Loading...
HomeMy WebLinkAbout0100 HUCKINS NECK ROAD - Health (3) 12 White Oak Trail Centerville A=252 —033 5 M EA®® No.2-153LOit UPC I S34 smeadcom • Made in USA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessme:n's Property Addres n / Owner Own is Name information is 6,eh.�✓y,�/� �� Dd,6�� �oL a6A?� required for T� -- every page. City/Town State Zip Code Date of Ins,-ec`--n Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the your "�r� key to move your O cursor-do not Name of Inspector _ use the return ,�� O _ / �G L -- key. `T_ (/ Comp an Name compaay s7i y+-� A% City/Town State Zip Coda Telephone Number License Number c. B. Certification I certify that I have personally inspected the sewage disposal system at this add", s and t1 At the e, information reported below is true, accurate and complete as of the time of the i,— ection. �'�e iny�ection was performed based on my training and experience in the proper function 2nd r n,tenare'of e ite sewage disposal systems. I am a DEP approved system inspector pursuant to ection-T5.34T.P- f Title 5 �QR 15.000). The system: r= A Y.I Passes ❑ Conditionally Passes ❑ Failsm, ❑ Needs Further Evaivation by the Local Approving Authority a - —/,91-A Inspector Signature Date The system inspector shall submit a copy of this inspection report to the ","_"ority 'Bce-o of Health or DEP)within 30 days of completing this inspection. If the system is 52s r e S'!S-em has a design flow of 10,000 gpd or greater, the inspector and the system ov ner report to the appropriate regional office of the DEP. The original should be sent to sys� mm. :" and copies sent to the buyer, if applicable, and the approving authority. ****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 f;;ture' under the same or different conditions of use. LA 010�1 t5inso•03/08 Title 5 Official Inspec'ion Form.:S�bscr""=c=_c==•=-_-.:is_- ,, - _ _ - Commonwealth of Massachusetts �_i P Title 5 Official Inspection Form =; Subsurface Sewage Disposal System Form - Not for Volunta y ASs2ssments Property A00� /MV?SF✓/ Owner Owner's Na . information is Cleo yfi✓Vi l/-e required for ever/page. City/Town State Zip Code Date ! .soec-;cn B. Certification (cone.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 appro',ed ty 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 exfiitration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complyinc septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sou.;d, not leaki;�c 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 tie cist-i� t c . ^o , a to broken or obstructed pipe(s)or due to a broken; settled or uneve. pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5inso•03M Title 5 Omciai insoec5or. Commonwealth of Massachusetts Title 5 Official Inspection Form D Subsurface Sewage Disposal System Form - Not for Voluntary Assess,�en-:s Property Add ass _ X ob1-,,.-,,,4, . Owner Owner's N me l information is C� ll� /j-4 Dad ? 1 required igr �N ��1 �"� _ every page. City/Town State Zip Code Date cf lnsgec-Lizln B. Certification (cone.) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pioe(s). T`1e system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Heap:, in order to determi; e 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 1 5_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 wvetla,d a sat aa: 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 t s S: .S is 00 feet of a surface water supply or tributary to a surface vrater supply. ❑ The system has a septic tank and SAS and the SAS is within u Zone _ supply. ❑ The system has a septic tank and SAS and the SAS is within 550 feat supply well. Onsp•03/03 Titie 5 OT1Cia Commonwealth of Massachusetts rI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Addre // Owner Owner's Name information is /_! �O�6 OZ� Tl:i? required for State Zip Code Cate o inspec.icr; every page. City/Town Q. Certification (cont.) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee. 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 coi-crm bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is ecual 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component. due 'o cver.ca_ec c / clogged SAS or cesspool ❑ ,/ Discharge or ponding of effluent to the su face of the gr our: ors ice = s u due to an overloaded or clogged SAS or cessoo( ❑ U Static liquid level in the distribution box above ou c tie` irr e- e ar. or clogged SAS or cesspool �i Liquid depth in cesspool is less than 6" below ir;veri ore •e'oie ._ u:M•e ss than '/2 day flow ElRequired pumping more than 4 times in the last year NOT e ;ao l� obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high crc n< ❑ Any portion of cesspool or privy is within 100 feet of a su=�c tributary to a surface water supply. Sirsv C3;C8 Tine 50?!di_!1^-.e:n-,7 S_c_ r __-_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assess,m,en=s —`y o ro ert dre s 1 p Z)o �q►�s`✓r Owner Owner Name information is ems_ Ile— every required for 7�V /•, page. City/Town State Zip Code Date of ins__eotion B. Certification (cons.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ 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 ,.,,ter supp';; ,%le'i. ❑ 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 fecal coliform bacteria indicates absent 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 nd chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow cf 2000ccd_ 10,000gpd. ElThe system fails. I have determined that one or more of the accve rarure criteria exist as described in 310 CMR 15.303, thereiore the s%s em fa s. T .e system owner should contact the Board of Health to determine what,,�.iill be necessary to correct the failure. E Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the follcrving, in addition to questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water suo�l ❑ ❑ the system is within 200 feet of a tributary to 2 surfa.. _ �.�i.. El Area system is located in a nitrogen sensitive area (1r:teriM, Area — IWPA) or a mapped Zone II of a public vjater su pra/ If you have answered "yes"to any question in Section E the system is con sidere or answered "yes" in Section D above the large system has faiied. The -ow c'cr o ._._ C :. system considered a significant threat under Section E or failed under Sectio : s,'-ai Dare e ' system in accordance with 310 CMR 15.304. The system owner should contact t'-:e _p_ _o.iat, regional office of the Department. 1i!10 SOffidal ,-c....:Sc^__._____,_____=__ _ -.--;-'° �_'_ _ <\ Commonwealth of Massachusetts rim Title 5 Official Inspection Form �( = 1=i Subsurface Sewage Disposal System Form -Not for Voluntary Assesses� er.s Property Addressn Owner Owner's Name information is C�jN yv� le— /��f Dab �� `a`dn f� required for _— I /�T every page. City/Town State Zip Code Date o;ir._ C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the follov."ir:: Yes No ❑ PZPumping information was provided by the owner, occupant, or Board of, th ❑ Were any of the system components pumped out in the previous two: eeks? ❑ [+� Has the system received normal flows in the previous hivo week period? Have large volumes of water been introduced to the system recent',y or as par ❑ this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? �❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tar.'.; inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth oI scum? �❑ Was the facility owner(and occupants if different from o`d:'r:erl oro.ia'ed ;tii h information on the proper maintenance of subsurface sev,,ace disposall sys=,7,s The size and location of the Soil Absorption System (SAS) on `he site '-as been determined based on: ❑✓/ Existing information. For example, a plan at the Board of 11e41t`,. Determined in the field (if any of the failure criteria reate- toa C is approximation of distance is unaccepla e) , 1%17R Tulle 5 06idai In«.ed:or. . Commonwealth of Massachusetts a=; Tale 5 ®ffiGial Inspection Form ' isi Subsurface Sewage Disposal System Form'- Not for Voluntary Assessments Property dress Owner Owner's Na e information is �� - Ile r2 Jk� required for — every page. City/Town State Zip Code Oa,J, ;nspeo n D. System Information Residential Flow Conditions: p� Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 1 of bedrooms): Number of current residents: Does residence have a garbage grinder? I Yes Is laundry on a separate sewage system? fif yes separate inspection required] D II Yes ✓ 'Jo Laundry system inspected? _j Yes I_': N0 Seasonal use? I Yes ✓ \o Water meter readings, if available (last 2 years usage (gpd)): Sump pump? I Yes No Last date of occupancy: ommercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day ( - Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? — — Industrial waste holding tank present? = - Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy(use: r-)ate -- Other (describe): 15inso•C3l08 iiJe 5 07-i-ide!Ins edicn Fc�r. 7_ _ Commonwealth of Massachusetts - =�� Title 5 Official Inspection Form ? — , �J Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property A restf o ©�Jra n S r Owner Owner's Name ` information is (9 0 / tate a required for C.� — every page. City/Town S Zio Code Data cf Ins _ ion D. System Information (cont.) General Information Pumping Records: Source of information: -- / Was system pumped as part of the inspection? !es I No If yes, volume pumped: gallons Now was quantity pumped determined? — Reason for pumping: Type of S tem: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if a^y' ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from syste`" owner) and a cony of ie est inspection of the I/A system by system operator under contract ❑ Tight tank, Attach a copy of the DEP approval. ❑ Other (describe).- Approximate age of all components, date installed (if known) and source of in:fcr-ztic;n: 19 00&- Were sewage odors detected when arriving at the site? ❑ `'� I/ ': t5insp 03l08 Title 5 Official!r:=_aec:io^F :T::Svc =_e=e q =e = Cornmonwealth of Massachusetts ���-- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment's Properly dyes ' — Owner Owner's Na Te information is �� �/¢ Oa b3o2 )4 a b/10g �e c — r V� G required for -- State Zip Code Date of in,.-- everycion oaae. �Ity i own D. System Information (cunt.) Building Sewer (locate on site plan): 30 Depth below grade: ;let Material construction: cast iron ��4OPVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting. evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal ❑ fiberglass Elpolyethylene ❑ other (explain) If'Lank is metal, list age: ye2r: Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes I_ do SX a� Dimensions: / Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 V� How were dimensions determined. -ins?•0 '08 tle 8 o-!cal Irsp2cio• - Sc=S_ 5=;:_;e .___-__ ._.__ `r=_-. Commonwealth of Massachusetts r, Title 5 Official Inspection Form ir;li ;i 1.��_o� Subsurface Sewage Disposal System Form - Not for Voluntary Ass=ss�;:en-s oar_ Tf-,L---- - -- Property dre s . ' 0Z ,T — Owner Owner's Nainformation�s e ���///JJJ ^� required i0f �� �� � every page. Cltv/Town State Zip Code Date of. ... D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, struct ra! ir: egritd, liquid levels as related to outlet invert, evidence of leakage, etc.): Orease Trap (locate on site plan): Depth below grade: ;eat Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethy!ene ❑ other (exp!2in): 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: D-`e Comments (on pumping recommendations, inlet and outlet tee or baf'..e conditier_ struct ra! ir.tecr` liquid levels as related to outlet invert, evidence of leakage. etc.): OT ght or Holding Tank (tank must be pumped at time of inspection) (!ocate on,, Depth below grade: ---- -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ pelyetl,;'e :e 5inso C3/CS Tile 5 C?iaal l— Commonwealth of Massachusetts i Grp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 21al. 1,��i,�� ---- --- oA�.- Proper, dd, ss Owner ovCe�a e �� � /�i� �oZ�3� a6 information is required for every p2ge. CitylTown State Zip Code D t c`ins Flo D. System, information (cont.) (9 ight or Holding Tank (cont.) Dimensions: -- — Capacity: gallons Design Flow: — gallons per day Alarm present: ❑ Yes El No Alarm level: Alarm in working order: ❑ i Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ach copy of current pumping contract (required). Is copy attached? ❑i "es . Nc Distribution Box (if present must be opened) (locate on site Plan): Depth of liquid level above outlet invert Comments (note(note if box is level and distribution to outlets equal. any evidence of solids carr;e;e . ary evidence of leakage into or out of box, etc.): / ump Chamber (locate on site plan): 77 Pumps in working order: Alarms in working order: "es _ `5insp•0310E Title 5 Offiaai'oscec5or.= -- '-=Se•:;- :_-___ _—. : Commonwealth of Massachusetts -�_- Title 5 Official Inspection Form ��M_— I l Subsurface Sewage Disposal System Form - Not for Voluntary Assessmena Proper ddf ess O tJr'a a1.S�� Owner Owner's Na e information is /�e" ��/le (0 recuired for C� every page. City/—I ovm State Zip Code Date 0f Inspe.,5cn D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurte ances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: ❑ leaching chambers number: -- ❑ leaching galleries number: ❑ 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. Soil. vegetation, etc.): (A G 1 l G4 rye - -- :Sins^•03!OS r(II=S 075d2l i Commonwealth of Massachusetts T7 Tale 5 Official Inspection Perm ! fi 'i�, Subsurface Sewage Disposal System Form - Not for Voluntary,lssessments Property Ad s Owner Owner's Name information is _ I�io?6 /^'�/ y required for �✓' — .f every oaoe. City/Town State Zip Code Date cI i .. ::on D. System Information (cont.) esspools (cesspool must be pumped as part of inspection) (locate on site ?Ian): 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 71 Yes i j No Comments (note cond;tion of soil, signs of hydraulic failure, leve! of ponding, condition of vegetatilon. etc.): rivy (locate on site plan): Materials of construction: Dimensions -- --- Depth of solids Comments (note condition of soil, signs of hydraulic failure; level of pond;^ , cc,-_`i ic-­, c1 v,6 etc.): iJl^:5�•03i08 Title 5 Otici a! Commonwealth of Massachusetts 72 Title 5 Official Inspection Form I e m e ICI Subsurface Sewage Disposal System Form No t for Voluntary Ass„ss,: Prope j Add,rf�ess OOwne 6JrG i inform Owner's Name / e //-� } information is Qh r` co �O � �� 2 6 �� required for — even page. City/Town State Zip Code Dare D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system inc!uuin t es to at least two permanent reference landmarks or benchmarks. LOCate ail Wei1S within 100 fee:. Locate where public water supply enters the building. /(moo f,o i dd- 3s i5insp•03/08 T,I? Olicial - -_ _ _ _ -— - •_ -- - Commonwealth of Massachusetts Title 5 Official Inspection Form !=! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Prop"Ad ress Owner ON. is Na/ne /�f,Q information is �� ✓(/7 Ile, eve %/l required for eye pace- City/Town State Zip Code Dave cf inspecti r D. System Information (cont.) Site Exam: ❑ Check Slope / 3 ❑ Surface water 3 ❑ Check cellar / ❑ Shallow wells �1/�7 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with locale Health - explain: — ❑ Checked with local excavators; installers - (attach documentation) ❑ Accessed USGS database - explain: You must des 'be h w you established the highIround wa�ter�elevation / L IOGr vt(%IN y-�✓ Gi 7� 7 �'1� /b Ce- �io r� i S -7/. 1 tsinsp•03/08 Title 5 Offircial Ins ction --_-; 3 =—•�---•- Wv L/ No. � A P P Fv� 10.00 THE COMMONWEALTH OF MASSACHUSE �rnstable Conservation Commission new aS �33 BOAR® OF HEALTFVk TOWN OF BARNSTABLE Signed Date Apphratiou for Rspniial Works Tomitrurtinn Prrutit Application is.hereby made.for a Permit,..to_Construct ( ) or RepairA{X)Xan Individual Sewage Disposal System at: 100 -H-Uckins`'Neck Road Centerville .......... -_....- --• --- - ---•--------------------------------- -------------------- ._........ ................ Location-Address or Lot No. .11.11idn-Camb.e.1.1................................................... ----------•••-----------------•-...-•-------•---...-------........................................ Owner Address =---------•--------------- -- ------------------- - -------••-----------------...........------.........------....-•-•---•--------••------......_..-•- ..� � Installer �" Address Te of Building g Size Lot............................Sq. feet U g •Expansion Attic ( ) Garbage Grinder ( )Dwelling No. of Bedrooms_____________ ___________________________ per, Other—Type of Building .....HE_ ______________ No. of persons.........2 ........ 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_-_____-___-___----_._-. fi Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ a ---•------•--------------------------------------------------•-...-•-----------------------•-•------.......................................................... 0 Description of Soil---------- -- ------------------------------------------------------- x Sarid---&--Grave T•---•---•---....----•--------- ---------------------•-------•----- v --------------•-----------___-------•--•--------------•-•-------------------•---•-------------------------- W -----•------•--------------------------•--•-••-•-•••-•--•-------------•---------...---------------------•-----------------------------------•------------------- ••--•----------------- V Nature of Repairs or Alterations—Answer when a livable__________________••:.____.____ . ____...___._._______.____._.________:.__________.______.. 1-10�J gallon leaching pig . -----------------------------------------------------------------------------------------------•--------•------------------------•---------------•-----------....................-••-------------•-----. Agreement: 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 Complia thhas n.- sued by the brd health. Signed --- . _ ----- ----------------- ---- A lication A roved B Application Disapproved for the following reason --------------------------- -_----...----------------:..................................... -- ------------- -------------------------------------- ---- - --- --------- --- ...... -- �- /J IY,hte Permit No. --- - Issued ---------- -. ........................ Dat' j � 1 00 No.A-•--- 'IF .. .... .. THE COMMONWEALTH OF MASSACHUSETS� ►''` BOARD OF HEALTH/ ` TOWN OF BARNSTABLE Applirati att for 14spusal Larks Tonstru.rfiurt ranfit Application is hereby made for a Permit to Construct ( ) or Repair}FXYian Individual Sewage Disposal System at: 100 Huckin's Neck Eoad Centerville ................_........__................ .............----•------------•--....._..._..._... --•---..........-•-••-............•-----------•--..................-------••------................ �v Location-Address or Lot No. ,l•� 1. _11_( m.T.2)?P�: .. ............................................... ........................................... ...........------............................. Owner Address a _-. ...._ ..........-•-•-•-•-------•----•----•-•--........-- Installer Address dType of Building Size Lot............................Sq. feet U Dwelling- No. of Bedrooms.............9.................. Attic ( ) Garbage Grinder ( ) a Other—Type of Building o p ( ) ( ) _____FtF;,�_._____________ No. of ersons........_�.__.___.......... Showers — Cafeteria P 1 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 Otherr Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by--.....................••---•-•-••-•...................................................... Date........................................ ,.4 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........................ P41 ...........................•----------•--------------------.........--------..................................................I...........................•. O Description of Soil-----•---- -= x Sand & GraVvel 14 W VNature of Repairs or Alterations—Answer when applicable............................................................................................... 1-1000 gallon leachink pit . Agreement: 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 ..-----.s��:..�1�f�.. �%ll� .!t //A /l..o —` `T/Z5r91 ---- --- ,. pare Application Approved By .. ...................................�f ......... ..... �- d -G�-- r Application Disapproved for the following reasons:V... ......... ..-------------------------------------------------------------...-------...Dire---....--`---...- ------------------------------- --.A.........---.................... / Dare PermitNo. . ...............�------------------------------- Issued ----------�-r.-���---�-----------.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CTertiftiate of Tarayliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by--..J_.P>MR.c.om Z.e r....,1r.......................--.......................----------------................----_---_--------_---------------------------------.......----------------------------------------- Insraller ' at -...Inn.... urk i-.n..e.----Neck....Road....CQ.0 t e.nd..11e._----------------------------------------------------------------------------------- - ---- has been installed in accordance with the provisions of TITLE�5 of The State'-Environmental Code as described,in the application for Disposal Works Construction Permit No. .`��... ''..�� �........ dated ..... C%....... ....- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIILT LIFLI rN(C�TION SATISFACTORY. 1'"C Ins ector -= �= = .lIt�L'it. ...DATE........ ..,..�--- -=----------------------------------------------------------------- p THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NOV 3 TOWN OF BARNSTABLE -' `-"� Disposal orko-Zo ts#rudiun prrutit Permission is hereby granted... ._. .e 1 C 1a ?"....... . ........................ ---------------------•-•------.................................... to Construct ( ) or RepairX(XX) an Individual Sewage Disposal System at No............ N �_rk n.S....11)ackna,�l__-( Ant Prvi.11 a �, ..............•-- ...- - - - ----------•--••--••...ram.. Street r v `r/ I as shown on the applicati,n for Disposal Works Construction-Permit No.. ... . -W---.. ate. !.. __ ±........ --------------------••-. ••-•----.... •- Board'of�ealth a� DATE------------•••-•-....... Y••�.I.......................••--••......--••-_. C ! FORM 38508 HOBBS&WARREN.INC..PUBLISHERS I l0�%C A�j ION SEWAGE PERMIT NO. CO� L ��� ILL INS A LLER'S NAME i ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED PY < ; DATE COMPLIANCE ISSUED -da Z/9 it gae a-(� 'Br J . N' .-7�_...... Fes$... '.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Pr_ L301 ..........................................OF.......................................................................................... Appliration for Ditipasal Works Tontrnrtiun jkrmit Application is hereby made for a Permit to Construct ( ) or Re Cpair ( ) an Individual Sewage Disposal S _�j , B.... .._... - ---•----• ......... .... Q Location-Address or !� W .._.. ......_._.. `�`?........................�i .._..... Owner Address . .... 2 -.------•-•--------------------------•--. ........e. ..... I taller t Address Type of Building Size Lot.................... .....Sq. feet. U Dwelling—No. of Bedrooms�..�.}........... ... —_................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ..l..dl_-o.® ----- No. of persons...........:................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. --------------------- ............ W Design Flow.......r 3.9...........................gallons per person per day. Total daily flow......... (2__.___gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------.------- Depth................ xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area---.-_----------__sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit---.--.............. Depth to ground water.......---...........--. (i Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water....................--.. a ------••--•-•----•••-••---------•-•----•-------------------------------------•--....•-•-•...._------......................................................... 0 Description of Soil....................................................................................................................................................................... x W -----------------------------------------------•---•-----------------------•---------•-----------------------------.._....----------------------------------------------------------------.._.._--•--- 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 T!'I TL. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued b d of health. . Application Approved By.... t-------------- Date Application Disapproved for the following reasons-------------------------------------------------------------------------------................................. ............................••---••••--•--•-•-•----•---••-•---------------.....---•-------------•-••-•---•••-----------••-•••----•---------••-----••--•----•------••-•-•----••-••------••-•------•._.... Date PermitNo......................................................... Issued....................................................... Date No.B-..-..........•--- Fes$... 's.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .-•----....................................O F.-.-..................... .���r�irttfilan .#ur �i��u�tt� nxk,� C�nn��xnr�iun �ernti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem t t • }. �qLocation Address or ty �..... ----•-----•.............•...........•..... .......Owner } l�E iFds. �K+ t� ................... id Address �QQ�l ............ ......... ..: ......................................... ...... ___ ...... _.. _?•�:. t............................ I taller Address UType of Building _ , Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._ ._..._. .... p Showers ( ) — Cafeteria ( ) ! No. of persons --•••----- Otherfixtures ................................................. .....::.---•--•-.•-•-••............................... W Design Flow____._. *...........................gallons per person per day. Total daily flow..__._._:___::_::__:::.• ._0..__gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________........ Depth..............-- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------- •-•.......................... ................ .--------------- ---•--•--•--•--------------------••------.... 0 Description of Soil...........................................................................................------------------•---------.........--------------•---.....----------.----- x U -------------------------------- ----------------------- •------------------------- •-------- •-•------------------ ••-•------------------------------------- •--••--------------------------•-- W UNature 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 TITS'la• 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued bpt-1ie�h d of health. Si #lla ..... ....... ...::-•--•------------------------•• ... . ..... ... Application Approved BY l<'t` ..... Z Date Application Disapproved for the following reasons:-----•---------•--------------------------------------------------------•-•---------................--....--•-•- ---------•-----------•-----------•---------••---....-•---------•-•--•---•-•---------------•..--------•---•••-••••--•-••--••---•-••••------------•--•-•-•--••---••-••--------•-•-••--•-•-••--.._....----- Date PermitNo....................................••-•---------•-----. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAW OF H ALTH ......................0 .................... :..:. ... wrtif irdr of Tontlifiitnrr THI O CZ " RTIFY, That the Individual Sewage Disposal System constructed ( ,'1. Repaired ( ) �i bY---------• -••--••-- .------ CST: `....-•-------•--•--•-------------------------------- at Installer ns Ier-•-•-•--••--•----••--••--•...-•---•.............................. ----------------------- has been installed in accordance:witli the provisions of TITLE 5 f The State Sanitary Code s scribe in the application for Disposal Works Construction Permit No.._�Z.'..7d................. dated-..... - j;:.. ...... ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... jl k, t.. Inspector :. THE COMMONWEALTH OF MASSACHUSETTS BOAR :0F7MATH �) �`c..-:........................OF..... .........................-_.... f No..D.v-4................... FEE.. :................ Dispoli nr, .5 Wnnstrudion jamit toConstruct ") or pair ..n.In:.._._ . .. --•--.----------------------------- .............................................................. Permission ':s ereby granted�_.�_,-:_ _.. (�Eel.. dividu 1 S : System V� i� ,4 atNo......•••-r ------ © "` .......-• ---.-- -• ---- ......................................----•-•----•••• •---- •.. ............... eet as shown;on the ppli ,tion for Disposal Works Construction P mit o _..... Dated....`. _��._...:._ ............ / , Board of Health DATE -- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS t-10 G,,Atzr3nG1= FiiZt"r-or-R T i L-4 t=ww z Ito x •S • 33o G.P•D �.- ��],21 Lo ' rE-�'tc -r'A"v- z 33o'd 150 P6.7: N uSE- t o00 6At_. VILp . .. r bI5Po5A1. FtT - u�.E lock Ge,_. �,,/M -d : 964 V7 J -,U.WALL AeG-A - 150 Ste. Ic�p 5� .c 2.S • �7S G,.PD. .. Pir �' 7 ' � sue. � t .o -. So C�.PD. , . _ _ . ..• _ . , - TOTAL "►' ,ES1G►J .42S 6..1?'[7. Pmc-DLpTIoLJ O&TE : CIO I-ml Q* O¢ LLSS. a. .icy. lreA au Tor F►ia 4 100.0 ►-tOl_T'�-82 8� ' v =�� ��F,`._.-may �� I,r::�i i '��rl P `� 4. �,, ......�• = Juv so d O {u� •�+ . LnA�M 1000 I -box & G ScvnC l o INV. 1000 96 tuv. IW �i• 4' 9e,•2" Y4'�. FT . sago 1'la/4 1'lz � . ._ .._• _�.� : • : ' .' ; : : • • : . . '•, . ,.. .: - - •� STo.-ifs EG=9p � � _ . .. A✓gam /•o G.o' �,[g� � � •: . C-SQTIFIED PLC>T PL.A.Q* El= P�'.oP:'t a� �2 N� �a>ra✓ . • � ( ''..sv �ATI± Z.,4..a2 .. Pt.At.1 Rai=c�E►.1cE GGRTIF`l T"AT Tldr-- Fov1JDATIC4 5uo%uw CCMPLVS WIT" TO;Z: SIDE.LI►-ram A�.ID 5C-T13�CtC �:G4�U1�E�titc►-1TS OF T'►-1E • Lo.•(- -(owU Ot= �67 Cover Puy{J. 323�3 LOCATF-D. W1114 ,4 •rt-cE-- T:'LOvU PL.AIQ- 4-$'Z. �: )� BQXTCtiZ �. u�E t�.1G- ��l I t^,. '. •c ..- 12EGlS'iLRED 1-Awo SuZvaYorz oSTCrV%L..0 o Yt-Its PLOW I-S uoT >✓n.5cv v�..� aN It.1,retJMG-t-Ir °�c..i�_�{ ^f�{t :. c�c=�,a✓T�. ;il�wln ANnt_tGA.trIT t�cV-o nLCV-Mt►!l:• LDY - l_1 Wes.•; -- p 12c,,