HomeMy WebLinkAbout0351 WHITE OAK TRAIL - Health 351 White Oak Trail, Centerville
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/77/ZElll� to Ip-c4b
UPC 12534
No.2153LOR •q��
NA&TI"04 MN
No. Fee 4
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for dig ar *pztem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ' l � Owner's Name,Address and Teel. o.
Assessor's Map/ParcelF/
Installe 's Name,Address,and Tel.No Designer's Name,Address and Tel.No.
. a6
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 gallons per day. Calculated daily flow gallons.
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)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b?,V this Board f Heal t .
Signed OANDate Acq_q jq�)
Application Approved by Date�1 ?� �r—
Application Disapproved for th following reasons
Permit No. 9 - Date Issued
No. Fee
THE COMMONWEAL�4 E M�SMUSETTS Entered in computer:
IfV tv/ Yes✓/
PUBLIC HEALTH DIVISION - TOW OF BAR S ABLES MASSACHUSETTS
RpPlicatfon for Mi!q ar ygte-m Cougtructton Permit
Application for a Pen-nit to Construct( )Repair( Upgrade(; )Ab don( O Complete System ❑Individual Components
Location Address or Lot No. Z
Owner's Name,Address and Tel. o., n
Assessor's Map/Parcel � _Dj a
l
Ins�taljler's Name,Address,and Tel.No. Designer's Name,Address"and Tel.No.
120�h& ()
CJ�• ,
a&�u
a(Ll
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 , gallons per day. Calculated daily flow gallons.
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)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance`of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board f Healt
Signed 4 in Date .
Application Approved by Date W
Application Disapproved for th following reasons i
Permit No. Se Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO C R FY, that the On-site Sewage Disposal System Constructed( )Repaired (/)Upgraded( )
Abandoned( )b ZZ
at has been constructed in accordance
with the provisions of Title 5 and the for Dispo al System Construction Permit No. !?e dated
Installer r
The issuance q f this permit shall n be construed as a guarantee that the system will function as designed.
Date F-- I c>> Inspector
---------------------------------------
No._ Fee .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
MfgPogal *p5tem 0 ongtruction Permit
Permission is hereby granted to Construct( )Repair(V)112gade Abandon
Syst m located at '
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: Approved by
•
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 Jolm GrAd
kip D.E.P. Title V Septic Inspector
P.U. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI 1O )l l 1
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL
ASYSTEM INSPECTION FO
P
CERTIFICATION RECEIVE® v
1_
Property Address: 351 White Oak Trail Centerville Lot 236 Nov 10 1997
Date of Inspection: 11/6/97 Address of Owner:
Name of Inspector: John Graci (If different) T0W)yOFBARNS7A6LE
Edward Gula C H�ITHDEPI: w
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
a9
5
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 This Inspection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 16.303.My findings are of how the system is
— Needs Firth Evaluation By the Local Approving Authority notIplyanytwarhe tranyo ime ofguarantee�oftelellInspection fthe
- Fails Septic system and any of Its components useful life.
Inspector's Signature: Date: 1116/97
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, 8, 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.
COMMENTS:
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co7hpliance(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.
(revlsed(MV97)
One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)2925500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property AddreSs: 351 While oak Trail Centerville Lot 236
Owner: Edward Gula
Date of Inspection:111`6197
— Sewage backup or,breakout.or high.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect 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 watersupply 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 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 and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
3)Other less than 5 ppm. Method usedto determine distance (approximation not valid)
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
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.
Yes No
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 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 351 While Oak Trail Centerville Lot 235
Owner: Edward Gula
Date of Inspection:1116197
D]SYSTEM FAILS(continued)
Yes No
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 1/2 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:
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:
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:
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)
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.
(revised 04127197
)
I ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 351 White Oak Trail Centerville Lot 236
Owner: Edward Gula
Date of Inspection:llreig7
Check if the following have been done-.YOU must indicate either"Yes"or"No"as to each of the following:
,c_ _ 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.
_c_ _ 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
'— - The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x _ Existing information. Ex. Plan at B.O.H.
Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
x — unacceptable)(15.302(3)(b)]
(revised 04I27)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 351 While Oak Trail Centerville Lot 236
Owner: Edward Gula
Date of Inspection:1116197
FLOW CONDITIONS
RESIDENTIAL: d./bedroom for S.A.S.
Design flow: 33o g p'
Number of bedrooms: a
Number of current residents: 9
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No last two 2 year usage d
Water meter readings,if available:(as ( )y g (gp )'
rda
Sump Pump(yes or no): No
Last date of occupancy:2wEEKsac0
COMMERCIAL/INDUSTRIAL:
Type of establishment: nra
Design flow:ll 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: nra
Last date of occupancy: nra
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped: loon gallons
Reason for pumping: Maintenance
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no).( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(If known)and source information:
197T with a new pit Installed In 1997
Sewage odors detected when arriving at the site:(yes or no) No
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 351 White Oak Trail Centerville Lot 236
Owner: Edward Gula
Date of Inspection:1116197
SEPTIC TANK:x
(locate on site plan)
Depth below grade: +' Polyethylene Material of construction:x concreate_metal_FRP (ex lain
_ y y lens_other p )
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L6'5"H5•7"W4.10"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:25"
Scum thickness:2"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 16"
How dimensions were determined: Measured
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.)
Septic tank and all components ere structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: Na lainexp_other(
Material of construction: _concrete_m eta l_FRP_Polyethylene )
Dimensions: Na
Scum thickness:Na
Distance from top of scum to top of outlet tee or baffle:Na
Distance from bottom of scum to bottom of outlet tee or baffle: Na
Date of last pumpingnla
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.)
Na
BUILDING SEWER:
(Locate on site plan)
Depth below grade: t'e�_
Material of construction:—cast iron_40 PVC_other(explain)
Distance from private water supply well or suction linetowo
Diameter: 4"_
(;�eimments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 04127197)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 351 White Oak Trail Centerville Lot 236
Owner: Edward Gula
Date of Inspection:1116197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nia
Capacity: Na gallons
Design flow: Na gallons/day
Alarm level:_nia Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Liquid levelwithbottomof pipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
The Dbox Is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ves
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Na
(revlsed=707)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 351 White Oak Trail Centerville Lot 236
Owner: Edward Gula
Date of Inspection:1116197
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:
n!a
Type:
leaching pits,number: 2_1,000 gallon leach pits
leaching chambers.number:rJa
leaching galleries,number: nla
leaching trenches,number,length: nfa
leaching fields, number, dimensions:rda
overflow cesspool,number:Na Name of Technology._..Ha
Alternate system: ,Va gY—
Comments: (note condition of soil,signs of hydraulic.failure,level of ponding,condition of vegetation, etc.)
The leach pits are alructurally sound and functioning property.
CESSPOOLS:
(locate on site plan)
Number and configuration: roa
Depth-top of liquid to inlet invert: nla
Depth of solids layer: nla
Depth of scum layer: We
Dimensions of cesspool: nla
Materials of construction: rda
Indication of groundwater: rJa
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.)
rva
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: Na
Depth of solids: Ma
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nfe
(revised OW27ST)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
351 White Oak Trail Centerville Lot 236
Edward Gula
1116197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
(
vw I�
Ore
A rc]
4610
Qq L
he hoy
FA
6
� d
pa9• 9 of 10
(revised OMT197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
351 White Oak Trail Centerville Lot 236
Edward Gula
1116197
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators,installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised0412T19T) lays 10 of 10
�2 -�5 / EW A E PERMIT N0.
LOCATIOgN S G
VILL4GE
IN.STA�^LLER'S NAME a ADDRESS
�J rv%,e 57 100 1/cc f n -r-yr!tC
B U I'L D E R OR OWNER
fn u.,r1ram H c/bl e:s .fin-6,:
DATE PERMIT ISSUED _ ; ,-i -
ISSUED
DATE COMPLIANCE - r..
ASSESSORS MAP NO: 190-
PARCEL NO. - .2 Fss..... ..f-
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.. ......... . ................OF...........................------....... ............................................
Appliration for Dwvviial Works Cnnntitrnrtuan V.Crmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/ram, /
•---- --•-•--------•----•------- ------------•----•--------.........-••---------•----------------•--..............
Loc lion Address or No.
------------------------------------------------------
p OW r Address
H !/..`L- /J O t S u/�4I�Sec!7�i
a -•------------------------�D�-•--• l.._..................... .r..�-----�sf h. ........... t
Installer Address
UType of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms.._....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ........................... No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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.......................
4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -------------- ---------------
Description of Soil................ 4'±...
U ------------------------------------------•--•----------------------------------------------•----------•••------------•--•------------•--------•---------------•------.
x ------------------------------------------------•-------------------------------------------._...------•----•-•- ..............-
--------------
V Nature of Repairs or Alterations—Answer when applicable........ 5.��___..w� o av mac
--------------
--------------..........................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Ti-- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' ued y the board of healt
Signed .... ---------------� ,1'2.1
�'87
---------------------------•------------
Date
ApplicationApproved By..............................----------------------------•-•-----------------....-----.......... ........................................
Date
Application Disapproved for the following reasons--------------------------------------------------------•------------------------•-------------------------------
---------------•----•--------•-----•-•-----------------------------------•------------•--•-•------••--•-----••---•-----------------------------------------------------.......-------------------••-----
Date
PermitNo......................................................... Issued-.......................................................
Date
r
....:".......
THE COMMONWEALTH OF MASSACHUSETTS
(BOARD OF HEALTH
............... ......................OF.....................................----...............................................
Applira#inn for Dispnoal Works Tomitrnr#inn Vvernfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ,
3s..
Lo ation-Address or, t No.
........................... ................_..__....._........_._...._._______._._............._ __...............__......_........._._......__.._.........____......_._.__....._._..__......_._
a Owner `` Address
----------------------•- H '' A�7R................................:...._ S_O /,e/q h!// .v_rH
....... -••-----•-••...........................
M Installer Address
UType of Building Size Lot----------------------------Sq. feet
I—I Dwelling—No. of Bedrooms.....3...................................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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------•----;/-........ .--•------•/............................................................ -----•. --
ODescription of Soil---••--------- --------•------------------------------------------------------•-------------•-------------------------------------•-
x
c.>
w
- ------------- ---------------
------------ - ------
U Nature of Repairs or Alterations—Answer when applicable......
'?s�rt`_...._...... /v`�___ !�._.�c
Ii
------------------ --...................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T x� ; of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be • sue by the board of heal .
,,�''/'
Signed. !1._---•--------••------------•-----•-•-..._.•••-- ..
Date
ApplicationApproved By.................-------•-•---••---•--••-•.............•-••--•-•---•--•-•---•-•-•--•••-••-.-----
Date
Application Disapproved for the following reasons:-----•------------------------------•--•------------------------------------------------------------------•---
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�p r-cat.-L .........OF......./5 - PZkt,,......................................
Tntifiratr of Tomplianre
THIS�T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by-------------- - G --
�n ----------------------------------------------------------------------------------------------
at--------------•-3-5----/ `' �`'---- �._ -I taller
has been instilled in accordance with the provisions of TILT-LE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. ......... 2.S--------- dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... ............................ Inspector... •---- -•-- - ---------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF........ .FEE..--��
-••............•-^
Disposal Workv
_To¢-n-ntr ion rrmii
Permission is hereby granted........ . --' `'"'�,�-
to Construct ( ) or Repair,') an Individual Sewage isposal System
at No............. .........
street
as shown on the application for Disposal Works Construction Permit N0V_3.;.(_-_ Dated..........................................
.................................•--•--•--...•---•-•---...---•-•--••...-•--••----•-•....................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
' TOWN OF BARNSTABLE
LOCATION '�f/ ly�iy�-c da/f ��"•ai/ SEWAGE # F7- J,;�;—
VILLAGE Ce Ile ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. ��0�h /is
SEPTIC TANK CAPACITY /00p
LEACHING FACILITY:(type) a_/l700 i�f (size) ,6 1%4 �O
NO. OF BEDROOMS. PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 6t4 r0
DATE PERMIT ISSUED:
DATE ,COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ✓
t
,
6 rr
/may 4/
No......... Fimis
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
u�.IJ.-------- -..OF...�...1� .IL?5: � �a
Appliratiun for Bhgpoual Worku Tunutrnrtiun famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
----------------•-------•-----------............
Location-Ad •sess or t No.
� LIYI� !� ...'rat----
------------- 7v� -� ...�'�,�M�!.�(............
.... ...
S_..._C'..... O ner 7 dd�ss Q ...._
••••-• .--••• . Da.17,WL�- ---------------------------- �1 G _ l SA..--•••-
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......-.�...............................Expansion Attic (-0 ) Garbage Grinder ( )
Other—Type of Building r __ _IZ .. No. of persons__................... Showers ( ) — Cafeteria ( )
a Other fixtures __________________________•---.__
W Design Flow.......H.0_...........................gallons per person per day. Total daily flow......3.�..{. __._._..._...gallons.
WSeptic Tank—Liquid capacitylP.9 '...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 Result Performed by.:_.... _G-l�•A1�.�._._..I.?� _..,._..__,_,.:_... Date_____________��__. •
aTest Pit No. 1..... .........minutes per inch Depth of Test Pit.................... Depth to ground water........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p+ ----------------------------------------------------------- ---------------
•--------------
.-------
...........
-------------•-•-------•-.--------------
O Description of Soil..... =- ------..I.A.4-...`�--_'c?k&.�as.i----•----------------------------------------------------•----------------------------------------
x
U •......... ..._.... La.�,t: 1111 ---•--------------------------------------------•••••......_......••-• ---••--•--•-•--•-•......•••.
---....•------------------ --------- --1. ��� � �R�.c.��--------------------------------...------------------------------------------------------.........------
U Nature of Repairs or Alterations—Answer when applicable_•-___•__-_•________________________________•----_-•---•-•---_•----.-__-_--__-_-_---_------___.
Agreement:
The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT�:;,,. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued by t oar of h h.
l �
Signed•...•. ••---•••-•-- •.•• ... ............................................... -•--•-••-L- 12-....-
Date
ApplicationApproved By••••-•-••••••-••-•••-••••••-••-•--•............................•............-••--•-•--•-•-••-••• ........................................
Date
Application Disapproved for the following reasons:---•----•-•---------------------•---------------....-----------------•-------------••-•••.............-•---•--•-
Date
PermitNo......................................................... Issued.......................................................
Date
----- .�► ti Fss.......:....`...'r....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�a
Appliration for Disposal Works Tomtrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual-Sewage Disposal
System at:, C
.......... ?- ; ... '�° ................................................... ---
Location Address or L-ot No.
.............. _c ......
.:�......._.._._
O ner Address,
-. .......................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_________ _______________________________Expansio�nAttic (� ) Garbage Grinder ( )
Other—Type of Building _.:_ _ : _.. No. of persons_..J...................... Showers ( ) — Cafeteria ( )
P4 Other fixtures -------------•. ---•-•••....---------- - - --
W Design Flow.......1�_0............................gallons per person per day. Total daily flow.....3 _.i .....................gallons.
WSeptic Tank—Liquid*capacityf05_/---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 Resul, Performed by......__s Ju . .. ..`..1 . ........................ Date.............� �h ............
Test Pit No. I.... :-------minutes per inch Depth of Test Pit.................... Depth to ground water........................
(� Test Pit No. 2................minutes per inch' Depth of Test Pit.................... Depth to ground water........................
a --------------------------------- ---------------..................
._.............. -------------------------------------•-----------............
DDescription of Soil.... ozl a ! � 1 }� , ---•-••--------------------•-.-•----------•-----•--------.-...•-------------------•---------•...
•'�' S� k <�F, -----------------------------------•---------•-•---...................................................
-••-•-----•----------•----- ...
,11
W •••-•----------------- ------•-•--'-• ------------ ��� '`` ' �1 -------------------- ......--------•-----------•--------------•--•-------•-----------•---•--•------..
UNature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________
-•---••---••••-•-- --------•---•---------------------•-------------------•-.._..----------,---------------------------------------...------------------------._.._....---••-
Agreement: Z t
The undersigned agrees r'to install,'the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary de— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ee issued by t Ioar f heal 7� /
�Signe f �' ------•------------------ ...
Date
ApplicationApproved By .....•............................•-•--........-----......................... ........................................
Date
Application Disapproved for the following reasons:_...---...-•----••-•----•--•--------•----••------•-----•------------------------•------•----••--•---•--......_._
s
Date
PermitNo..............................................."-�`•--••--- Issued.......................................................
Date
F'.
THE CO;MMONWE-ALTH 0F MASSACHUSETTS
`BOARD OF HEALTH
.. .+ .._hJ ......... .o� +f ?i 1.......ar-.r4-.raj -c .................................
Tnrtif ira#r of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ..... ,E 5 --� � ...........................................................;� ....................................................
� I staller - �
at...."._�...... -p,..-6--Q-�- -�-. ;-1 C.,- A-i -- --C-C.�ql-IIZ U1���Ct ����4.......................................................
has been installed in accordance with the provisions of T T 5 of The State Sanitary Code as descri ed in the
application for Disposal, i+/orks Construction Permit No. _.. .......c-6'--�%....__...._. dated-... :" `..��-'..............
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............::... ........................................... Inspector- ------...------------------------------•=--•---....---•----------...••••.....--
THE COMMONWEALTH OF MASSACHUSETTS
BOA. OF HEALTH
. .. .........OF.........L� I......... .....................................
N �l.Q."..... FEE.................:.....
Disposal Morkp 05onotrurtion Virrmit
Permission is hereby granted.., ...-_.. ....... _ f_t4 ?.t.. _
to Construct ( ) or Repair ( ) an Individual Sewag D* osal rtc
at No... .�l..I! -.w t_s. �l-# ,�_ ...1 � .- ...J }.. t ). t,...... '�........................
Stre
as shown on the application for Disposal Works Construction Pern et o.___-- .__- Dated_ p ................................x ?� ��
Board.of Health
DATE............................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ••
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