HomeMy WebLinkAbout0610 SKUNKNET ROAD - Health v
610 Skunknet Rd, (Centerville)
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IN
UPC 10259
No.H�R
NAGTINat.UN
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) 'Business Certificates are available at the Town Clerk's Office, 1°`FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
F r DATE: 0 . �b Fill in please:
r , < . APPLICANT'S YOUR NAME/S: U
BUSINESS YOUR HOME ADDRESS: �O f1 K-n C�
Qh
TELEPHONE # Home Telephone Number 01l
NAME OF CORPORATION:
NAME OF NEW BUSINESS TYPE OF BUSINESS I&P
IS THIS A HOME OCCUPAT ON? NO i
ADDRESS OF BUSINESS MAP/PARCEL NUMBER t (Assessing)
When starting a new business there are several things you. must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth_
Rd. & Main Street) to make sure you have-the appropriate permits and licenses required to legally operate our business in this town.
1. BUILDING CO MISSI NER'S OFFICE
This individ al h n info m f ny rmit requirements that.pertain to this type of business.
MUST COMPLY WITH HOME OCCUPATION
i' Au,tho ' ed Sigpa e** RULES AND REGULATIONS. FAILURE TO
OMMEINITS: COMPLY MAY RESULT IN FINES.
2. BOARD OFYAEALTH
This in has been infor Qe o�tpe�rte G ents that pertain to this type of business.
ut oriz&dSi ature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
'do
s Materials Inventory Sheet Checklist
�v gDate
u
Physical Street Address-Check database to ensure it exists
Working Phone Number
d' 'Actual Amounts -( ie.gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials-no blanks)
/U Storage Information -location of storage, how long is storage for?
If none, note that.
Disposal Information -where and who? If none, note that.
�`-L,,""Applicant Signature -understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy and
plain it
Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
f
{
444
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIAL ON-SITE INVENTORY
NAME OF BUSINESS: u ��f e" S #
BUSINESS LOCATION: n INVENTORY
MAILING ADDRESS: (U( A TOTAL AMOUNT:
TELEPHONE NUMBE- :
CONTACT PERSON:
EMERGENCY CONTACT TELEP ON MBER: sa:)&" MSDS ON SITE?
j TYPE OF BUSINESS:
INFORMATION/RECOMMENDATIONS: Fire District:
5
,! Waste Transportation: Last shipment of hazardouswaste:
Name of Hauler: Destination:
j Waste Product: Licensed? Yes No
I
NOTE: Under the provisions of Ch. 111, Section 31 , of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be reg1stered regardless ofvolume.
Observed/Maximum ,_ .. Observed/Maximum
_ Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid `1_ Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
•-o
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
`i Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
II Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
i
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint & varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be t xic o hazardous (please list):
Laundry soil & stain removers .
(including
cluding bleach)
II Spot removers & cleaning fluids
(dry cleaners)
2 tlt 14L-Other cleaning solvents
Bug and tar removers
�4L )Ilwindshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r a DEPARTMENT OF ENVIRONMENTAL, PROTECTION
1M SV4� RECEIVED
JUL 0 5 2001
TITLE 5 TOWN OF
HEALTH DEPT.
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �Q S n I��T �v� � M14
Owner's Name:
v 2,-) v,�?S
Owner's Address: C/o 11--ah(/US
�0 86X a 00 E�5� � rs A� 0��7`l
Date of Inspection:
I �
Name of Inspector: (please print) Joseph M.Martins
Company Name: Accu Sepcheck
MailingAddress: 17 Northside Drive,S.Dennis MA 02660
�
Telephone Number: 508-385-5891
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I-am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMIt 15.000). The system:
Passes
Conditionally Passes
Needs Fu Evaluation by the Local Approving Authority
F '
Inspector's Signature: Date: ,�� OI
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 �� M��' /CPCo��t�?P✓l��G� 2
****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.
Page 2 of 1 i
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) �]
Property Address: 4`O S�v�/��e �G1 C�� �v //� " ' 'X
Owner: ✓ 4S
Date of Inspection: 6 a
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional ss.section need to be replaced or
repaired.The system,upon completion of the replacement or repair. 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.
tank is metal and over ears old*or the se tic•tank(whether metal or not)is structurally
The septic y P
unsound exhibits substantial infiltrat. 1 or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a co plying septic tank as approved by the Board of Health.
*A metal septic tank will pass' spection if it is structurally sound,not leakina and if a Certificate of Compliance
indicating that the tank is I than 20 years old is available.
ND explain:
Observa n of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pi (s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval o oard 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:
- - J
Paite 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6,10 5.��„�� PT
P i
Owner: �Q � , �
Date of Inspection: 6 020 O l
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 determi ' accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner wh' ill protect public health,safety and the environment:
_ Cesspool or privy is with feet of a surface water
Cesspool or privy i ithin 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+vithin 50 et of a private water supply well.
_ The system has a septic tank and SAS and the SA ' ' ss than 100 feet but 50 feet or more from a
private water supply well". Method used to det one distance
"'This system passes if the well +vat nalysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic con unds indicates that the well is free from pollution from that facility and
the presence of ammonia ni en and nitrate nitrogen is equal to or-less than 5 ppm,provided that no other
failure criteria are trigge A copy of the analysis must be attached to this form.
3. Other:
f
Pa-e 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: 6 Z� c) (7/
D. Svstem Failure Criteria applicable to all systems:
You must indicate'des"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 +ater elevation.
t,— Any portion of cesspool or priory is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ !.-- Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ t—Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _L—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 cope of the analysis must be attached to this forma
(Yes/No)The system fails. 1 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 fol lowing criteria apply to large systems in addition to the trite ove)
yes no
the system is within 400 feet of a ace drinking water supply
the system is within feet of a tributary to a surface drinking water supply
the syste located in a nitrogen sensitive area(interim Wellhead Protection Area—I WPA)or a mapped
Zon 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.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST / A�
Property_ Address: 610 S40 7— �//
Owner:_ IV
Date of Inspection: 07 d l
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)
t� 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,ex ding 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:
Yes no
Existing information_ For example,a plan at the Board of Health.
_✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CIV1R 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// i SYSTEM INFORMATION
Property Address: C��� S/ Un44,0T Cc2l
ON%-ner•
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: I d ry �g 2 P.e/
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no):I [if yes separate inspection required]
Laundry system inspected(yes or no):_--
Seasonal use: (yes or no): A10
Water meter readings,if available(last 2 years usage(gpd)): /F!J�q 2 000G
Sump pump(yes or no): _l ✓ d
Last date of occupancy:
COR'MERCIAL/INDUSTRIA.L
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.
Grease trap present(yes or no): _
Industrial waste holding present(yes or no):—
Non-sanitary was ischarged to the Title 5 system (yes or no):
Water me eadintrs,if available:
L ate of occupancy/use: _
OTHER(describe):
GENERAL INFORMATION
Pumping Records /QJ-0e�,PQ" !h /Owo /)Q�
Source of information: 4(�
Was system pumped as part of the inspection(yes or no):A/O
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
1/ 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)
Ti 6t tank _Attach a copy of the DEP approval
_Other(describe):
if kn
vn
Approximate age of all components,date installed( gg,, )and source of information:
lS�o�S
Were sewage odors detected when arriving at the site(yes or no):
Page 7 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORM�ATION (continued) `
Property Address: j6,10
Owner: / 1re /
Date of Inspection: c;�6
BUILDING SEWER(locate on site plan)
Depth below grade: 02 " -
Materials of construction:_cast iron V 40 PVC_other(explain):
Distance from private water supp]y,,{,ell or suction line:
Comments(on condition of joints;venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
/
Depth below grade: V
Material of construction:_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 /Y S 7 l� X 6 4L y1r1'/ L,/4di0 iX� , /f
Sludge depth-
Distance from top of sludge to bottom of outlet tee or baffle: 7
Scum thickness: 6 ,1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of out] t tee r baffle: /
How�,vere dimensions determined: ! UGjIP ,S'�-V� vd�� e
Comments(on pumping recommendations,inlet and outlet tee or baffle ondition,structural mtegrTty liquid levels
as related to outlet invert,evidence of leakage,etc.):
4.
GREASE TRAP:_(locate on site plan)
Depth belo\v grade:_
Material of construction:_concrete_metal fiber _polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum op of outlet tee or baffle:
Distance froZbotto scum to bottom of outlet tee or baffle:
Date of last Comments( g recommendations,in
and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
i
Page 8 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) �Q
Property Address: 1�610
Owner:
Date of Inspection: a e7 O
TIGHT or HOLDING TANK: (tank must be pumped at tir nspection)(locate on site plan)
Depth below grade:
Material of construction: concrete al fiberglass_ polyethylene other(explain):
Dimensions:
Capacity: Gallons
Design Flow: gallons/day
Alarm pres ,es
or no):
Alarm level: Alann in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(loc/ate on site plan)
Depth of liquid level above outlet invert: /� T d //7 c,,P/T
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakaoe into r oyt of bon etc.): / v
PU!�IP CHAMBER: (locate on site plan)
Pumps in working order Lyes or no):
Alarms in working order(yes or no):
Comments(dote condition of pu chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUB
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION
' (continued)
Property Address: G /6 S ,n rG e T /v✓i `24 key I/r/
e / 4-
Owner:
Date of Inspection: ova O
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number: , {�
leaching galleries,number: T X X /CLd 1) "� -
leaching trenches,number,length:
/oZXo7- T %O� � r
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): .�/La✓e Fl�� /�c'% /.S C�e�/� _ //
erg° avl lu P t CYaa�c 70
CESSPOOLS: (cesspool must be pumped as part inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site an)
Materials of constructio
Dimensions:
Depth of solids:
Comments(not ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
r
Pacte 10 of l 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �(d StUnk e /P-61/ C&4 k(////C-
Owner Cl�
Date.of Inspection: 6
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.
W
_ a
E
A
° C iST A W-&-s
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= 26 ' f3C-:i3 (o
4b = 2q &b
- S. �
A� -36. , FE: q6 ,5
• i
Page 11 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATI/ON(continued)
Property Address:
Owner: �CG
Date of Inspection: O o
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells ;-��
Estimated depth to ground water
����� �' d v ��5 �
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on re -If checked,date of design plan reviewed:
_L/Observed site(abutting property nervation hol within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
/—k) /e' �O /o�� /O l
/U vtl C/�P j/) v✓il Trod s
�d
6
3 .
t
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
JUN 2 7 2001
TITLE 5 TOWN OF BARNSTABLE
HEALTH DEPT.
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY AS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �Q �S Cjl)/A- AT M14
Owner's Name: ��
vr�2� k�/'vz?S
Owner's Address: =/0 Cih t a-sr-0 Q
Date of Inspection: � /a
Name of Inspector: (please print) / Joseph M.Martins
Company Name: Accu Sepcheck
Mailing Address: 17 Northside Drive,S. Dennis,MA 02660
Telephone Number: 508-385-5891
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Fu Evaluation by the Local Approving Authority
AInspector's Signature: Date:
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 � keCoMM
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address thow the system will perform in the future under the same or different
conditions of use.
t
Page 2 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 4`a ��U12A,�e7-/1Gf . &4A-/1//e_ 414
Owner: /V
Date of Inspection: 6 a
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Svstem Passes:
[have not found any information which indicates that any of the failure criteria described in 310 CiviR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional ss'section need to be replaced or
repaired.The system,upon completion of the replacement or repair 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? years old' or the septic tank(whether metal or not) is structural],,
unsound,exhibits substantial infiltrat' I or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a c plying septic tank as approved by the Board of Health.
*A metal septic tank will pass i spection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is I than 20 years old is available.
ND explain:
Observa n of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pi (s)or due to a broken,settled or uneven distribution boa. System will pass inspection if(with
approval o oard 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). "fhe system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Pate 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) ``e-
Property Address: 610 S�vi t,4 PT l 04 kl-vl``Owner: �a / , q37
Date of Inspection: 6 02 0 O l
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to detennine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determi n accordance��ith 310 CMR 15.303(I)(b) that the
system is not functioning in a manner wh' 'ill protect public health,safety and the environment:
_ Cesspool or privy is with' feet of a surface water
Cesspool or privy i ithin 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 ,�et of a private water supply well.
_ The system has a septic tank and SAS and the SA. ' ass than 100 feet but 50 feet or more from a
private water supply well**. Method used to det^ me distance
**This system passes if the well wat nalysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic con unds indicates that the,,yell is free from pollution from that facility and
the presence of ammonia m gen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are trigge .A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address 61U S�v��.,eT ��Il �/J7'��l//�/ Av -
Owner:
Date of Inspection: 6 "1 d O�
1). System Failure Criteria applicable to all systems:
You must indicate"yes'or'i)o"to each of the following for all inspections:
Yes No
_ Backup of sewage into facility or system component due to overloaded or clo-Med SAS or cesspool
_�
�DischarMe or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
cloMMed SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or cloZ7—ed SAS or
cesspool
_ l,/� Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day Ilow
_ Required pumping ore than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
r/ m
of times pumped
_ V'-Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ _� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ (,— Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ tl-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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facilit},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 cope of the analysis must be attached to this form.l
0 (Yesflo)The system fails. 1 have determined that one or more of the above failure criteria eNist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to dote;nine 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 (Yl)d to 15,000
bpd•
You must indicate either"Yes'or"no"to each of the following:
(The following criteria apply to large systems in addition to the crite ove)
yes no
the system is within 400 feet of a . ace drinking water supply
the system is within ? feet of a tributary to a surface drinking water supply
the systen located in a nitrogen sensitive area(interim Wellhead Protection Area -IWIIA) or a mapped
Zon of a public %kater supply well
if you have answered"ves to any question in Section E tf)e system is considered a significant threat;or answered
"ves" 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.
I
Pate 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIIST
Property Address: 610 S4, T �V
��/I je�e—`///�l/A��/ 9
Owner:
Date of Inspection: IC 07 d Q l
Check if the following have been done.You must indicate`dyes'or"no"as to each of the followinc-):
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'?
lave 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)
V'- Was the facility or d,,velling inspected for signs of sewage back up'?
Was the site inspected for si<gns of break out?
Were all system components,ex dmg 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 owlier(and occupants if different fi-om owner)provided with Information on the proper
maintenance ol'subsurface sewage disposal systems''
The size and location of the Soil Absorption System(SAS) on the site has been determined based on:
Yes no
Existing information. For example,a plan at the Board of Health.
_✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IN,FORMATION
Property Address:
0,%vner• /1 G
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Nut-�tber of bedrooms(design): 3 Number of bedrooms(actual): 33(�
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x E of bedrooms):
Number of current residents: / tig 2 P.e/
Does residence have a garbage grinder(yes or no): /�t)
S,F,�
Is laundry on a separate sewage system (yes or no):IVP [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): Nd m U�
Water meter readim?s, if available(last 2 years usage(gpd)): ��r�j 36,000E
Sup pump(yes or no): t ✓ d
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): _
Basis of design flow(seats/persons/sgft,etc.
Grease trap present(yes or no):
Industrial waste holding present(yes or no):_
Non-sanitary wa ischaroed to the Title 5 system (yes or no _
\hater m eadings,if available:
L ate of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection (yes or no): A10
If yes; volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
I/ 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): _ .—
Approximate age of all components,date installed(if kn vn)and source of information:
0 2�2S/ /0 a Y ,Oe/L 9. 6/e ,Q • /�
Were se�,vage odors detected when arrivin,y at the site(yes or no):Q
Page 7 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: /�q
Date of Inspection:
BUILDING SEWER(locate on site plan)
7 !
Depth below grade: a -
Materials of construction:_cast iron V 40 PVC__other(explain):
Distance from private water supply well or suction line: 7 /0
Comments(on condition of joints,venting,evidence of leakage,etc.):
IF1
SEPTIC TAiNK:_(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass_J�ol�ethylene
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 X S~ 7 X 0 L 41%F�� Z- /G��l i� �� O/%f
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 7
Scum thickness: 6 '/
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of out] t tee or baffle:
flow were dimensions determined: r��UG,J .SLV� ✓GT5'e
Comments(on pumping recommendations, inlet and outlet tee or baffle ondition,structural integrity; liquid levels
as related to outlet invert,evidence of leakage,etc.):
��/b�i N G' �'v 2 , Ali
GREASE TRAP: (locate on site plan)
Depth below grade: _
Material of construction: _concrete_metal f berms _polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum op of outlet tee or baffle:
Distance from bottot scum to bottom of outlet tee or baffle:
Date of last pum tg:
Comments( pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Pagc S of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: <�r�
0-wner• —
Date of Inspection: v
TIGHT or HOLDING TANK: (tank must be pumped at tin nspection)(locate on site plan)
Depth below grade:
Material of construction: concrete al fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/da_v
Alarm pres yes or no):
Alann level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition ofalarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locaate on site plan)Depth of liquid level above outlet invert: /� 7- 0 011e l 14C P �B
T
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or oy� of box, etc.):
17
/ � vf
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alanns in \vorkin- order(yes or no):
Comments(note condition of put E 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: 616 S�Uh(O e F Y`�✓l 624 le'Pu d/e ll A
Owner:
Date of Inspection: ova
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number: ,
leaching galleries,number: �jr��'� �La T- ►t/SLS w S�'?
leaching trenches,number,length: P,C�in e
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.): , a✓� G� ���7(� 5 Cle��
Xq cew/C i lure- 7U
CESSPOOLS: (cesspool must be pumped as part inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver:
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 an)
Materials of constructio
Dimensions:
Depth of solids:
Comments(not ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: Ct
Date of Inspection: G j
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..
W
_ p
G
0 CIST �
D = 26 �C_ 3
l
-30 - RE: �6,5
8 F= 557.E
1
Page I 1 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Vj/G si\u (C/1 led j 6eli
Owner: �`G U
Date of Inspection: O
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells \ r _
Estimated depth to groundwater / ` !�koJYI
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on re -If checked,date of design plan reviewed:
Observed site(abutting property servation hol within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
i� 1� � 6 /d-0 /0
s e,
(2 ),//1 lrod<
� . G"r-Cfde-
3 .
Health Complaints
30-Aug-99
Time: 11:30:00 AM Date: 8/30/99 Complaint Number: 2048
Referred To: GLEN HARRINGTON Taken B ,
Complaint Type: CHAPTER II HOUSING
Article X Detail: \
Business Name:
Number: 610 Street: SKUNKNET
Village: CENTERVILLE Assessors Map-Parcel:
Complainant's Name: ANONYMOUS
Address:
Telephone Number:
Complaint Description: THE WOMAN AT ABOVE ADDRESS FEEDS
ABOUT 15 STRAY CATS. THEY COME IN
TO COMPLAINANT'S BACKYARD AND
URINATE IN THE SANDBOX AND HANG
AROUND THE PROPERTY. THE ODOR IS
BAD.
Actions Taken/Results:
Investigation Date: Investigation Time:
y c'o^-►s i w c &J/S
ad -
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TOWN OF BARNSTABLE
>CATION 6t O SVAI SEWAGE #
V1 LAGE &Wile, ASSESSOR'S MAP & LOT 015,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY � Z7
LEACHING FACILITY: (type 2 FW VJ S W 5�4_efnzej 2�
NO. OF BEDROOMS 3 �Sl 6A/
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f' 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 o Ching fqMit Feet
Furnished by
.40t MARTINS
A60U OEPCHECK
17 NORTHSIDE OR
S:®RNNIG,MA 02610"
- =�I
1
If
OF BARNSTABLE
LOCATION � � (20' SEWAGE # 01'0
dVIL LAGS ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. rt
i
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
140. OF BEDROOMS
1ahM
BtJII.,DER OR OWNER/ `
PERMITDATE: 10 COMPLIANCE DATE:
� M
Separation Distance Between the:
Maximum.Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist s
within 300 feet of leaching facility) r Feet
Furnished by &' u� a2,4s 0,, d-�(R
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.fit 5I-IOWI./�:(.IF�ZEOhI Go.NGI.YS Yi�+.r' -• ., -
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A,T IONj 1 S E W A G PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED � 0�.
DAT E COMPLIANCE ISSUED L3
. _ ���
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�:
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No .... Frss...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
C7t�?..fl..........OF....... f�.. .................................................`—Appliration for Bhipoii al Workii Tonstru.rtiun Frrmit
Application is hereby made for a Permit to Construct (L4 or Repair ( ) an Individual Sewage Disposal
System at:
.............5 . ._.. � ---............._.... ........... - -------��----- ---------------------........------------
....
M Location-Addre _�� ` .30\ of t No.
-- s --..�...------•----------•--- ------------- ----------------------- ...�...J ............................................
Owner dres�
a --•--------._ e- R-� ----•- ---.....s:....................... .......... L�.n 's •---••---••-..........................
Installer Address
Type of Building Size Lot... k _,.,ft0 __....Sq. feet U
a Dwelling—No. of Bedrooms................. ......................Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria ( )
a Other fixtures -------------------•-•-••-•••••• .
W. Design Flow...........\\.Q........................gallons per person per day. Total daily flow................3-3 0..............gallons.
WSeptic Tank—Liquid*ca.pacity\Nv!?..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 t ( )
Percolation Test Results Performed by......... .1 �.__ ......4.._...N._. ....._._. Date.....5.`_.9.�_:_ .........
a 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........................
P ----•----------•--- ..................................................
-------------------
•---------
----------
--------•------------------------
O Description of Soil...C� ?----- ..............dubs o
U ........................62,....... -•...... 1n . . . ................................................................
------------------------------------t -•----r`^ ------- tee...---- 5 .............. ............�R ►......
V Nature of Repairs or Alterations—Answer when app icable........................................................... �.
---------------------------------------•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of C Compliance has been issued by the board of health.Sig d }G9�1! -�r� Y-�__..
• r� 1
•-•-•- ••-•-----••-
D
Application Approved ----- ••......• ----- --..----•---.......--•----------------•----••---------•........_•----_.. -� --••----
Date
_.Application Disappr ed r t e following reasons:................................................................................................................
....................................... •---- -----•------------•-----•......_..----•---••-------••••--
---------------------------------------------------------------
Date
PermitNo......................................................... Issued_....................................................
Date
FEB.. ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. s n..........OF......-
ApplirFatiun for Disposal Works Tonstrnrtion rumit
Application is hereby made for a Permit to Construct (t.-) or Repair ( ) an Individual Sewage Disposal
System at:
...........I..`.s
'-•`--`•-C�---------•--........... ....._ .........:,.�_....---�`°.... ..........................................
• Location-Addre �Qt No.
..._.,
\ , Owneroc
`� 1 Ad Tess
Installer Address
�A \�
Type of Building �,� Size Lot___ _..._,________________Sq. feet
aDwelling—No. of Bedrooms................... ......................Expansion Attic ( ) Garbage Grinder Q c�
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ..._...•---•---•----•-•-•--••••• - •-- --------------------------------------•-
t(l ." �..........---------------------
W Design Flow___________ \ ________________________gallons per person per day. Total daily flow____..__._.__.__._..__._.____._..._.__._____gallons.
9 Septic Tank—Liquid capacityV.9—q__gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing t_ ( )
'� Percolation Test Results Performed by.......... f ... `-_________ ......_____ `"'........ Date..... `_ _ .........
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(t Test Pit No..2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------------------------------------
.....................................................................................
ODescr>ption of Soil... -------'-r---...---
--------------.----........
•........
. .-------•------------•--..._....-------•-----
S _._..---- Sv ---- -- ---------------------------- ----------------•---------
- � ---- ==�•-----•. =----•••� --- ---------
------ � 1 ...
U Nature of Repairs or Alterations—Answer when applicable._______________________________________________________________�._�:sL....
5_Ca�c�_c�
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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.
. rnrv� ,v
Sig cd__ :.._ ! -�...__._.v^ A \ _ t
• �,, Dat
Application Approved By_-:_ :_:.. n -'='`----------------•-._.........•-••-•-•---••-••••••-.._..•••--•.._.... ... 0. -
�� .
Date
Application Disapproved r Y f ollowing reasons:----..........................................................................................................
--------------------------------- -- r' ----•-----------...-----------... ----------- ---------------------------•-•-----•--•-----•--------•-------...-------... --------•---
Date
PermitNo......................................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�Nr�.........OF..........�:...CM r1 s
..................................................................
Tntifirtt#.r of Toanpliaaurr
THIS. IS TO CERTIFY, That the.,4dividual Sewage Disposal System constructed (c.__� or Repaired ( )
Installek
has been installed in accordance with the provisions of TITLY; 5 of The State Sanitary Code de- ribed in the
application for Disposal Works Construction Permit _____________ dated.... ..............
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................ ---•-------- Inspector........ ............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�5.a jn....-......OF.......... ..�aA. ....................... :................
No.. ..... �'"� FEE........................
Disposal Works T-5ono#r�nrtion rranii
Permission is hereby granted.......... _._-._.____ �
------------------------------------------•-..................
to Construct or stem Repair an Individual Sewage Disposal S
P ) g P Y
at No... �- `' _...-----_ �.--------------- a tU N
..................
f<'S eet .,
as shown on the application for Disposal Works Constructi P`er it N 0. Dated..........................................
s
-• _.... -- ---------------------------- --------------------------------------••----
/ Board of Health
DATE..1 / --- ---------------------------------------------1..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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