -� f S � f� 7 171 -11,3 N09 EZ.3.A2................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........OF............_16R ------------------------------------------- Appliration for Disposal Marks Tonstrurtion 1hrmit -1,/ Application is'hereby made for a Permit to Construct 0 or Repair an Individual Sewage Disposal Syst at: .. ........ ..... . ..... ............ ... ........ ........... ................?�F............................................................ L t*o oca.; Address A�or Lot No. ......... . ...................................................................... . ....... Address Own er Owner Address . ..... . .. ........ nst--- ....... .........................0!.. ............................................................... Installer n s t a'I"I'er Address Type of Building Size Lot............................Sq. feet U _ Dwelling—No. of Bedrooms...........Z?..............................Expansion Attic Garbage Grinder (.,f40 Other—Type of Building ............................ No. of persons......................_._... Showers Cafeteria Otherfi tures ....................................................................................................................................................... Design Flow............ flow........ .. _..._...___.__._._..gallons. ....................... _gallons per person per day. Total daily flow.........3' P 9 Septic Tank—Liquid capacity/..gallons Length------ ......... Width................ Diameter_______..._..... Depth....._.......... Disposal Trench No...................... Width.................... Total Length_................... Total leaching area....................sq. ft. Seepage Pit No. Diameter..........4..... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box Dosing tank Percolation Test Results Performed by..-------- --------- Date_1Q,/X.X/`ZV.......... '2 Test Pit No. 14. ......minutesperinch Depth of Test Pit...... ....... Depth to ground water.:->,-�........... Test Pit No. 2................minutes per inch Depth of Test Pit.._................. Depth to ground water____................_.._ ............................................................................................................................................................. 0 Description of Soil..................C2.7:6.t../......j��Y..S...... ... ........................................ W ......................................................................................................................................................................................................... U ........................................................................................................................................................................................................ 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 TLIME 5 of the State Sanitary Code—The undersigned, rther agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o ealth. S* ed ... ------- ------ -_e" ate Application Approved By........... :2 . ................. ....... te Application Disapproved for the following reasons:.................................................................14 .............................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA r P � Es...3i.P_............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,►!!.- ................OF............ ' Appliratinn for Disposal Works Tonstrurtion Frrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at Location-Address a. .................... ' or Lot No r Owner 7 ,,� Address L Installer UType of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms---------.-rc:'.............................Expansion Attic (AL)�.-) Garbage Grinder (A)" aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . W Design Flow........... ., . .. ..............gallons per person per day. Total daily flow.........i;;Ln5_0....................gallons. WSeptic Tank—Liquid*capacity✓:4._:..:_.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.... Diameter........../r^..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by.......... a __9:='.__.: ............... Date.J4. *,#'gl�i .......... Test Pit No. 14�.Xw ._..minutes per inch Depth of Test Pit......s...... ..... Depth to ground water. yr•.......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w ._----- ---------------- ------•---•-•-----. r. _....... .-•••••-------•--••• ... .. D Description of Soil......---- --•-• +! t .r._..... .r� > ............ V ........................................ ........ ...`.......__...._._ ._....... ~r. � ._. ............................_..._.... W 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 TITIZ 5 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. ................................................. ----'�$� Application Approved By............. r- , ,, ' ate to Application Disapproved for the f ollowirg reasons---------------------•------------------•----------------------------------------------•----.........._•----_.. .......................................................--------•---------••-•--------••••-------•-----...-----------.....----••----------------------•--------------------•---------------------......._ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... #"...?''+:.................OF........ "<t?crt t ............................................. Tertifiratpof �C�ant li�anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) r by "�� ..... Q�.............•••................................................................... Instal}er ,,✓ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No 'G_ __ _ t i .............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. DATE l � Inspector - -------•--••----------------------------._----------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .JO ".. ................0F... �g o FEE.. ...4+ .......... Disposal Works TUan#rnrtion rrrmit Permission is hereby granted----- --------�..-h' ...._.0 ........................................ to Construe or Repa��( an Individual Sewage Disposal System � ,at No. sy': ._.... -------•-•......................... Street as shown on the application for Disposal Works Constructio mit No..................... ................ Dated.......................................... f ,� ! ✓' ' ----••-------------------------•--•- Board ealth DATE........y .,( --=- Z.9 'I.12.5d FORM 1255 HOBBS & WARREN, INC., PUBLISHERS S fs®szooM Flo C,ArrgAc!r �r�t�to>� _ I I_�dt�`� Clow a 1 tb +� 3 + �3b G•P•17 / �E�1't c �-�:�k. = 330� ISo % • 4.��6.P v. -"�- ---y- --�- --"' , 3 U,;C-- t o00 6At_. t PoS ht..� Pt_T t-)SE I ooc Gam. �t7xu�dtl. A�Ep, : tso ISo St= 2.S • S; > F'D• i ol � 426 G raw 0 TOTAL 'L�ESIGtJ = ?D. � i � }'�. Q' • Tt�To t_ qa'I t:.�f t=t.cw s 330 6�PD. f y'1► �- P rr d %? t t <; t ..lZGot,drloLj 04T : "IU Z.MttJ•O¢ LESS. tf r,ac �ouTto►.!� I4f • ,� art- - J p" r''tt 7.j "�1 -lit• �,. _.� 'c i { j - .. 41 I i SAXTT- 41 h". 'icei� � tA- "1''�ST �Z 19 16 _ _...•. .rG•SS Tar Fwv %S �. .. I . ELF S3 .. •� " t..o a«s 'ca � hIS1 G,eL. QIS 71s '8oX �r SE•vnC '= S1 LEaGH � • ; : :A • ' PIT •v t WAp•ICfl " CECLTtFtED pLe>-r PtZO�'1 L� L oCAT I O" EL-4I 1 1 I Z w c, Sao.�.1'c- h bATC— (18,(g� Sc.AL C— � z.� Q 7 0 V k mL T 1-i r--, Fo u pnAT l o Q 5t40wt.! ti-1 :t.'t.z7t�1 Gr 1Pl.�(S W VDA TWG: -54Gr=-A-1 tE-- Lc�•r• "19 } au>, SCT��c� �c4utcE��uTS of TNT M, 'jowv.1 or P6 " ZZ. q j CJA�t: -"�_e�• !3/S.XTCtit. c`, 4J',fE RcGts rc=rzED t..a.►.tD 5uev�Yves. ' o5-TEr~v%L-Lr= c MASS. '('t-Il5 C�LAt•.! t tJO•T >�,ASEt7 06J A-" AwireofnC=w i �,Uc_�ic�� T��C: caFc•,i�t'�. Srl�wub ANr��t GA.ti.IT AA __ . ,._ ._ •�._. ..,..•,-..,�....ir— l_n•Y• t_ts.�«::.� U►L�1.� � � �l"V1A•lrL- �+�C.r y TOWN OF BARNSTABLE (,OCATION SEWAGE VIL-LAGE_ ASSESSOR'S MAP & LOT 1 -71 INSTALLER'S NAME PHONE NO. . SEPTIC TANK CAPACITY , ek; � LEACHING FACILITY:(type) P Ye P(r (size) L NO. OF BEDROOMS ._ PRIVATE WELL BUILDER OR OWNER DATE PERMIT ISSUED: T.- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I .s, No.. � .. FEB..3 ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE AMOVED COMM Om Department Appliratiuu for Uiupual Works Ton '_ n rind# 2 �,,,,�-g�- Application is hereby made for a Permit to Construct ( ) or Repair (� Individual Sewage Dispop System at: nn yy a� ................--.... .......k�_ _l� ._o$�� ...................Z.e. c ........................................................ Location-Address or Lot No.. -. -�•��.�- ..... ....... ..... ................... .... ,/y� '` ----- �•— /may a ............... -.qw. � rie D �!�V l... � Add, s =. Installer Address y Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....._�_-�.................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixt Fs --------------- ------------------------------------------------•---------------------------------------•---------------.-----------------•--_---•-- W Design Flow..........1S._5.....................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.._..d.......... 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........................ fN Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ Ix --•••--•------•-•--•-------•••-•-------------•••---•••-----••-•-------...----------•---•---•---------•---•-------•-----•---•••-------. .... ..... .-- 0 Description of Soil..................................................................................................................................................... ............... W V .....-•------------------------••-------....•-•-------------•---...•----------•••-•--..........-----._.--------- •---•------•--------•---•••--------•••----.........•--------•----...--•-•-••----•--- W x -- ------------------------------------ ....... •------- U Nature of Repairs or Alterations—Answer when applicable_. Xv _ t�-__--I..i .......� C 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 Complia ce has been issued by the board of health. Signed -- ---L"z---` -------------------------------------------- ---------------------------------------- e Application Approved By .................. tc Application Disapproved for the following reasons- ------ ----------------------- - ---------------------------------------- - ----------------------- ------------ -- --------------------- --------------------- ---- --------------------------------- ------------- --------------------- -- -- ---------------------------------------- ------- ---- ----------------------------- Date PermitNo. ,�............. ........... Issued ........................ .......------------------ --- Dare J. No....... _..n Fss... ��l-�.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Toustruftiori Grp utit Application is hereby made for a Permit to Construct ( ) or Repair ( L,,an Individual Sewage Disposal System at: Location•Address �w -. or-Lot No. Owner W ---------------- n I' V11- � ff ./7J_1/ 1_l ...E_.�I>� ddres��n N t�-r A K l a L/.•..- -- - .................. ....................... ....................... Installer Address V Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--_--.�..............................Expansion Attic ( ) Garbage Grinder ( ) aN Other—T e of Building ............. No. of ersons._..___.-_......_..._..._... Showers YP g --------•----•- P ( ) — Cafeteria ( ) POther 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.....1_h..... Depth below inlet...... ------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ 4 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1-4 44 Test Pit No. 2----------------minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a -------------•-•--------•-•---•-•--•--•....••-•-----•------•---•••------.............--•••-•-•--•............................................................ 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------•------------------------------- W --------•-------------------------------------------•-------------------------------------------------------------------------------------------------------------------•---------------•--------------- W U Nature of Repairs or Alterations—Answer when applicable._-___'7r.No `�tE �______l.i ----- -._._ �!G _ +` ''"' t 1 _ A r _=• -------------------------------------------------- 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 board of health. Signed � ........... -- " Dare Application Approved B ------------------------------------------------- ^ -Date ----- Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- -=--- Date PermitNo. - ------------------_ Issued ........................................................ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �ex#tficate of (gamplia n e THIS IS TO CERTIFY, That the Individu�al Sewage Disposal System constructed ( ) or Repaired ( (�)! by--------------- — ...-_. �L alter .................................................................-----....... ---------- -------- ----------- ----�-� -�- - at r ! --e--f---------- ------------- ------- ---- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .----.�,;.,..-.- .6;�- ___-..__ dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAcir il(� - DATE------------------------------------------------------------------------------------------------------- Inspector ------------------_--v-------------------•--------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....q F TOWN OF BARNSTABLE �- r`� ... ------------- Disposal Works k"unslrur#iun f amit Permission is hereby granted-------flA 19/=".. `-�--f .CL.......................................................--___ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System � at No--------------------------------------� ✓ Street f------------------------ ------------------------- as shown on the application for Disposal Works Construction Permit No._ _ S Dated.......................................... ...........-••-----------------4-AD----------------------------------------------------_ 7 _ L �n Board of Health ---------------------------------------------------- DATE------------ FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS