HomeMy WebLinkAbout0617 STRAWBERRY HILL ROAD - Health 63C7 Strawberry Hill Road, Centerville
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UPC 12543
No. 53LOR ���n•cONS°�`
HASTINGS, MN
TOWN OF BARNSTABLE
LOCATiONQ01-1 SEWAGE #
VF,LAGE Ctf?.1'll)\tl�. ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. gyp®
SEPTIC TANK CAPACITY X(n , V�S ► ®�I
LEACHING FACILITY: TtyT) 1� ��� Q t� (size)
NO.OF BEDROOMS °
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts Jotu><Grad
Executive Office of Erwiron wntai Affairs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket,MA02536
(508) 564-6813
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR a1��
PART A
CERTIFICATION `►� S
o
Eo i r
Property Address: 617 Strawberry Hill Rd.Centerville Address of Owner:
Date of Inspection:12169196 (If different) 1y9�
Name of inspector:JohnGracl AnthonySchlano ,. �
Company Name,Address and Telephone Number: 4
L �
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes
_ Conditionally Passes
Neeilds F her aluation By the Local Approving Authority
Fas
r
Inspector's Signature: Date: 1219196
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B.C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.)
_ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street . Boston,Massachusetts 02108 • FAX(61T)556-1049 • Telephone(617)292-5500
' 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 617 Strawberry HIII Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:12109/96
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four 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
CJ 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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
DJ SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115/95)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 617 Strawberry HIII Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:12109196
D] SYSTEM FAILS(continued)
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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information.
I
(revised 11115195)
3
t ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 617 StrawbenyHill Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:12109196
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 617 Strawberry HIII Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:MOMS
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 4
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available: nla
Last date of occupancy: 1994
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER: (Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
X Single cesspool
x Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1964
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115/95)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 617 Strawberry Hill Rd.Centerville
Owner: Anthony5chlano
Date of Inspection:12109196
SEPTIC TANK:
(locate on site plan)
Depth below grade: nla
Material of con struction:_concreate_metal_FRP_other(explain)
Dimensions: n/a
Sludge depth:nla
Distance from top of sludge to bottom of outlet tee or baffle: n1a
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:n1a
Distance form bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n1a
GREASE TRAP:
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nla
Scum thickness:nfa
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n1a
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 617 Strawberry Hill Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:12109196
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level:. n1a
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
nla
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nla
i
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 617 Strawberry Hill Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:12109196
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
nla
Type:
leaching pits,number: H•10[each pit
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: n1a
leaching fields, number, dimensions:n1a
overflow cesspool, number:n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit was empty at time of Inspection.
CESSPOOL$:X
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: empty
Depth of solids layer: 0
Depth of scum layer: 0
Dimensions of cesspool: 6'x6'
Materials of construction: block
Indication of groundwater: none
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
Main cesspool and all components are structurally sound.Recommend pumping system every year for maintenance.
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: nla
Depth of solids: Na
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PrivyComments
(revised 11115195)
8
♦,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 617 Strawberry Hill Rd.Centerville
Owner: Anthony Schlano
Date of Inspection:12109106
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
1/
�t 1.
AA
a
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DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
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TO OFFENDER:
Failure to obey this notice within 21 days Place
after the date of violation may result in a Stamp
criminal complaint being issued. DO NOT Here
MAIL CASH. Post Office
will not deliver
without stamp
is
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MAIL TO: J
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BARNSTABLE CLERK
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P.O. BOX 2430 ittae
HYANNIS, MA 02601-2430
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---_—l---NAME OF OFFENDER p ; BAR 7�9 9
TOWN OF ADDRESS OF OFFEND 1 J p + (] p}$
BARNSTABLE CITY,STATE,ZIP CODE . t� , y !>
INf►q,- MVIMB REGISTRATION NUMBER
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T' AND DATE OF VIOLAT914f r► LOCATION OF VIOLATIO + Z
NOTICE OF .a0 ( . .i >oN 9 2of�` aLLI
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SIGNATURE OFENFOR ING`PERSO� ENF RCING DE RA iw... BADGE NO.
VIOLATION , _ L 1 `
OF TOWN I HQ Y ACKNOWLEDGE RECEIPT OF CITATION X
ORDINANCE b Unable to obtain signature of offender.
THE NONCR N AN F THIS 0 E IS $ J
Date mailed ►U
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OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL d
DISPOSITION WITH NO RESULTING CRIMINAL RECORD.appearing y y w
CIO
REGULATION b'fo may elect table Cle k,above sheet,Hyas,MA 02601oor bay mailing g a check,money order or postal ote to BarnstableygClerk,P.OSBo 24 0, J
Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a
VIf you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST
UUNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this
citation for a hearing.
(3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the
hearing to be due,criminal complaint may be issued against you.
❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$
Signature
NAME OF OFFENDER A j , v n �{ BAR 79996
TOWN OF ADDRESS OF 0 FENDER Yf1\y,, �+G /C�l' N
BARNSTABLE CITY,STATE ZIP CODE
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pf�Nfi)qr, - MVIMB REGISTRATION NUMBER
• IfArNE\1 1'A�PI�.E. ' OFFENSE
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TI AND DATE`0 VIOLATIONS LOCATION OF VIOLATION W
NOTICE OF �e7 `� (���is•M, ON a `+> ! ,20 0° �3 �r 541z •1 1tf�r pt�
SIGNATURE OF ENFORCINGVERSON .� ♦'/ +l ENFORCING DEPA. +.. BADGE NO. N
VIOLATION "_" •� G6 �c
OF TOWN �
,rI-H,,,,E,,RR�ESY ACKN WLEDGE RECEIPT OF CITATION X a
ORDINANCE u'Unable to obtain signature of offender.
Date mailed
THE NONCRIMINAL FINE FOR THIS OFFENSE IS S
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OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a
DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w
REGULATION r
(1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w
before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstabfe.Clerk,P.O.Box 2430, J
Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a
(2)If you desire to contest this matter in a noncriminal proceeding,yycu may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST
BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this
_ citation for a hearing.
(3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the
hearing to be due,criminal complaint may be issued against you.
❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$
Signature
COMPLETE •N COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1,2,and 3.Also complete A. !ig ture
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse X t L C14 ❑Addressee
so that we can return the card to you. B. Receiv d by(Printed Name) C.Dat of Delivery
■ Attach this card to the back of the mailpiece, ` � V 9 r
or on the front if space permits.
D. Is delivery address different from item ? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
Maus Rivera
34`Strawberry Hill Road s. Service Type
e
Centerville, MA 02632 610ertiffed Mail ❑Express Mail
❑Registered etum Receipt for Merchandise
` ❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) p Yes
2. Article Number. , �;i7008`11830 ��2't 050�� 8017
(Transfer from service'lakel)
PS Form 3811,'February 20041 Domestic Return Receipt 102595-02-M4540
iUNITED STATES FQ TAL E VICE
rS' � 1�' �trst��fas� f,wo.:;•�
4 y
aid
• Sender: Please print your name, address, and 7IP;4 in this box •
Town of Barnstable
Health Division
�— 200 Main Street
Hyannis,MA 02601 `
� J
I _ .
ealfh Master Detail Page 1 of 1
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i._ogge; I ';s 1':)i'vN\0"0nnei1 Hez l t=m Master Detail iday, A
&oDim'on Center `Ccel Lookup ?Eli;^ ";",, lterns
(parcel � tic erc well t�el Tak
Parcel: 249-018 Location: 617 STRAWBERRY HILL. ROAD, CENTERVILLE Owner: RIVERA, MAURO 0 &AIDJ
Business name: Business phone
1 _.... .., _..,.
Rental property: w'' Deed restricted: Number of bedrooms
_.
Contaminant released: Fuel storage tank permit:
Saue Parcei Changes Returnrto Lookup
Parcel Info Parcel ID: 249-0 8 Developer lot: PAR I &
Location:617 SI RAWBERRY HILL ROAD Primary frontage: 162
Secondary road:WEST MAIN STREET Secondary frontage: 1.62
Village:CENTERVII...LE Fire district:C-C-MM
Sewer acct: Road index 1546
Asbuilt Septic Scan: 249018 1 Interactive map
9
Town zone of contribution:WP (Wellhead Protection Overlay District) State zone of contribution:IN
Owner Info Owner: RIVERA, MAURO 0 & AIDA.� �0 �3 -- ,G� Co-Owner:
Streetl:34 STRAWBERRY HII...t... RD Street2:
City:C NTERVILL_E State:CIA Zip: 02632 c
Deed date: 1.0f 2.5/2002 Deed reference: 1.5803/095
Land Info Acres: 0,51 Use: Single Fam MDL-Ox Zoning:RD-1 Neighborhood:
Topography:Level Road: Paved
Utilities:Public Water,Gas,Septic Location:
Construction Info�iiilc'inc Noy-a—vu€ii``f f ti1'= A€'? cILSE ."...:, :,i t?rtFu!'r;S
1 1970 11808 13 BedroomsI Full + 1H
Buildings value:$136,000,00 Extra features: "3,300.C10 Land value: $1.62,600.00
� 1
http://issgl/Intranet/healthMaster/HealthMasterDetail.aspx?ID=249018 4/3/2009
' - Town of Barnstable
Regulatory ServicesBar
` ``` '
��FTHE.Tp�'1
�F o Thomas F. Geiler,Director
Public Health Division
* sARNSrnsLE,
9 MASS. Thomas McKean, Director
��
031 91 o�
�prEp ,�A 200 Main=S`treet
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 3, 2009
Mauro Rivera Adoo
34 Strawberry Hill Road
Centerville, MA 02632
As of October 1, 2006.a new rental registration ordinance was put into affect requiring
all property owners of rental units to register their rental units with the Town of Barnstable
Health Division. According to our records, you own the rental property at-617 Strawberry
Hill Road, Centerville Enclosed is an application. Please use a separate application for
each rental unit you own. Should you need more applications, they are available online at
www.town.barnstable.ma.us. Go to the Health Division page by looking in the Department
Menu. There is a link to the Rental Registration information on the Health Division page. You
may print out as many as you need, and return them to the Health Division with the appropriate
2009 fees included. This must be completed within (14) fourteen days of your receipt of
this letter.
Failure to comply with this ordinance will result in the issuance of a non-criminal ticket
citation in the amount..o.f$100. Each day of rion-compliance is considered a separate_offense.
Should you have any questions, please feel free to call 508-862-4644. Thank you in
advance for your cooperation-:
1 " F
Timothy B. O'Connell, R.S..
Health Inspector
Health Division
Direct#508-862-4646
FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Appliration for Uhip seal Works Tanstrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..06(------- ---------------------------------•-----•--- - -------•...--------- - ------
oco•- t �vti����'� -.
__-- ______________ ��. --------
_ e e
----
Installer Address
Type of Building Size Lot____________________ _____Sq. feet
Dwelling—No. of Bedrooms_______________________.___.____.._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------•----•-••--------------------------------...---------.....------------------...----------------...-----•--.........----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water_.-__----__-_--__..._---
(4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 _...------•----------------------------------------•----------------------------......_..-------•----........-----•-----....................................
0 Description of Soil........................................................................................................................................................................
U ------------------------------------------•-----.._..---•--••------•---------------------......-------•-----------------•---------------•-----•---------------------------.....----..__...--------------
------------ --------------------------------------------------------------------------•----------------------- ---------------- ----------•------------
U Nature-of R irs or Al atio s—A ver when app -cable___-__
....----;�1--------�1,�-a'a ..1.. ----------------------------------.............................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAILL 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i the oa f lth.
Signed....... .... ---- ..._ -------•---•- --��. .....
Date
Application Approved By...... � . .... q .Z._^.!Da^_ .._.
Date
Application Disapproved for the following reasons---------------•-------------•-••----•--•----------------------•-----------------------------------._...---_•----
-•-----------------------------------------------------------•-----------••-------------.....-------•-••-'------------------------------------_._..._..-----------------------------------•--------------
ore Date
PermitNo.....P.0....3 ------------------------ Issued_..............................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....�,170'4 i9...............OF......... ..-2./.
Appliration for Disprioul Works Tonotrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
_ f'Locati
1r-- ,r.�.sue ems '-•'' o�I.ot Not ,sJ' /�/'/ //(/�
......................�✓. '�l .J......G.y-�::_�4.�^:......... ..�1:c?��..^—�'���.$."....�r°/.l � !f'•
......... ----. ...... _=:-----. -•--•-----..•------
�� Awner
L>a ......J < I4". (f t f�•Z�Kaa Y .. �i�'�...... � 1. " e4-
_..! .. ........................ .......•----
Installer Address
Type of Building _- Size Lot............................Sq. feet
Dwelling—No. of Bedrooms........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures -----------------------------------------•-----•....•-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by....... ----------•---------•.......•----------•-------------------•----.. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................
W ...........-••-----•••---•--•-•-------•-....--•-.....-•......................................................................................................
0 Description of Soil........................................................................................................................................................................
x
V ......-•-•--------•---••-••-----••----.....---•--------------------•--•------............•-••-----•------.....-•------...---•-----------•-•----•••---------••-•------•----------••-••------••----•-----.
W
--------------------------------------------------------------------•---•--------------.....------•--------•-•---•- ......... ............................ . ... --
U Nature of R irs or Alteratio 's—Answer when app cable....___...' f_.� .. .............r .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L ITA IZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu-� the oa f lth.
Signed.......! - 1 - =�' ��................
�- ----...... a,- '
Date
ApplicationApproved By.....................T"""....U........ ........................ ..... --••--.. �. ---
Date
Application Disapproved for the following reasons:-----•-------------•----•----•--•----------------------•-----...---------------•----------...--•-----....._._.._
-•..................................•----.........----------...---------------•------........----•---•-----.........---•----•-•-------•--•----•-•---•-••--------•------...----•--------•----•--••-------
Date
Permit No........ ..... ........................
Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,Oy F HEALTH
�
.......... :!1 ............0F...........Y.:-?d?,�:� �:r"�Y.�.:�f...................................
Trr#if iratr of Tomplianrr
THIS IS TO CERTIFY, That the Individtial Sewage Disposal System constructed ( ) or Repaired (�)
by........................ /..........cle I . •-•----•--•--- --•--•--...••-•--•.....----...-----••--•-•-----•--.........---..._.............-•---....-----•--
` Installer
at e 7----•-.�2.. LP.�. 1 h /sl al .............. �•(•c..................••...
�....: -------------------
has been installed in accordance with the provisions of TITT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._.__. ........ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... .�...�.D:. g ............................. Inspector.........................
.......---...--•-----....-----••-----...---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
QQi� ,1, ..............:4 -.............OF........ :: .dill f.............._....................
NO..�.a......{%:. .FEE--- .....-----
Dispooul Vorkp %T-Fonutrurtion Prrutit
Permissionis hereby granted------..... .. ....................... .._. .......................................................................
to Construct ( ) or Repair (>e,) an Individual Sewage Dispo� System
at No...............1�.17.......... ...X�icrxr. " � .�. ..�1....f{�._....-----•-----•- .c.........................................
Street
as shown on the application for Disposal Works Construction Permit No... .. Dated..........................................
.:...r. .........-•--•-•---•-•••-------•---------------
r / ..................................•-•---, oard of Health
FORM == l� �-•-•-•-•--...--•--...-----------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ! '
�`T ,
TOWN OF BARNSTABLE
LOCATIONA49!�tYa
SEWAGE # ET-3rb�
VII.LAGB� _ ASSESSOR'S MAP fe-LOT o7YP! 01e
INSTALLER'S NAME ISz PHONE NO.�%�
SEPTIC TANK CAPACITY Xe00
LEACHING FACILITY-(type) 107/'%
NO. OF BEDROOMS PRIVATE WELL OR UI3LIC We CT1 R
BUILDER OR OWNER
DATE PERMIT 13SUED:
DATE CO1IPLIANCE ISSUED_
VARIANCE GRANTED: Yes No
I_
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