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HomeMy WebLinkAbout0036 ROLLING HITCH ROAD - Health 36 Rolling Hitch Road Centerville , MA A= UPC 12534 ' 2-153L0 w�twaer I No. �.�� �� Fee ( THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACH_USETTS 91PPYication for Oiopool bpotm°CongtM: rtion permit Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon 64L O Complete System El Individual Components . Location Address or Lot No. Owner's NName,Address and Tel."No. 36 Rn"i 1n5 14i v y Assessor's Map/Parcel C Te C v�r C � r5�k; e'_h' 070 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. LPL- Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 e� gallons per day. Calculated daily flow ' 3:3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank `b0® Type of S.A.S. L^P Ate. �►T Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0—b tl 4p3e � l�i�1 Q 1 Y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boo of Health. Signed ` ' Date fv "Lit^ .®©') Application Approved by ` rW_ Date —27—G-S' Application Disapproved for the following reasons Permit No. .20d.sP — 3 Date Issued No, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for.-igo5al *pgtem Conotructfott hermit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. ,-Assessor's Map/Parcel e►1Z�f ti Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3v gallons per day. Calculated daily flow 37!) rj t gallons. Plan Date Number of sheets Revision Date l Title ~" Size of Septic Tank onn Type of S.A.S. i_eA" Description of Soil Nature of Repairs or Alterations(Answer when L applicable)� 1� 1 A412�� 1 ��t y im) Date last inspected: Agreement: ^ �"`TThe undersigned agrees to ensure the construction"and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the EnvirQnmehtal Code and not to place the system,in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Y - Signed Date "2-1; .Z©oj Application Approved by C Date Application Disapproved for he following reasons e Permit No. 211 d o f Date Issued �X-o ff THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance m IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded( ) bandoned- by at has been constructed in accordance with the provisions ofTi e 5 and the for Disposal System Construction Permit No. ated_( - 2 Installer Designer The issuance of dus permit shall not be clonst ue as a guarantee that e syste, ct''o a deug gd. Date '� Inspec�or No. D Liu , d y Fee �— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ltgpool *pgtem construction permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon System located at 362 1&1I I;44) and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must a completed within three years of the date of this Date:_, _ , e) "Approved by IM R °F THE tOW Town of Barnstable BARNMABLE, * Regulatory Services 1639. 10 Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 July 19, 2005 Ms Virginia Cahill 36 Rolling Hitch Road Centerville, MA 0263 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 36 Rolling Hitch Road, Centerville,MA was inspected on June 10`h, 2005 by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Conditionally Passed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) DUE TO THE FOLLOWING: Plumbing needs to be combined in the basement and the old single cesspool must be removed or abandoned. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE TH DEPARTMENT COMMONWEALTH OF MASSACHUSETTS3�/ Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m , d DEPARTMENT OF ENVIRONMENTAL PROTECTION e� O,,M Sy6 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM. .. PART A CERTIFICATION Property Address: #36 Rolling Hitch Road Centerville,MA V d Owner's Name: Virginia Cahill Owner's Address: #36 Rolling Hitch Road Centerville,MA Date of Inspection: 06/13/05 Name of Inspector: (please print) Mr.Carmen E.Shay .Company Name: CAPEWIDE ENTERPRISES,LLC Mailing Address: P.O.Box 763 Centerville,MA 0632 c Telephone Number: (508)-428-4028 C0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the ih#'1 rmation-reported= below is true,accurate and complete as of the time of the inspection.The inspection was performe based onjny training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP c approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste C,> Passes OF��P��N 4MS. XX Conditionally Passes o� CARMEN tiN Needs Further valuation by the Local Approving Autho g- E. "a Fails SHAY y � �FgTtF �o Inspector's Signature: t Date: 6/13/05 4P5aVs `� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments I Bathroom,Kitchen and Laundry Area still connected to old single Cesspool. A Septic tank,D-Box and Leach pit was installed in 1998. Plumbing needs to be combined in Basement and Cesspool abandoned. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 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: _XX One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #36 Rollin Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 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. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up'? XX _ Was the site inspected for signs of break out XX _ Were all system components,excluding the SAS, located on site'? XX _ 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 ? XX _ 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 XX _ Existing information. For example,a plan at the Board of Health. XX _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #36 Rollin Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 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: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 67,000 gallons—2003/78,000 gallons 2004 Sump pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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 INFORMATION Pumping Records Source of information: None Available Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): I Approximate age of all components,date installed(if known)and source of information: 1998- per Owner&BOH Records Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: cast iron �40 PVC XX other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 6"to Top of Tank Material of construction: XX 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: 5' deep x 5'wide by 8' long (1,000 gallons) Sludge depth: 4.0' Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness: '/4 inch scum laver noted Distance from top of scum to.top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltrationlexfiltration 4" PVC Tee present at inlet end. Outlet baffle present and in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(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 _ rJ Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box Present—one outlet,no evidence of significant carryover. PUMP CHAMBER: (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX leaching pits,number: 1 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.): No evidence of hydraulic failure of septic tank or of leach either leach pit. 1.5' Liquid observed in leach pit. Cover located and removed as part of inspection. Top of leach pit is 10" below ground CESSPOOLS: 1_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1-6' x 6' Cesspool with part of house flow connected. Cesspool needs to be abandoned and piping re-configured in basement. 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: (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 h OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 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. Swing Ties• Rolling Hitch Road A- Tank In— 15' B- Tank In—20' A—D-Box—20 B—D-Box— 17 Water;Line A—Leach Pit —26' B—Leach Pit —59 1A Septic Tank Exist House (1000 Gal.) B %Pitt Cesspool Page 11 of 11 T OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #36 Rolling Hitch Road Centerville,MA Owner: Virginia Cahill Date of Inspection: 06/13/05 SITE EXAM Slope Surface water - %Z mile+/- Check cellar -Yes Shallow wells—None Estimated depth to ground water 31' 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: XX Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Quadrangle of USGS Map. Per USGS MAP PLATE 2: Elev.of Ground=66 Feet Elev.Of Groundwater=35 Feet Elev.Of Bottom of Leach Pit 59 Feet Therefore: 59-35=24 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well SDW-252(Zone C): 3.4 feet Adjusted Groundwater Separation=24' -3.4=20.6 feet between bottom of pit and ad*.groundwater Grade=Elev. 66 feet Pit Septic Tank Bottom of Pit=Elev. 59 feet Adj. Groundwater=Elev.27.4 / TOWN OF BARNST ABLE May / LOCATION 3 6/ �a/(,�. ��e�, SEWAGE # �` VILLAGE ��� �� :�a �-ASSESSOR'S MAP & LOT °Cl1 INSTALLER'S NAME & PHONE NO.c,,Oe- Y �t � SEPTIC TANK CAPACITY / r LEACHING FACILITY:(type) 4 cc.�L size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �X / i � .. � �� �� ����� �� Y Fas.... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di►ipooul 3lurk.6 Towitrurtion rrrmit Application is hereby made for a Permit to Construct ( ) or, Repair (%,�an Individual Sewage Disposal System at ---......... --.. �� .:.... � . °�---- - �/��(�J�. .._-•-Loc, on-Addre or Lot No. ..........�.•-l�"•�. N�. ... _._ ..a ..................•..............• _.._...._._..------'.._. ... iG..6...•......................•.....•........................ Owl Address pq Installer Address UType of Building 4 Size Lot............................Sq. feet .. Dwelling—No. of Bedrooms--------------------------------------Expansion Attic ( ) Garbage Grinder ( ) WOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . d -- Desi n Flow.....-----�` ��C�----------------•-----•--...._.._._... W g :5 ------.-.--C�-----_gallons per person r day. Total daily flow.._..'......................................gallons. WSeptic Tank--Liquid capacity __-.-._---.gallons Length__. r...... Width................ Diameter................ Depth................ xDisposal Trench--. o_ ____________________ 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........................................ ,.a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......:................. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------- •.... •................................. •-•-------------- •••••------------------ - --••••............... -...... --------------- ... -•--------- ODescription of Soil........................................................................................................................................................................ W x ---------------------------------•---------- U Nature of Repa' s or Alterations—Ar..nswer when a4pplicable.. ^-fi��----ve"O s'Xe..�� .................. ,J�� Y ----------------Q.`-L�..d`e........ i�rO. k .L. f�� ,e,, ---------...--•-----------------••-•-•---•--••--------...--•--•---...-- 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 Com li e e b d of health. Signed ...- .................... ....... . ... ............................... .................................:...... Date Application Approved By ............. ... ....... .: .................... Application Disapproved for the following reasons: .. -- ' .-- .... ......................................... ..................... :' ' ............................................................................ ' .... ................................................................................. .. ................ ........................................ Date PermitNo. ------7-Li---... ..t-. ........................ Issued .................................................................... Dare � i4-�. r �. ..U• T FPS.... . >........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripwi Il Works Tonitrnr#inn rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (%.,<�an Individual Sewage Disposal System at: .....---•---- ----- ---------•------------- Loca. r \d r.. r� ' �°`on :�ddn'ss or Lot No. Installer�+ Address d Type of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms.3------------------------------------ Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------- ----------------------------------------------------- ��C� W Design Flow......... ` ......................gallons per person per day. Total daily flow.___-_-__._...._..._.___._....._............gallons. WSeptic Tank—Liquid capacityl(W.galIons Length.__..._..___ Width________________ Diameter_..--___--___ - Depth................ x Disposal Trench--No..................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-------)............ Diameter____/_�-:-------- Depth below inlet-----q.1......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ,-� Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------------------------- -----------------------------•-•-•-••------•--•......------...-•------------------....._..........•---•-----•............•-_...-- 0 Description of Soil......................................................................................--------------••---•--•-•----•---------------•---•--..........---..------........ x U --------------------------•--------.......----•-•--•••••-••••----•-•-••...-•-------•-••........•----••---------•---•---......-------•-•-•---------•••---•-----------------....---•-------•--............ w ................... U Nature of/R� epa/irs or Alterations—Answer when applicable..-`t-L. -St.Pt((____C.�' it CY/l!G t . ................... ' ................ `-`'•lS'(1`'-_-_-__•ce✓-G!_f-i-_�./�f.%_._._ t.._Im <-F--?(/q.?rC v ...... ......... . ....... .•....... ........... 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 ............ �''�' —....... .-...� ..,.... y, ............... ............`---....--. ................. Dace.................. Application Approved By ------------ --- _. - ......_. �.-. ...-9...k Dam Application Disapproved for the following reasons: .......... ..... . ....---- ....................................... .................-- ..... ............ ...... ..... ...................................................................... ................................. ........... .. .......................... ........................................ Date PermitNo. ------ !i..-...- . 'c ......................... Issued ........................--............................ ......... � Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF1 BARNSTABLE C�P4�t�t.Ci`S�E D� �IIZYC��i2XYtCP THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �.► 1 by ........................................_.._.....- = r�.-��J�---:�_. ..t._�..C._. .. .... .. ............ .............._............................. .......... O�� pTC- i� G �h.... _ I�t at ............................................. :`--.- � ----- ,........... ..............--.::.. ...............-------------------------------------------- ---------------- has been installed in accordance with the provislons of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. -..-.. L�.r.-. .....y.�`?-.- dated ..................._....._.--..........__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST�UEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-......._ .......'....° -.... ..= - Inspect-r- . . ......-`............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q TOWN OF BARNSTABLE No...-d.. ! -.ku FEE . MiVwial nrko �nnntr rtinn erntit Permission is hereby granted................ ----- -_(_ :_L.±--.-_.f� _- to Construct ( ) or Repair ( an Individual Sewage Disposal S tem atNo................................... "Z(` � c.SA`_------------=� .......-- ----------------------------------•-------------------.._....--------........_........ Street as shown on the application for Disposal Works Construction Permit No. -------------------------------------- ,0.......... y G(' oard of Health DATE-------------- ..�.. . . FORM 36508 HOBBS&WARREN.INC..PUBLISHERS