HomeMy WebLinkAbout0051 THREAD NEEDLE LANE - Health 51 Thread'Needle Lane, Centerville
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UPC 12543 o-
No. 53LOR •o��A.0pN'J��
HASTINGS. MN
No. 7— Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for Misposaf 6pstem Construction permit
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 51 --THRUM j11(2eb4E-C46jL:r Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel 2(D 2-77 91 AI l[.E i4W 6V4KC-F? . P' 4
Installer's Name,Address,and Tel.No. Z�_C$-*77-02 77 Designer's Name,Address,and Tel.No.
cmEL-ji-04S I )14
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3 ra ty4 1
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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) L(A'C
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 Certificate of
Compliance has been issued by this Board of T!n,
SignedDate
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 20 / Date Issued
F
No. . .0 I •- :; Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Misposal Opstem Construction permit
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Andiviqual Components
Location Address or Lot No. 51 _T+%6Ab N1aub4E'C445 Owner's Name,Address,and Tel.No.
1EVOWAM -t iEar •4LV_ZS G Gd�piRD
Assessor's Map/Parcel a10 077 e g /''IYRTI.F AW 4V KC- 7 M 4
Installer's Name,Address,and Tel.No. .5108-*77-997'1 Designer's Name,Address,and Tel.No.
CIlPEwtb& 6nrretPA LcSag' NIA
is Cu+ ,�c Sz- ktl t
Type of Building: `
Dwelling No.of Bedrooms ! -=Lot Size sq.ft. Garbage Grinder( . )
Other Type of Building Nd-of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4L4tCJE 4*_"A4WC C
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 Certificate of
Compliance has been issued by this Board of Health. ,
P
Signed A ,�~ ` Date /
r /
Application Approved by Gam) 0, `- Date
Application Disapproved by Date
for the following reasons E#
Permit No. Date Issued ( � '
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal syslem Constructed( ) Repaired(x) Upgraded( )
Abandoned( )by 64P&A)17)E'
-at 51 714ikQ � &Jt5WQ6. "AJE '044,95 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2d(7-,,Z 7jdated ' / /-7
Installer CAPEwf Oe 6,Xr?E 4p" Designer /J A I
#bedrooms A1�/� Approved deign ow� gpd
The issuance of this permit 1hall not be consIzued as a guarantee that the syste will fun 4i=n as de 1gn d.
Date ?S Inspector
7 G ( � � -- ----------------------------------- -------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Vsposal :6pstrm Construction Permit
Permission is hereby granted to Construct( ) Repair A) Upgrade( ) Abandon( )
System located at .51 11- a¢2b [V>�i ,D4-6 &-*Ije e_1y,(,,,LIC
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. AA
! i
Provided:Construuc�tii'on mu t be completed within three years of the date of this permit.
Date O [ �� (� Approved b
PP Yf"�
te. r_
A.
COMMONWEALTH OF MASSACHUSETTS` "
t r EXECUTIVE OFFICE OF ENVIRONMENTgL AFFAIRS
DEPARTIVIE'�T OF EN IRO:�MENTAL PROTEt;t
0N.E•N INTER STREET: BOSTON. �fA 0;1`OS 01;•29?-Sj00
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WILLIANI F.VELD' �roF��r 1 UDY t
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ARGEO PAUL CELL UCCI �'' DAVID HS
Lt.Govemor' SUBSURFACE SEWAtvE DISPOSAL SYSTEM.INSPECTION FORM a sioncr
. .t PART A j
ri CERTIFICATION
Property Address: 51 Thread Needle Ln.' Center-Address of Owner:
pity , Betty Ramsey •
Date of Inspection: August 25, 1997 ville (lf different) C/0 Puttnum Auctioneers
r>;Name of Inspector: Tim Rnrdetz--. 137 Laurel St .
I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Melrose MA 02176
Cumpany Name:, Castle Homo Inspections
Mailing Address: ' 243 Reed Rd . Westport , MA 02790
Telephone Number; ^`Q 8_h-1 h—5 q A
CERTIFICATION STATEMENT
1 cemfy that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
'r and complete'a.s.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: _
" Passes
Conditionally Passes
R,
Needs Further Evaluation By the Local Approving Authority '
Fails
Inspector's Signature: 'C"" e,, Date:
The System Inspector.shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. .It the s stem is a shared system or has a design flow of.10,000 y y g 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 0,
V
A) SYSTEM PASSES;
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below:
t ;COMMENTS: '
,a B) SYSTEM CONDITIONALLY PASSES:
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 4oard,,of Health, #�ill pass.
n .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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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.
trwisod 04/25/97) Pogo 1 of 10
DEP on the World Wide WeD: htip:/twww.mapnet.state.ma.us)dep
a{'j Printed on Recycled Paper
r. SUBSURFACE SEWAGE DISPOSAL, SYSTEM �N§PECTIQN
} PART A .
;.. n• CERTIFICATION (continued)
'-'Property Address: "'51 • Thread Needle Ln. , Centerville',!, Map 210, Lot 77A
owner: 'Betty Ramsey'
'Date of Inspection: August -25 ,'' 1997
B] SYSTEM CONDITIONALLY PASSES (continued) :... .
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution,box: The system will pass inspection if(with approval of the ;
Board,of Health). Describe observations: x
broken pipe(s) are replaced
�� •A 1 t. '.'F E
obstruction is removed
distribution box is levelled or replaced
` k The system required pumping more than four times a yoar 1due.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
,T gTMC] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: t
Conditions.exist which require further evaluation by the.Board of health 1n order to deterrr)ine 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system ($AS) and the,SAS is within 100 feet to a surface water supply or
tributary to a surface water supply:
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well
The system has a septic tank and soil absorption system and the SAS.is.within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a' "
private water supply well,.unless a well water analysis for coliform bacteria arid 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..Method used to determine distance (approximation-not valid).
�A 3) OTHER
(revised 04/;5/97) pays 3 01 IQ
=, SUBSURFACE SEWAGE pISPOSAL SYSTEM INSPECTION,FORM
s PART A
CERTIFICATION..(continued) '
Property Address:..51 :Thread Neddle °Ln. , Centerville, Map 210 .`Lot 77
Owner: Betty Ramsey
Date of InspectipmAugust 25, 1997
DI SYSTEM FAILS:, " t
You must indicate either "Yes" or"No" as to each of the following: "
IVO 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_.cgntacted to determine what will be necessary to correct
the failure.
Yes Noi
Backup of sewage into facility or system•component due to art oYerloaded`or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS•or a ty
.i -^ cesspool.
A Static fiqurd level.in the distribution boa above outlet invert due tq an overloaded or clogged SAS or cesspool
R liquid n
depth in cesspool is less than 6"below invert or available volume is less than 112 day flow..
3: ,.Required pumping more than 4 times in the last year NOT due.tg dogged or obstructed pipes)
Number of times pumped a
z Any portion of jhe Soil Absorption System, cesspool or privy is below the,hrgh groundwater elevation
n j
�A Any portion of a cesspool or privy is within 100 feet of a.surfoce-water supply or_tributary.to a surface water supply. '
.+
Any portion of a cesspool or, privy is within a Zone I o(.a p41;11rc well
/V
9 An portion i in f[ ono of a Cesspoolof or r is within 0 feet o a riv t wa r su 41 w
'•;: _ Y P po privy i 5, ee . ._ p d:e Water... Pp Y . e
Any portionG'of a cesspool or privy is.less than 100 feet but greater than 50 feet from.a private water supply well with op
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water ar►alysis for
cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.,
El LARGE SYSTEM e FA 1 . >
You must indicate either."Yes' or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above
t r
>"
to The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threaa,lq
public health and.safery and the environment because one or more of the following conditions exist.
-
Yes No r
_ 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'11 of a.
9,.. public water supply well) -
The owner or operator of any such system shall bring the system and facility into full cornplianre with the groundwater treat(rlent prar AI
grarn
`4a: requirements of 334 CMR 5.00 and 6.00. Please consu)t the local regional office of.the pepartmertt for further.information,
% - -
.. (revised 04/75/07)
-
•
"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s
,. PART B s
=Yr CHECKLIST •. u
r>. 1
Pruperty Address: 51 Thread Neddl,e Ln. , Centerville, Map 210, °Lot 77
Owner Betty Ramsey }
Date of Inspection;
August 25, 1997..
.Check if the':following have been done You must, indicate either "Yes or'No as to each of.the following
7 <Yet, fVP r 3 ri
Pumping information was Provided by the owner, occupant, or Board of Health Iv
None of the system components have been pumped for at least two weeks 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
tx as pan of this inspection.
i4 'As built plans have been obtained and examined. Note if they are not available with N/A.'
The focility•or dwelling was inspected for signs of sewage,backup.
'The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout �r
_ All system components, excluding the Soil,Absorption System,hhave been located on the site.:' l '
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles ortees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. c
x.. The size and location of the Soil Absorption System on the site has been determined basedon:
t* The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of.
i
Sub-Surface Disposal System. .
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance,is +
>, unacceptable)JI5.302(3)Ib1J
i
Pogo }
(revised 01/25/97) of 10
„x. SUBSURFACE SEWAGE DISPOSAL. SYSTEM,'INSPf CTI„Ott I QRM
} PART C '
SYSTEM INFORMATION '
,Property Address, 51' Thread Needle Ln. , Centerville, , Map 210, Lot 77
Owner: Betty` Ramsey`
Date of Inspecttoni.August 25 1997 _r
FLOW CONDITIONS
RESIDENTIAL:
r* Design flow:/1/_!7' .p.d./bet(roonl for$.A:S „
2 r
Number.of l?edfOOm,S: y ,
Number of furrent residents: Rc'A�
Garbage gru:der dyes or no):
f 6
Laundry cor;nected to system (yes or no): -S "r
,*Seasonal use ryes or no):�a
Water meter readings, if available !last two (2)year usage (gpo):
,.Sump Pump (Yes or nq): ti
Last date of;occupancy:
(
'pf COMMERCfI.4UINDUSTRIAL: r
r
Type of establishment.
-Design flow: Rallons/day
Grease trap present: lyesorno
industrial !haste HQldmg T present: !yes or no!
t nun•sanitary. waste disc arged to the Title 5,system:`!yes or no)_ r
4V'.Ier meter realm tf available,.
la�i dale o� upann
OTHER: IDescrtbe!
Layrdate of occwponc
i
{_ GENERAL INfORh1ATION
s PUMPING RECORDS and source*of information /4 NO v ��-c1I'dS 49 VAI1Ab �P rX9�.�s�.4 1P eJe,I r •^G �' / S+ /leer
System pumped as part of inspect (yes or no)...../I'
j' If yes, volume pumped: eallons '
Reason for'pumping
r
TYPE OF SYSTEM
..
SY . ,S _
Septic tank/distri4ution box/soil absorption system .:
Single cesspool
Overflow cesspool '
Privy s
Shared system (yes or no) (if yes,attach previous inspection records, if any)
/A.Technology gtc. Copy of up to date cantraqt
, .
Other S P.DZ C. -r-f+h K '/P � H i ✓t i S
ry '?APPROXIMATE AGE of all components, date installed (if known) and $ource of information. 74
.{ • - 3,1 tr � �MTk�3jY� ��j {✓ 'Fb[yt ...fk ' 1
Sewage odors detect' when arriving at the site: (yes or no
d s
g led g Y
sz (z•vie•d 04/25/97) of
1Q
3
;? u d
{ ' ' r
SU5SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
-,:Property Address: ,51 Thread Needle Ln. , Centerville Map; 210, Lot 77
n Owner: Betty Ramsey
Date of Inspection: August 25; '1997
BUILDING SEWER: `�
(locate on site plan)
Depth below grade: °Z"
Material of cpnstructian:. cast iron ,40 PVC other(explain)
Distance from �iVate water supply well or suction lint
t }Diameter x
Comments: (condition of joints,venting,evidence of leakage, etc,( '
".*SEPTIC TANK:ze.3
' (locate on site plan)
U Depth below grade: D
Material of construction: Zoncrete-_metal _Fiberglass _Polyethylene _other(ex lain)
`P r e A h e /1/ O /.S-e t S r-fJ ✓ r-r
`If tank is metal, List age Is age confirmed by Certificate of Compliance (Yes/No)
'Dimensions - R`
'_Sludge depth:' .,
r_.Y Disidnce from top of sludge to bottom of outlet tee or Wffle:_4 ,. .
y. Scum thickness: , �r ..
Distance from top of scum to top of outlet tee or baffle: .Ff rr 1 ,
" Distance from bottom of scum to bottom of outlet tee or partle:
How dimensions were determined: t c
;r Comments:
k (recommendation for pumping, condition of inlet d outlet tees or,baffles, depth of liquid level in relation to outlet invert, structural.
integrity, evidence of leakage, etc.) r=21 svn ><'
GREASE TRAP:
TRAP: dt/
(locate on site. plan)
V, Depth below grade:
;Material of construction: _concrete metal ,,,_Fiberglass. _Polyethylene;,,_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum 1 6p of outlet tee or baffle:
Distance from bonom of s m to.bottom of outlet tee or baffle:
Date of last pumping:
Comments: i
y :(recommendatn for pumping, condition of inlet and outlet tees o►baffles, depth of liquid level in relau'on o outlrtt lrivelt, strtrcwural
integrity, evi ence_pf leakage, etc.)
(revi.•d 04/25/97) y�q• 6 of ;9 `.
I i
SUBSURFACE SEWAGE DISPOSAk. SYSTEM INSPECTION„FORM }
g, PART C
} SYSTEM INIFORMATION (continued)
Property AdOress;,51 , Thread Needle Ln. , Centerville; M;3g','210, Lot 77 "
Owner: Betty Ramsey
' Date of Inspection;Augus.t 251. 1997
LL TIGHT OR HOLDING TANK g(Tank must be pumped prior to, or at time, of inspection)
(locate on.site plan)
Depth below grade:.
Material of construction: T„concrete ,,,,,metal Fiber ,ass _Polyethylene ,,,,_otherlez lain)",:
p f ?
Dimensions:' a
, ,. Capacity: gallons
? Design flow: gallons/da
Alarm level; Alarm i orking order_ Yes; No
K• Date of previous pumping::
Comments:'
'.'(condition of inlet tee, nditlon of alarm and float switches, etc.) ^. '
,.
}
DISTRIBUTION BOA(:/✓lA r
(locate on site plan)
Depth of liquid level above utlet invert: '
Comments: r
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,.etc
PUMP CHAMBER:
, .
(locate on site.plan) ;
Pumps in working order; (Ye/sN
Alarms in working order s or.No)
Comments:
- .. (note condition of pymp chamber, condition of pumps and appurtenances, etc.)
•/ is �° y-I ; v '
` lrwi��d.G�/1S/A71 pogo 7 pi 10
SUBSURFACE SEWAGE f)ISPOSAI SYSTEM,�tOPECTION FORM
PART.0 <:
SYSTEM INFORMATIQN (continued)
:Property Address:'51 Thread Needle Ln. , ' Centervi le, Map ,210, Lot 77
Owner: Betty Ramsey
Date of Inspection:August '25,, 1997
SOIL ABSORPTION SYSTEM (SAS):,. nj
(locate on site plan, if.possible;,excayation not required, but may be approximated by npn-(ntrusrve method
°a
It not determined to be present, explain: +
..4..
It� leaching pits, ngmber.�w
leaching chambers, number:
leaching galleries, number:
" h leaching trenches, number,length;
Teaching fields, number, dimensions;
overflow cesspool,<number:
Alternative system:
Name pf Technalagy:
z:CUM ments:
E ,(nute condition of soil signs of hydraulic failurejevel of ponding$, condition of.vegetation,etc l
N
CESSPOOLS: iU/ f c 4t fi
£x(locate on site plan)
INumber and configuration.
x
Depth-top of liquid to inlet invert:
Y�
Depth of solids layer. . .,: . .
Depth of scum layer
Dimensions of cesspool:
„Al materials of construction:
Indication of groundwater:
inflow (ces�lpool must be pumped as part of inspection)
a
3, -
'. Comments
(note coAdition of soil,'signs of hydraulic failure,`level of ponding, condition of vegetation, etc.)
PRIVY
(locate on site Plan)
Materials of constructio Dimensions.
Depth of solids:
a Comments:
(note con diti of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 04/ /97]
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIQN fqRM' ;r
PART C
SYSTEM INFORMATION (continued)
property Address: 51. Thread Needle Ln. , Centerville, Map ' 2i0, "Lot 7,7
Owner. Betty Ramsey
4Date of Inspection: August 25,' 1997 g.
`SK[TCH.OF SEWAGE DISPOSAL SYSTEM: '
include ties to at least two permanent references landmarks or benchmarks ;
.locate all wells within 1Q0'-(Locate where public water supply comes iri Ouse)
y "
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6HYAHC.f� t.T
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(revised 04/15/A7) Y�y 9 OL 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTfpN,FORM
i PART C r
SYSTEM INFORMATION (s gntinued) t
r` ' i,
Property Address:,,.51 . Thread Needle "Ln. Centerville, -.Map.,:210,'.Lot 77 .
'*.Owner: -Betty- Ramsey
Date of Inspection; August - 25., 1997
�Hck&s / /
Depth to Groundwater�� /1/O Cr a o Pt cY t j -er e N ra c169�e-�b
Please indicete.all the methods used to,determine.High Groundwater Elevation
Obtained from,Design Plans on record r
Observation of Site.Abutting property, observation hole, bosamr'nt sump etc.)
Determine it from"local conditions
tiµ .-
Check with local Board of health-
Check FEMA Maps
Check pumping records
T
Check local excavators, Installers
Use U$GS Data
Describe in your"own words how you established the High Groundwater Elevation. Must be completed)
(r0 4-
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,
4 /
f.. (revised 04/15/97)- P496 10 of 10
.
No. •�-
THE COMMONWEALTH OF MASSA.CHUSETTS
7T 9 7/ BOARD OF HEALTH
TOWN OF BARNSTABLB .
. >��Ilirtttiitn fur. M pwial Ui vrlpi Chnzifitrur#inn Permit
Application is hereby made for a Permit to Construct ( ✓) or ,Kcpair ( . ) an Individual Sewage Disposal
System at:
.:... Q..:J �- P 1!! Cjj k?i✓c.. ......................
...... ..... . _ ..... or _. .................. .. .
f- /../ .. Lot No.
tr a....,..Al
Own�erC D•..ir/�.!a...4� �. .T.
lusialler Address '
Type of Building
•Size Lot.. .�� ...Sq. feet
ms ........./...........................Expansion Attic ( ) Garbage Grinder
Dwelling—No. of Iledroo
Other—Type of Building ........ No. of persons,..............:. . Showers ( ) — Cafeteria'(. )
Other fixtures p P y ......... ..
d J �,2............ ....... ... ........................... ..... ..:........
aG
i Design Flow...................LJ�. ...........gallons er per day. Total dailyflow.................... ..............gallons.
fs: i Septic Tank—Li uid ca acity.. ......•
q p• ,��11.0...galluns ;.ength.....`......... 1�Vidth. r Diameter....... Dep�i.....
Disposal.Trench :�10. .... Width................... Tot11 Length........ Total leaching area..... .....y.sq. it.
3
3 ` I Seepage Pit No..................... Diameter....'............... Depth below inlet........... ...... Total leaching area..................sq. ft.
Dosing tank
z Other:Distribution box ( ( )
y
Percolation Test Results Performed by..& .. .r1>.,- .... .. :. Date..:....�I,17�g Z"
7Pt. ..............
Test'Pit No.. 1.G.Z....minutes per.tnch Depth of Test Pit.../.2�/ �� Depth to ground water
Test Pit N'o. 2..t*.2L....minutes per inch Depth of Test Pit...I!M........ Depth to ground water ......
I Q Description of Soil. EIf?!,!Q>� ,1 f1^ ....� r�l�R - ................................................................. ....
...... .. . .....
... .... ....... ............................ .
U Nature of Repairs or Alterations—Answer when applicable...... ......
,. Agreement:
The undersigned agrees,to install the aforedescribed Individual Sewage Disposal System in accordance with "
Y. Code—The undersigned further agrees not to place the
the provisions of TITLE 5 of the State Environmental
system in operation until a Certificate of Compliance has been issued by the b and of health.
Signed a«............
Application Approved By ...............�,e�nr�c .... ..t..nnry x..�. .... .... ... ��
Application Disapproved for the following reasons: ........................ ...:... ......................I.......... ..,...........................................
.
Permit No. ......CT3...-.....Y...................................... Issued ........................ ........
Dan s I THE COMMONWEALTH OF MASSACHUSETTS`
BOARD OF HEALTH
TOWN OF BARNSTABLE
gertifitttte of fQomplizzncE
hat the Individual Sewage pispasal System cRnscructed ( �G) or Repaired( )
THIS S TO CCTIFY, r. ...
by..............� ! =.,.. l.• a V imm�wr ldl4
tr L
r �t ....•.:.�,rQ........QQt .......:�V ............ .... ...
r dated
has been installed in accordance with the provisions of TI'fl,E S of The State Environmental Code as describe in
n the application for Disposal Works Construction Pcrmu No .. . ..3•. `/...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
..
.. 1nspl'ctur ...,. ...:
DATE.... !lam—. A
I� THE COMMONWEALTH OF MASSACHUSETTS
I BOARD OF HA�.TM
_TAT of 1-a�s (P 79�) NOTES .
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