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0990 WEST MAIN STREET - Health (2)
990 WEST MAIN ST. CE'NTERVILLE A = 229 101 LOT A S�� �aECYCIEpC ® 2J oyT UPC 12534 No. 2�153LOR $AosT.cONS�� HASTINGS, MN e i Town of Barnstable �1 6 P# Q Department of Regulatory Services Public Health Division Date 6 7, THE OF 200 Main Street,Hyannis MA 02601 BARMADLK MAM 039.r���� �Daatte Scheduled y e J I I o d Time : 00 m Fee Pd. a U — Soil Suitability Assessment for Sewage Disposal Performed By: IN%LL% AM (Tern 1 444 Witnessed By: �A��� JTh�rtTdl� ..... ... •:-..nn-::::.:::.::::....:_�:r!e.r.=.!is.::::::,n:::r!Izai:a::::d::r-:._:!!s!m::m:!:: �,- .:�. I.!, __ ,4.1.,'....a..... ..... J....,.,!..1,,,...rJ........,L..!,r.n,.r:.r II J...L,L.,u J...... .... ........ .....�.�!.:..:....: .. .. ... ..... ..._.:. .........:......,1..,:vn.:,,..._,.,..,..._..r....:.:....:1.: _..J-L..,,.I ... ....rT ...r...�"�:..,�,.T.�...}.,..i.:.. ,... ..... ,..,.. ,. :::::,:,:_,L._.. ynl..,.:::�1!::AI_gr.:I l'1:�nf:.:_�� ,�.., �..r T'^�,:::h4 i:.::Y.,!iali!�,�•:�1.:14�'ij`,�:',::, ,.. Owner's Name � . Location Address ri to Ala o 1,ol. l L gs►t o l �^T, I,J. "."`M -/, Icvv W, t'y��� S'T. H Address (� 4 A t-►�1 I Assessor's Map/Parcel: 2 S-D---� �- Engineer's Name / 7 Telephone# 7 0 0,p y'B,S�� NEW CONSTRUCTION Land Use _R L-S A Gtr!"T I:iA L Slopes(%) in Surface Stones r-� 0 Distances from: Open Water Body i-�0 ft Possible Wet Area ' j�ft Drinking Water Well t4 O ft Drainage Way .3 On' ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) p PO a$v Z� 00 P\- oz 161 I LA~© 4104 kk 99 0 Parent material(geologic) 7�t-A t C Depth to Bedrock 16. Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face b►,� Estimated Seasonal High Groundwater ..:I.:.,e:._.:y,.�....,-....r:.,•:r d.......!L'...r..,u::a.,r!an.J:!..:...J.r.:.:I.q.:!._;..;!N_...:;!.!.;.,.!..r!:.!L,,.L..,_I._:G.n.v..1...:�.,:.:,:.:..:.,:..,.::y._..ar:u:�.n,:;..,...::u.:..:.:!1.:,....r!!:.._.:.:..:rr..::�!:..:,:,:.:...r,.:,_n.:...:h.;..,.1......l,,r!..,;..,,.:r..e,.....r.,.!.,.......... ...r._.......!. ...n.....,..,:..:. .......:,.,�:- n.p!...v ..,:..r:. !en a .:............ Methodr:J:..I..I,.!_:..::!!.:.:!.r.:::I.�m:.�..i!a.!:J:.!:ra":.rn.!,C::r!a.�,::::,:I�n,!!:!:,,;L:"a•::::c:::.;::_a::!:,:!::�Ifi:_i:c.:::.:rru..:, .:. Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level— n:..:,..._,..:::n........................r........... �'�( .!..I................ ..,..t.....:..................,J,. ,..., .. ...,....... .. .,... -... ......!....r..... !!...... :......a r� u.Ir....l. . ,.r. ....::,:I..I..r......,....._.. ..:i_,...I.,v.Il.rr..,..r. :::...... .. ...... :�::. ........ :.,\.- ,_,.......J In„..In.._n:.15...r.L „1........v..J......_v:....r.:.:!......,_.I..........r,......v!:._.. ... .r: .. ......... .n.: ...�. .... ,:....... ..,: - j �:I:::_:u�: �..F'fi��t..._G.nr._-...�....v,_v,....... nl :...:........I r.....r.......:::,:!::.:....r..,.,......,.._...,�...:.....:1....,...l n....:....�_....._.....:........ .. L .....:, J l��a.L��ii!!F n _ _ ,. .....,......n.................. v r .,rr..:..:..:....I..,... .......1._...,...:.:..I..,.......,:..: .. .. .. .. ..._,,..... .:nl,.. .... ..a.... 1...v..................1.. .....v_,...:...1..a.....:: ... ...a....,.......i....r..l.. ..... _,...n.......,. In;i;...,L...._:.. li'rl�!?Lnl!!ta4::�"r ( vl l o'Z loy Observation l o I I o Z I oy Time at 9" Hole# - i1 Depth of Pere w-- _(_Q 6 0,218. Time at 6' _. Start Pre-soak Time® I O:`�I l 1; 0�1 i �I.s Time(9"-6") l o y Zy GAL_ 0SE+0 ir-1 AL-L_ End Pre-soak l i ' 1 �� - _._ NaL-CS UNra VC,t.(-- -r,= ;ir-J tat Rate Min./Inch . _ `1 " Q 4- Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- - :::>::>:::.::: :< 3Cut� >::>s:»>:;:<::<::z:»:«s<:>::::::;<::>:<:»:<:::>:: a:;:;<:;s:<:.;:•;: :.:::.;;;:.;;:.:>;:.:.::. Soil Other Depth from Soil Horizon Soil Texture Soil Color MottlingStructure,Stones,Boulderes. Surface(in.) (USDA) (Munsell) ( ° 4- 12 of2CaAnllL ibf� 2 1 12" 'Tb S.oL- A/2 O LooSE SArt/3 1 S L 11- 35 Q Sn /J to I c-t s Fr�I a.4L.(- -s.G- M-G SA 10 3� _ 9Z CI SA>.11� Z,$ • b LIS 10 6YLA.JtL- La�oSE M-G SANiO STQATIPIE✓J 2_ ' C Z SA,4 p Z. u dL A. •. V a T�c1D Coc.o�tS 8$tI-9411 c 12oIt i3 N _ 7.S /L e ST 2AT�p1E� t✓A1�✓t-S `I 7J �. mffo Depth from Soil Horizon Soil Texture. Soil Color Soi! Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. b - I2 ASA MO. A 3 Z 1FC'L1A16Le 2-Z$ SAt-+� tu�� '� $ �rLIA,PjLE 1l�►U SF►..t►o PLooSE M=GSQ1�-tam STRATITI60 • t..o o SE. 1'I 't= S A-A ID (p - I b� C Sds►-IJ'� 2. 5`( � 2 - o 5. `a.A%1&I-- vA121�tsAr1E4 Ga�adaS a 60�I- $`!4 - �i61►I I�t�° -7,5yVL S� RA�r�-F1E10 L�n�E►2S a bAjI'Y�.fit:.;.........:.;:.:>:.::.;;;:::,: U:.:;::.;:;:.:::.:<.;::.::.:::::::::::::...:.................... .. Other Depth from Soil Horizon Soil Texture Soil(Munsell) Color Soil Mottling (Structure,Stones,Boulderes. Surface(in.) (USDA) (M Consisteripy.° G_ L oAM SA�� 1 o�i,2 �� Fia val3 k e -1-o�+�l t_ LoA1va.) �-f:R 5� , v FRIABLE- 74C^O .Sat1�t1>a O-ZS -C. S AN 0 1S F- W Svc. G G SAS 2,5`� 5 t`� 1 e ST�A�I I C SA 2 S L 3 Loc.Sa - H-G SA je _I� -4. 4—IL-t-.. V a r�I to 'f�✓� Co L- 4S e �9'► - 7 5 a S fb e 2AT ► .q Ls} E.2J .. Jj �! q � Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. ° 0- 5 A Sa�ldy - SA,.►V FeUA6L+-- LoA#,I SA1410 Z,5`{ 's O F✓LIA✓SU— li�✓J-SAN0 z) aXItOIZ�� CoA✓LSL 2 S -Q-1 6 S A.J 2 A E-L- �(© C2- SA1.�10 2 5 3 . L1,oSC- H-C SA-SA S-re�T►Flc� GcL Flood Insurance Rate Man- Ahon 500 year flood boundary No— Yes Within 500 year boundary No_ Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious Material exist in all areas observed throughout the area proposed for the soil absorption system? E3 If not,what is the depth of naturally occurring pervious material? cc-d-i&Mion I certify that on S 7 (date)I have passed the soil evaluator examination approved by the 3 Department of EnvWorlrdental Protection and that the above analysis Was performed by tote consistent ith the required training,expertise and experience described in 310 CMR 15.017. 1 �V � 'Town of Barnstable P# pa/ 4Z Department of Regulatory Services oF,t�,� Public Health Division Date h6 U Z O� 200 Main Street,Hyannis MA 02601 r BABNBrABIA MASS. 1°rEor►��� Date Scheduled �( U Time Fee Pd. r/V Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: G I di.. . G ` Location Address owner's Name /�ie.q yy�„�„-^� • i y w nA SA $1 q80 � �t$o ? C G�� ��eP lone t�. •1 &°"�, (,�, A i t<t�'� Address }-I r A hd M t S 11 A. Assessor's Map/Parcel: Engineer's Name iv{r� J zz9— Ivi NEW CONSTRUCTION ✓ REPAIR V1 Telephone# 7�� - �J Land Use ES i ion tiQ Ti A L- Slopes(%) Q -3 Surface Stones Distances from: Open Water Body_Cft Possible Wet Area N A ft Drinking Water Well tl o ft Drainage Way 601 ft Property Line Z o ft Other — ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 0„-r,J q s H Parent material(geologic) P t-A i t4 �G r4 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater ......................... Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. . Depth to weeping from side of obs.nol"e: in. -,Groundwater Adjustment ft. Index Well# Reading Date: Index Well level / Adj.factor Adj.Groundwater Level NO i �iri#iJ� TT Tfate r i �i1re , n 1 -� Observation Hole# q `.� Time at 9" Depth of Perc 4 4-$2 Time at 6" Start Pre-soak Time @ I I S`1 Time(9"-6") End Pre-soak (Z•'0-i Rate Min./Inch _ / Site Suitability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(P/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- Q:HEALTH/WP/PERCFORM 910 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency o L o��, Arta t 42 3 �_ 8 S / •FRrAbLe -ram �.+Se}rl.. Q, (1� Z,S,-( S loose. rt—C. SAeD Z�� $ V .. �i�� jt o 2 �A�El_ ST �TI�t i� 8 8-1 S C Z SA 1-4 0 2. 5'( 6/3 E oAso o 2 t T L..tl CAS, AT eo .: : Q ::;;:::.�::.;•::.::....�:. :.............:................: Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface om (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % s Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % ot Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. r ' ,r ° Gravel) ♦ ..... s:.,�� i•• ro ' 7 � t cs � "� � a����. �,,s N:.�,i 3 ' y� 1 9 �-:ro �r'�'•t F �1 -Ri't1�t�l? :� 4 t y u aF° s },. " ram' 7 1 '� .44~q *,. T J :•.j �ET yy _} l' Z L ./� el r^ rop ;� 4 Y ?�' y > tir '1E;F~ .D _ 9 n . • Flood Insurance hate Maw Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No_ Yes Depth of Pipturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification (date)I have passed the soil evaluator examination approved by the I certify that on ,5 b Department of Environ ental Protection and that the above analysis was performed bDy rqe consistent With ,. s the required training,expertise and experience described in 310 CMR 15.017. Stenbeck & Taylor, Inc. Letter of Transmittal Registered Professional Engineers&Land Surveyors ✓ 844 Webster Street Suite 3 Date: 02/26/02 JOB# 6406 ;'. . Marshfield, Massachusetts 02050 Drawn for: M.Lambert k` (781)834.8591,Fax(781)$37-8238,_ Re: 980& 990 West Main Street ; -.Email: san&@gis.net Lot 4 West Main Street..#980 & 980 W. Main Street,,__ To: Town ofBarnstable - - Board of Health WE ARE SENDING YOU 2 Attached ❑under separate cover via the following items ❑Shop Drawings ❑Prints ❑Plans ❑ Specifications ❑ Samples ❑Copy of Letter ❑Change Order ❑ F Date No. Description 1/30/02 Soil Suitability Assessement for Sewage Disposal THESE ARE TRANSMITTED as checked below: l Q For approval ❑Approved as noted ❑Resubmit Copies for approval ❑For your use ❑Approved as noted ❑Submit Copies for distribution I ❑As requested [] ❑For Bids Due ❑Returned prints loaned to us Remarks Mailed via regular mail. Copy To: file Signed: ZacwalAf, Waoh*v If enclosures are not as noted,kindly notify us at once f COMMONWEALTH OF MASSACHUSETTS z _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 350.MAIN STREET WEST YARMOUTII,MA ra m 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 990WEST MAIN STREET RECEIVED CENTERVILLE,MA 02632 Owner's Name: BINGI-IAM,DONALD Owner's Address: 990 WEST'MAIN STREET J U N 2 0 2001 CENTERVIL,LE,MA 02632 Date of Inspection MAY 15,2001 TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector:(please print) .TA-ME'S D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT .ccrt.ifv 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 1.5.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: — Date: s'/✓�-O/ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of s Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design(low 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 lot he buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 / 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner:. BINGHAM,DONALD Date of Inspection: MAY 15,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X _ 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: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Healthy' broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 C. Further Evaluation is Required by the Board of Health: N/A _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Forni 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in leaching is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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 CNIR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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(3Xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NONE [if yes separate inspection required] Laundry system inspected(yes or no): NONE Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1991 PERMIT#91-484 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 18" Material of construction: X 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: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.TANK AND COVERS 18"BELOW GRADE.INLET TEE,TWO OUTLETS,ONE WITH TEE.ONE WITH OUT TEE.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene _ other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal tiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,.etc.,): DISTRIBUTION BOX IS 12"X12"P,ONE LINE IN,TWO LINES OUT.BOX IS 4'BELOW GRADE. NO SIGN OF OVERLOADING SEEN INBOX. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 r - Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: 4 leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING NOTED ON ASBUILT,FOUR INFILTRATORS.LEACHING IS 4'TO 5'BELOW GRADE.DID NOT DIG UP LEACHING. DID TEST HOLE ABOVE AND BESIDE LEACHING.NO OVERLOADING SEEN NOTE: OUTLET LINE FROM TANK WITH NO TEE,BELIEVED TO BE OLD FIELD,SEEPAGE 10. CESSPOOLS' N/A (cesspool must be pumped as part of inspectionXIocate 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): Conunents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 990 WEST MAIN STREET UNTERVILLE,MA 02632 Owner: BINGIIAM,DONALD Date of Inspection: MAY 15,2001 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. Lj 0US ------------ �3 . ----------------- Title 5 Inspection Form 6/15/2000 10 a Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 990 WEST MAIN STREET CENTERVILLE,MA 02632 Owner: BINGHAM,DONALD Date of Inspection: MAY 15,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 20+ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: X Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you'established the high ground water elevation: G.I.S. BARNSTABLE HEALTH DEPARTMENT. Title 5 Inspection Form 6/15/2000 11 No. Fee Ifo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for Miqool *pttem Cow6truction Permit Application for a Permit to Construct( )Repair(C/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 990 Cu 95 r MAJW ST I Owner's Name,Address and Tel.No. Assessor's Map/Parcel f VU 64 Installer's Name,Address,and Tel.No. � /�(t�E Designer's Name,Address and Tel.No. R07-A&7W erA, a�- Type of Building: LPl'T Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �t Design Flow T gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title a" t&5 Size of Septic Tank_ fiso� Type of S.A.S. � � Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maittenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the ironm al Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued s Bo d He Signed Date 6-',� Application Approved by Date Application Disapproved fo t e following reasons Permit No. Date Issued No. - Fee o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISIONTN OaARNSTBM Ys( s ZIpplicatiou for Oigpooat 6potem (Construction Permit Application for a Permit to Construct( )Repair(t Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. NO tu6-5r n'►AIr/S7-,� Ow er' e,Address and Tel.No. n� Assessor's Map/Parcel _ /O/ DwIguo_ UI&611-11q. Installer's Name,Address,and Tel.No. $U4,y/9 ya77C Designer's Name,Address and Tel.No. Type of Building: } Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building — No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 440 gallons per day. Calculated daily flow gallons. Plan Date f' Number of sheets Revision Date Title P I 4%115. Size of Septic Tank Type of S.A.S. 1 Description of Soil 4 Nature of Repairs or Alterations(Answer when applicable) x Date last inspected: Agreement: "$ The undersigned agrees to ensure the constructs n and m ' tenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti e 5 of th9l�p iron al Code and not to place the system in operation until a Certifi- cate of Compliance has been' s ed is Board He "l Signed b' J O Date 6-;r Application Approved by 1_ ! ( _ 1 J Date Application Disapproved for the following reasons Permit No. Date Issued ` ————-------- ---------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (tompliance THIS IS TO CEPM, that the On-site Sewage Disposal System Constructed( )Repaired(v)Upgraded( ) Abandoud( )by V077E at 7 0 WEST I`l1/XI.1 Sj`, 110i constructed in accordance with the provi ons of Title 5 and the for Disposal System Construction PermitN Zated `mac' Installer 8Ip-4///)/DrT6 Designer The issuance this ermit shall not be construed as a guarantee that the system ill f tion as designed. Date r 7 - �� Inspector t —7 — ———————————————————————————— �� Fee J-0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopo!5al *pgtem (Conotruction Permit Permission is hereby nted to Construct( )Repair(v )Upgrade( )Abandon( ) System located at � � 6Qe5`? m/�ter and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construe rrr us/ e co leted within three years of the date of t4i'} p fit. D � Date: 7 D Approved by JI / Al 1 � t Ii6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH :ki`+FD :APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAYSI 4H Y(3Tfi- hereby certify that the application for disposal works cons=aion permit siped by me dated 6-30-00 conc--mina the property located at T70 ES7- �� V��eets all of the following criteri'a: Ir T' �• The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dweilins. �• The soil is classined as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. �• There are no wetlands within 100 feet of the proposed septic system There are no private wells within 1:0 fey,of the proposed septic srsem ✓• There is no increase in flow and/or change in use proposed �• There are no variances requested or ne`ded. ✓• The bottom of the proposed leaching facty w liill not be- located less than five feet above the maatnum adjured groundwater table e!eration. (Adjust the groundwater table using the Frimptor method when applicable] ✓• if the S.A.S. will be located with 250 feet of any vegetated wetlands. the b4aom of the proposed leaching facility will not be lccated less than founeen (1') feet above the maximum adjured groundwater table e!evauon, Please complete the followin;: A) Too of Ground Surface Elevation(using CIS iruormauon) B) G.W. Elevation _the:NLA C. High G.W. Adju-,nmeat . _ Dff—: ERE`+CE EE i`WEEN a,and E 30 SIGNED : D a.i: (Sketch proposed plan of sr Ve , n backs. q::-c-LM folder.c-t �clKr 0tQ®� El 3 -60,0 WITH TOWN OF BARNSTABLE �'cc LOCATION Aor-&s , SEWAGE # 00_ . 3 VILLAGE_C&ZdZ%=�,,-= ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. f of SEPTIC TANK CAPACITY LEACHING FACILITY: (type)�� � � (size) R K� � 3 NO. OF BEDROOMS BUILDER OR OWNER &N6&1V) o PERMITDATE: 7 7-W COMPLIANCE DATE: C9 Separation Distance Between the: Q � M Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet e Private Water Supply Well and Leaching Facility (If any wells exist r 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 TOWN OF BARNSTABLE �'Ce c ON 4j6-4-7 1YtNE& Sr• SEWAGE # 00 — iAG"3 VLLAGE C66T4 11,41-- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 6PINY ,1 V07 X—: 1YQ0•W4A SEPTIC TANK CAPACITY l' C� LEACHING FACILITY: (type) ,6MftV-02--5 (size) /3 ` 4 ,,2 NO. OF BEDROOMS BUILDER OR OWNER 63W&,IS,001V) PERMITDATE: 7;7-co COMPLIANCE DATE: -7—17'oa Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 _rAb �l 3 3-soo c#waps Fx$. �.�.......... No......7�..=.yoy THE COMMONWEALTH OF MASSACHUSETTS f P P R 0 V E D BOAR® OF HEALTH Barnstabi•. Car. -.1ation Comirif-' onTOWN OF BARNSTABLE 3% o et wo A�--��,�'►_ , n -jrat, _ fon fiar Eliipniia1 parks Tomitrurtinn ami# '— gd Date SA 'p�,cation is hereby made for a Permit to Construct ( ) or Repair (�' an Individual Sewage Disposal System at: .....................1 ac?..•.W.n?x.-----V. ., 4...5! C sP ................................................. Location-Address or Lot No •-•f b:i t: .... .:1 !! l`c z f �,(.---•- . -----•------•---.a.Y� !`e.....-••-------------•----•------------..........-. Owner Address a .............. - - ` ° .................... ---•-----••••••pjo2,�_. I + Gee Installer Address UType of Building t_f Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms......._'7..............................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.........�'l. _.._...............gallons. WSeptic Tank!-Liquid*capacityl. gallons Length-----YD.... Width,.'S........... Diameter________________ Depth................ x Disposal Trench—No.4&c 144.11 Width.....Vl............. 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 x Performed by................................................................--•------ Date.................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 1:4 ••-----•--•--•.................•-•-•---•-•.....-•-------•-••--•--•---••...--•-•-••--•...-•--••.......-------•••-----•-•---•----••-----•-..._........--•.•••. 0 Description of Soil...............................................................................=........................................................................................ W V ......-•--•------------------------••-••--.._.._...-•-•---•-•-•....-•--•-•---•••--•---•-...---••---•-•--•-••-•------•--•••-•-----...-••-----•------•-....•-•--•-•••••-•-•--......-••-----•--•-•..._....-- W x -•-•-•-•••-••---------------------•-•----•-•-----•---------------•----•--------•---•--------••--------•--•-•. --•-•---------••-•-----•----•••..... ----------•-•- U Nature of Repairs or Alterations—Answer when applicable._____J=N5-7�..(�------y-S-b-D--�•1���,-�c�:-]'(4{iC� fl �� = ----------- - -- ._. .v --�tyc> 1Z_ vw` ?? -•-... Agreement: Lo` &c S'Cb N cam. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com liance has be n issu a board f health. -� 2 �- Signed :A---------------- -- ---------------------- ---- .................... ---- ...---- . O Application Approved By ...............(� ----- Q -- Application Disapproved for the following reasons: ................ .................................... .............. .. .................. ........ ... ............. .................................................................................. ............ . ................. ..... ............................................................ ...................... ......... Permit No. ----------- J... V-..g.��...................... Issued �Ce...... Dare No... :_.. ..: . y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `f TOWN OF BARNSTABLE "3\ u -< l� -• � r ltratiou Tux Disposal Works Tonstrudiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ......................Q_n....L.ar(aT......kc 5 1-��<.�l r.���...... ....-•--........ Location-Address or Lot No. ....---•--- �4 •'^ -----�n��_-� � c t T`�---- -------------- r`' Kl.!!�........................................................... 4 ,/� /� �AA Owner D /[ Address( W4.n = t±.t �--5- c------------ }-r- .: ►Ja� t-1. L4 c, 1'(a i V�f 1� q Installer Address UType of Building L-' Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms_________ ______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons____________________________ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------•--------------------•----------- Design Flow............ _'�� _____________________gallons per person per day. Total daily flow..........L4k4.t2____•__•__-_.•____gallons. W Septic Tank+Liquid capacity_1.50Dgallons Length------/0.___ W i d t .......... Diameter________________ Depth................ Disposal,Trench—No. Width......7........... Total Length_.__.................... Total leaching area....................sq. ft. Seepage Pit No...... Diameter.___ Depth below inlet-----6-............ 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........................ rs.l Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ W' ------------------------------------ •............ •---------------------------- -........ -......... -•----------- -........ •..... ••--------•--••----------------- 0 Description of Soil----•----------------------------•------------•-------------.......--------•------------------------------------------•----------------••-------•---•-••-•-•••••----•-•- U ..............................=.................................................................................................................................................................... W x ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------•------- V Nature of Repairs or Alterations—Answer when applicable-_____F a1145!TrA(_t______�__ _ ?. __ _► _�� .•� -l41 4f h •---••-- - •- - ..--•-•_..._�__ �- r 1 - Agreement: UA a t S�N c t,r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued_by the board of health. -Signed --....-- 1 . -- ----�.. 0 � 4.` . �- Date .- Application Approved BY ... �^^J .. Date Application Disapproved for the following reasons- ...................................................................................................................................... - - ---- --------- ------------- --- --------------------- -- --------- ----------------- ---------------- --............................................... --...................................... Date Permit No. -�- .. . .-.�L---------------------- Issued .................. Date J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertifirate of C110lrnyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by--...................................------- -- Q= L- -` ... -�. - Installer at .........................................................:_:.V�V ...-.....-I -..y +- K...--S----------------- ---- ------------------- has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......t ..--..---- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. `1 C DATE--------------------��-C�-- ..- ----------------------------------------- Inspector ��//A/.A. 1, I � =...................... f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y TOWN OF BARNSTABLE .... ..d l FEE.•. �? .... `. Disposal Works Tnnfr ion - rrmif Permission is hereby granted......... . .. t C to Construct ( ) or Repair ( 1,1 _an Individual Sewage Disposal System C, i at No......................................... --•--C Street as shown on the application for Disposal Works Construction Permit No._ _Z=_yK_l Dated.......................................... ....................................•-- .......................................................... /-•----••-•----•-- Board of Health DATE.................r--�--�--:��-�----/-•_ `J FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS r TOWN OF BARNSTABLE LOCATION - q'�® We�g McQt4 S( SEWAGE #9(—qz,,-( VILLAGE ASSESSOR'S MAP 6 LOT r �, INSTALLER'S NAME & PHONE NO. SEPTIC TANK.CAPACITY S(JD 2)4 J oa LEACHING FACILITY:(type) K jc L-TC WX-6(2S (size) OJ �c S 1 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER dT 'Fo r- �tMartro'T DATE PERMIT ISSUED: Iq 1 DATE COMPLIANCE ISSUED: ti VARIANCE GRANTED: Yes No I'Z 71 cj A4 r R� 11.1307) �