HomeMy WebLinkAbout0283 PINE STREET (HY - Health 283 Pine Street
Centerville P -
A = 228 045
UPC 12543 �a
NoPosrcor�°�
HASTIMS,MN
TOWN OF BARNSTABLE
LOCATION ��� Fi�j�s L S-i SEWAGE #
VILLAGE `�T ASSESSOR'S MAP & LOT ;j r-o Y-f-
/i✓Y.0Fu a s
II*iS=PR'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �--
LEACHING FACILITY: (type) (size)
NOti OF BEDROOMS
BUILDER OR OWNER Q Q /Sti
iv 3 P£c//Iw^
Rqk; TDATE DATE: y`
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
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lE�t Lp
R EAR
i
0
qq
No._! -� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer.
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Oie;pool *p5tem Construction Permit
Application for a Permit to Construct( )Repair(1,11upgrade( )Abandon( ) ❑Complete System 2ql;lvidual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. �'0 `�S —a �yr—d Designer's Name,Address and Tel.No.
17- Lt '11,44
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) I. 1-,Zd C. F
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 iss by this Board of Health.
Signe Date y
Application Approved by Date Z
Application Disapproved for the following reasons
Permit No.aaA20 Date Issued 4A
_ r
' No.
j i z_ 4
THE COMMONWEALTH OF MASSACHUSETTS Ent$.edn cotpputer:
��`"'�' Yes
'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS
ti
ZippYication for 30i!gpooal *pgtem Construction Per tmt
Application for a Permit to Construct( . )Repair(L)''Upgrade( )Abandon( ) ❑Complete System 2l<dividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. S d, • '7')>-S 9 y,4
i A13 P/Avs ST C f,44—
Assessor's Map/Parcel y
tt
IPL
Installer's Name,Address,and Tel.No. ,;`O$-7',l S' �p-p 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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
II Title .
Size of Septic Tank Type of S.A.S.
Description of Soil 1 e
Nature of Repairs or Alterations(Answer when applicable) C f
Date 1asilnspected:
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 issueq by this Board of Health.
Signed Date
Application Approved by Date (0
Application Disapproved for the following reasons
Permit No. '�C�C.�! —G�✓�'" Date Issued 6 "SL
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( 'Upgraded( )
Abandoned( )by fi C'�9 N C O 3 S a 47041 ti 3 7' CA-' ' 4-,4�P
at `R`S P1 .cam I— has been constructed in'accordance
with the prov" "ons of Title 5 and the for Dis osal System Construction Permit No. .U i)��—r a(l dated A f �,
Installer Designer t
The issuance of this permit shall not be construed as a guarantee that the syste�Iwill function as-designed.
Date Inspector
I
---------------------------------------
No. C�C-/ --��" Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigpoal bpotem Construction Permit
Permission is hereby granted to Construct( )Repair( t-)Upgrade( )Abandon( )
System located at 3 00i A,'£' 5 T C f�.Z -
` 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 pe
Date: 1/6 10''f" Approved by'__�
. 1
'i�p 2`Z�
COMMONWEALTH OF MASSACHUSETTS,LOT
v _
Z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m d DEPARTMENT OF ENVIRONMENTAL PROTECTION
e� F�MIA
IVED
oqM Sve
350 MAIN STREET
WEST YARMOUTH,MA3 2004
508-775-2800
TOV'vi:i}F tSARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 228 PARC 045
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner's Name: Mark O'Brien
Owner's Address: 283 Pine Street
Centerville,MA. 02632
Date of Inspection 04/02/04
Name of Inspector: (please print) James D.sears
Company Name: A& B Canco
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
1 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 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 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
1 Needs Further Evaluation by the Local Approving Authority
( Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. 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 DEP.
The original should be sent to the system owner and copies sent tot 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: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: 4
l 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 Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
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 I 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 Form 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: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
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
Backup of sewage into facility or system component due to 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 SAS or cesspool
./ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in leaching is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
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. 1 have detennined 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
snapped Zone 11 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 CMR 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 I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
./ Has the system received nonnal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of 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 tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
4 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
Existing information. For example,a plan at the Board of Health.
./ 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(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
FLOW CONDITIONS
RESIDENTIAL,/
Number of Bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms:
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pu np(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: 2003
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detennined?
Reason for pumping:
TYPE OF SYSTEM
./ 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:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
I`
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
BUILDING SEWER(locate on site plan):
Depth below grade: 8"
Materials of construction: Cast iron ./ 40 PVC ,/ other(explain) CLAY
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan):
Depth below grade: 17"
Material of construction: ,/ 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: 1500 GALLON PRECAST
Sludge depth: 1"
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of stun to bottom of outlet tee or baffle: 18"
How were dimensions determined: ASBUILT&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.):MAIN TANK AT WORKING LEVEL,INLET COVER 4"
BELOW GRADE,INLET TEE,OUTLET TEE,NO SIGN OF LEAKAGE OR OVER LOADING.
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 pupping 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 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
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 fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alanm 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: ./ (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.,):
D BOX IS 16"X 16"— 3' BELOW GRADE,ONE LINE IN,ONE LINE OUT,BOX IS CLEAN&SOLID.
NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alanns 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
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
SOIL ABSORPTION SYSTEM(SAS): ,/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number: 4 12'X 36'
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 IS FOUR 500 GALLON CHAMBERS WITH 2' STONE. LEACHING IS 40"BELOW GRADE.
NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate 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):
Comments(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 10 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04,
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.
tcK
i
I
Title Inspection Form 6/1 j;12000 10
Page 1.1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 283 Pine Street
Centerville,MA. 02632
Owner: Mark O'Brien
Date of Inspection: 04/02/04
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO groundwater 1 1 feet
Please indicate(check)all methods used to detennine 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:
Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TEST HOLE 1 I'NO WATER
TEST HOLE 4' BELOW BOTTOM OF LEACHING.
j
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N- r
Title 5 Inspection Form 6/15/2000 l 1
TOWN OF BARNSTABLE
LOCATION All lam/s� SEWAGE #
l�1�l/1/l
VILLAGE Ce e ASSESSOR'S MAP & LOT 2Z�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /TVO GEC
LEACHING FACILITY: (type��Lhw lob 644_(size) %O'A3e'f.V
&0.OF BEDROOMS -7
BUILDER Or0*9-
PERMITDA ,: 1_ Z 6 `�7 COMPLIANCE DATE:
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) Alf; Feet
Edge of Wetland and Leaching Facility(If any wetlands exist I/
within 300 feet of leaching facility) Feet
Furnished by
'f
�0 I
7
No. o..... rs Fee
1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
y
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Mkzpaal *pgtem Con!aruction Permit
Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) Ltl Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
7T,5 •���� s� ,¢gin
Assessor's Map/Parcel 6_e#WZ111/e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(✓��
Other Type of Building 425.f No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 1l152 gallons per day. Calculated daily flow ® gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. Caw,
y .0
Description of Soil o
Nature of Repairs or Alterations(Answer when applicable) rxnle
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 by this BoarA of ealt ---- ��f���
Signed Date
Application Approved by Date -of
Application Disapproved for theYbiloW4 reasons
Permit No. 7 0Y ry 3 0a- Date Issued
No. Fee Ves
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplication for ;Di.5pool *p!tem Conotruction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) L7 Complete System ❑Individual Components
Location Address or Lot No. ^�g' Z, ,p �C�' - Owner's Name,Address and Tel.No.
G ✓ C ,¢fin z e
Assessor's Map/Parcel - �� !// � ,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
BD! 7`219 Z10
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( �
Other Type of Building ACeNo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 3® gallons.
Plan,.-'Date Number of sheets Revision Date
Title
Size of Septic Tank / S�Ol> Type of S.A.S. 'Y " lyl!9 Q.dl
Description of Soil AO x.7241/XZ
i
Nature of Repairs or Alterations(Answer when applicable) rle
,
.r 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 by this Board of
Signed a' Date s
Application Approved by Date �°"r
Application Disapproved for theqllowiQ reasons
- rr-
Permit No. 3 o a Date Issued
THE COMMONWEALTH OF MASSACHUSETTS Z Z g_Z�9` 5
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Upgraded( )
Abandoned( by 021 fOLO l,,Wi
at Z 9� 194ta— 5/_ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer Q
The issuance of this p t shall a construed as a guarantee that the syst wi fu ction as esig.tt ed. qmj,�alta
Date �� Inspector / I fJ
No. �! —3a�� Z Zg ®< Fee 1- 6
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -YBA.I►RNSTA�BL�*E, MASSACHUSETTS
_ ILA lVX1N 7.;i-itiaY—r�s :.�.+L ZCibG39-3-C- -�L.L_it
Permission is hereby granted to Construct( )Repair( ✓fUpgrade( )Abandon( )
System located at Z,$'c3 eplee 5 CD'� ryO�lC'
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
TOWN OF BARNSTABLE
LOCATION g� �/ S�, SEWAGE #
VILLAGE C�rI �'v111e A//SS--..ESSOR'S MAP & LOT ZZ9=�,�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ITVD GEC
LEACHING FACILITY: (type)' 60�— (size) %O 7X?o ff
NO.OF BEDROOMS 3
BUILDER Off:__3_—Z
PERMTTDA COMPLIANCE DATE:
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) ek Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
Of
fh
� O
9 s� C
0/5
i
L w,
1/6199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, hereby certify that the application for disposal works
construction permit signed by me dated 3"11J�e concerning the
property located at �v7 ����' v� Ce"K*11"r/le— meets all of the
following criteria:
V"The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
4/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
6 There are no wetlands within 100 feet of the proposed septic system
Y There are no private wells within 150 feet of the e proposed septic system
l✓ There is no increase in flow and/or change in use proposed
There are no variances requested or needed
1✓ The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
lifthe S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) .
B) G.W. Elevation Z4+the MAX.High G.W. Adjustment
DIFFERENCE BETWEEN A and B Z 3'
SIGNED :— DATE: ✓� ' '//71
[Sketch proposed plan of system on back].
q:health folder cert
7r �V
1
J
I
I
3
M P_
1
-Commonwealth of Massachusetts
Executive Office of Ernironmental Affairs
Department of RECENEED
Environmental Protection
FEB 2 9 1995
Wllllam F.Wield WATH G"mor Q 'o
Trudy t oxs . OF URNSTKAE
8anra7r EDEA
David B.Struhs
Cpnmlpbner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Cal 3 CtrJ/Zf,� CERTIFICATION
Property Address: f different) _
,1"va^+2 ���s3--1' �.Q�►t-�iil . Address of O n wer:
Date of Inspection: 2—,1—�l — cjG O
Name of Inspector: /I> ��
Company am Address an�elephone.Number:
T X 6 R r►tdp S ,o� CC �..
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,ezpertence in the.proper functwn and —
maintenance of on-siteseAe disposal systems. The-system:
Passes
Conditionally "
_ Conditionally Passes -x
_.._Needs Further Evaluation By the Local Approving Authority
Inspector's Signature: �J�, Date.
The System Inspector shall submit a copy of1this inspection report to the Approving Authority within thirty(30) days of,completing this
inspection. If the system is a shared system or has a design fl�ow.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.
r if applicable and the approving au.hon . '
sent to the s'stem owner and copies'sent to the buyer, pp pp S �
should be se
The original )
INSPECTION SUMMARY: _
Check A, B, C, or D: . ..- ,
Aj SYS M PASSES:
__- I have-not found any information which indicates that the system violates any of the failure atteria.as.defined.tn_3'10 CMR_15.303�_
Any failure criteria not evaluated are indicated below.
Bj SYSTEM CONDITIONALLY PASSES: `i
One or more system components need to be replaced or repaired. The system,upon`completior the replaoemeM:or repair, ~
passes inspection.
`• '. - .2.. .. w,.`..t •,.,r�.. -kit.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in'Al instances: If"not determined",'explain why not)
_ The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming°septic tank as,
approved.by the Board of Health.
(revised 8/15/95)
- One Wlrrter Street • Boston,MassaahuseM 02108 • FAX(6M MG-1049 • TeNphone(617)202-SM
0 Primed a+.ItKy ed Papa.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
P4� CERTIFICATION (continued)
:SC:.r
Property Address•
Owner:
Date of Inspection:; rj
Bj•SYSTEM CONDITIONALLY PASSES (continued)
..e,-.�-Sewageabacku or breakout or high static water level observed in the distribution box is due to broken or obstnicted
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s)are replaced -
obstruction is removed
distribution box is levelled-or replaced
_ The system required pumping more than four'times a year due to broken or obstructed pipe(}. The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
i
r�,..e t...r. .. z•.vk.. - ,:_. r..ro a:-.x•..waea,:.e.:.-. ..
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH '
" - ---Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of asurface 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: }. w r € 4} x,'•
_ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system ha! a septic tank and soil absorption system,and is within a Zone I of a public water supply well.;.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.' -
more from aprivatewale r
stem has a septic tank and soil absorption system and is less than 100 feet but 50 feet or o e o
The s p
Y
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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
- .:ed4r4'i G.�•..., r,+w .: ;�-� "�"�aii n? -�'.triS{'�nr �al't.�z�z��w S, �:�..�;:. ate.F'-^i, 7'fA:. rs, 'Y t�;t'�t..»,,a-;7ik)d;r �"fr_a. �`<t�v;._-uer-_'c;r�_.er.s�:.i>w•.r.
SYSTEM FAILS: =
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR.15.303. The basis
fo_r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
- •'? ,F-•- ;-A., ,hr t*�C:� �'is:_;'�:,. ` .�.r .•., t.3" �Y:: ..,k=r 'ri• . r x,�i"� .. # ;;'�>:,a n:'xt? � a>>7.
the fa ilure.
Backup of sewage_into.fac�hry or system component due to an overloaded or dogged SAS or cesspool•
5 I�, t .• C o».. -.. a a.. .T'. .1! H ._ `r{�/. Y S q`..�'
3
_ Discharge or ponding Hof effluent to the surface of the ground of surface waters due to an overloaded or-dogged SAS or
cesspool,
(revised 9/15/95) y.` Z
'� CY i.5 x '.:1.��vt•.'j�
Y b.
r .ir.?"-r+ ��,�a'i R ..d�.h,` t�y` � JM,iay.::s+ vr',.". k...,..y'G.,j> ,•i.,l`i�'!" 4,'s`ix l;�.y,`r d��7�:,4 ;:..r '��n F;Ra�'y�,[�-
--,, sT z"e _.,:,..... _..__._.._.. .�: ....+�;:r' .a>z....,�„— ,... ,_..., �•.. � ra .,•. r ``'_.. �-"�-,..,,-.�,.•K :. ;.' x'B :� g� r u '"{"�>,�„"..
fy-;' .✓w ,w�.-,. . �s«a.�h.. .r,•rr'v t lo.,,.. � T s`a• Ui.` `'4z"e1''.Fi$4Yc
4 k,�_.,�_;r..i,w.. s aa_.A. , 'm. z n +ny'a`i ...sx ��. .. €s .r..s am..k uc o S. w�trt
i .
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property dress:
Owner:
Date of Inspection:
Check if the following have,been done:
±f-p-Limping information was requested of the owner, occupant, and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water,have not been introduced into the system recently or as part of this inspection.
/4As built plans have been obtained and examined Note if they are not available with N/A. -
_� ;•.:ser:..a.•�.e.�r��..nt. ,cs:vc..xz^e.+r:rm.�r_+s;..a.sc..r.rx..ma..:vsu�rroi•�x�-raas_..s..�.a -�,...es, ,..,....F x.�....a,.-a,.,. ..-. ._ ... ,s.... .�-,:.- „-.xe. <a....;�:. ..�he_faciliry or_dwelling=was inspected for signs.of.sewage back-up.
�TFe system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
arr
/`fhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods. f'
�_ he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance•of Sub-
Surface Disposal System.
a s
A'` (revised l3/15/95) '' � y�e .47.
�a "
4.
z. t +.,�" p`" { F' t at Y ? x v Gr ;1 r$c ✓*4 a e
�6 ^.e ^ 3wrre ten«,,
:"Ss' .x '.:.:.` x.�'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM I.-NFF}O-RMATION
Property Address: � X � -
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: S gallons
Number of bedrooms: 3
Number of current residents: Z'_
Garbage grinder(yes or no):=
Laundry connected to system (yes or no):�
Seasonal use (yes or no):-4—i
Water meter readings, if-available:
Last date of occupancy:S
COMMERCIAUINDUSTRIAL:
Type of establ is ment:
Design flow:_gallons/day J�
Grease trap present: (yes or
Industrial Waste Holding Tank present:
Non-sanitary waste discharged to the Title 5 system:..(ye"s'orno)_ _
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date-of-occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: '
System pumped as part of inspection: (yes or no)_
If yes, volume pumped gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
e—' Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: / -3 q �ry'Kc�ii_ 7?7
Sewage odors detected when arriving at the site: (yes or no) !�
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Sludge depth:___
Distance from top of sludge to bottom of outlet tee X-
(recommendation
Scum thickness:
Distance from top of scum to top of outlet tee or baffDistance from bottom of scum to bottom of outlet teeComments:
for pumping, condition of inlet anbaffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain) \
Dimensions:
Scum thickness:
Distance from top of scup, to top of outlet tee or baffle:
Distance from bottom ni .riim t- bottom of outlet tee or baffle:
,
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, etO
6
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: p'Z to�
Owner:
Date of Inspection: � 7
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal _FRP—other(explain)
Dimensions:
Capacity: jallons
Design flow: ¢allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of`alarm and float switches, etc.) '
i
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: =\caryover,
Comments:
(note if level and distribution i= equal, evidencidence of leakage into or out of box, etc.)
\
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
r
r 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: ( ote condition soil, sig of hydraulic failure, level of pon ing, condition of v e tion,etc.) AJi
� omQ
y
CESSPOOLS: �
(locate on site—plan)
Number and configuration: o-��
Depth-top of liquid to inlet invert: -
Depth of solids layer: 44- f
Depth of scum layer: *efl G `� d
Dimensions of cesspool!
Materials of construction:
77
Indication of groundwater: V
inflow (cesspool ust be pumped as gn of in pection)
Comments: (note condition of il, s ns of hydraulic failure, level of ponding, condition of vegetation, etc.)
!J
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Commenu: (not oid7711 n of soil, signs of hydraulic failure, level of ponding, condition of ve tit etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a z _
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
( 'tf
-t+
DEPTH TO GROUNDWATER
Depth to groundwater:../�feet
method of d9lumination or approxi tion:_ 4" -
(revised 8/15/95) ° 9
LO,C AT ION SEWAGE -PE RMIT NO..
VIL AGE �� /-p �
INSTA LLER'S NAME & ADDRESS
•9
B UYLDE R OR OWNER
DATE PERMIT ISSUED � a _r��
DATE COMPLIANCE ISSUED {
f,31
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
/�OF HEALTJH
Appliration -fur BigVviial Workti Tow5trnrtion Vrrumfit VX
Application is hereby made for a Permit to Construct ( ) or Repair ( � an Individual Sewage Disposal
System a k: 1
.........................:.. r ............. ----- - ------------------------------------------------•••-•----•---------
�' \ Location•Address Lot
... . . ...................u/N_�[_.__.• --••------•-- ----------------- -.`r/. �..•/� lr���- -- ----
Address
'j
..................•---._......
t er Address
Q Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building __- ----------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther 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_-..--_-.-_____________-.-_-_---
a Test Pit No. 1_---____-____--minutes per inch Depth of Test Pit____________________ Depth to ground water....----_-_.---._..-__-.
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water......._.__.-__._-__----
1:4 ------------------------------------------------------------------------------------------------------------------------------------------------------------
0 Description of Soil..............................•-----------------------••--......---•--•----•------------------------•--•------------------------------------------------------------
x
W
cE-E?/
V Na . e of Repairq or Alt tions—Answer when applicable._ - -� tr®
.
------------
------------------------------------------------ ---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued y the bo d f e
Signe -- - -?���-- ---------
Date
Application Approved By----••--- - ---- --- -- --- - ----�'-�1�..-..-7 7
Date
Application Disapproved for the following reasons: --•------•---------------------•----•-----•------••-•-----------------•-----------
---------------------------------------------•---------------------------•-•--------------------------------_------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
No........ ------- F i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H ElA T
............OF.. ................. ......... ....
Appliration -for Bhqpoml Workii (6tmtrurtion 1junift
Application is hereby'Made for a Permit to Construct or Rep air an Individual Sewage Disposal
Sy .
stem -N PO., jl..� , 01"M
...................... .... ................
---------------------------
............
0 1 Location-Address
... Y10. ---------- ................ ............ ......1).......................
441 1) -4
n j�
;Muasess'
..................L.
.. ............ ------.......................................................................
Wta Address
Type of Building I Size Lot-------------------------Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder
Other—Type of Building -----------------_-------- No. of persons.__P------------------------ Sho i Cafeteria
Otherfixtures ..... --------------------- ---------------------
----------
.......................!...........................
------------
",
Design Flow...........................................gallons per person per day. Total daily flow._.:_ ..................... %..........gallons.
Septic Tunk—Liquid capacity------- ---gLllog§,_,,.Length---------------- Width.------- ------- Diameter,_..-_t------------ Dj)'th................
Disposal Trench—No......__... twi&11------------------- Total Len- -------------------- Total leaching4ire1_---------_------sq. f t.
Diamet�r,,.......j4.! th below inlet.,
Seepage Pit No_____________________ -----------------�.-Total leachi fret-------------_71..s(1. it.
Other Distribution boxDosing t�i f� ,(
---------------------
-----------------------------
Percolation Test Results Performed ....... Date--_--_---_--R - ----------------
Test Pit No. 1................minutes per inch Deptf p .... . . .
�-�Tgst Pit........._ ..".-..'--- ' '-'Depth t,ogr'ound water.:...-----_-..--.-. . .
Test Pit No. 2................minutes per inch Dept B&t.,Pit--. e--------��` Depth r to ground watero.......................
� I �'I ;
........................ ------------_'U".......-------- ................... ........ .................................. ........
'-i---------- -
0 Description of Soil-------------_- ...!1.......................... *�.Z.........1,---------------------------------------------------------------------------- .........
U ............................................................................................................. ------------------------- -------------------------------------------------------
..... .... ...
Nat�w *1
U e of Repairs_gj_Llt0?'�t* ns—Answer when --- _11V;V �------ ---- ---------------
..........
. ........... ------ ---- -.............1. --------------------------------------------------------------------
4A�reement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary '�de — The undersigned'ied further agrees not to place the system in
operation until a Certificate of Compliance e ssued the bo a
S' e . .. .......... - - - ------- --------- ----------------------
igne
Date
Application Approved By
•------------
Application Disapproved for theJ611owing reasons:-------------------------------------------------------------------------..........------------n............
----------------------------------------------------------- ........................................----------------------------------------------------------
Date
f.
PermitNo.............................................. Issued................................. ......... ........
7-1 .• .. . .V
Date
THE' COMMONWEALTH,OF MASSACHUSETTS
BOARD 'OF H:EAL
OF............ . . ..... ... .. ............... ...........
Tntifirate of 0.111lujIliaurr
T 'ISI RT That!lhe Individual Sewage Disposal System constructed or.Rep9fted
by-'7 e�_. .. ............... .. . ................................................ ............................................ ........./------L........................ .
Inst
ti
has been installed in a ordanqe wi the provisions of J" r XI of The State Sanitary Code as described * th In e
------------------ d ..... ....7%........
application for,Disposal Works,Construction Permit No ....... at�d-----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A'GUARANTEE THAT THE
SYSTEM.'. ILL FUNCTIOkj SATISFACTORY.
'7_ ...................DATE......... ._/... Inspector. ..........................................
-----------
THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF,,tAEALTH
OF......
4?"T:..... .....................
...7..
.r/-_-------- FEE........................
-- -------- -- ------------- --VV*4?0k7_.4P. .....
--
...... ....... . ..
Permission is hereby gran -- -- --- -- ------------- -------------
to Construe or Repai an Individual,Sewag Disposal 10"gm
------- ..................
.. .........
40
at No.._!-.*._ --- --- ----
treet
No._------
as shown on application for Dis;pos -Works Gctnstructi�n P&�to - ---- ted-.-' 47-AP- 77
---------------------------------------
------ .....
4.
------------------ ----- -----------------Board of Health
...............................................................
DATE----------------.
FORM 1255 H0813S & WARREN, INC.. PUBLISHE RS