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HomeMy WebLinkAbout0232 PLEASANT PINES AVE - Health 232-Pleasant Pine-Avenue Centerville A=2341001 001 UPC 12534 .2-153LO ft�wr DATE 7/20/06 PROPERTY ADDRESS 232 Pleasant Pine Avenue Centerville MA 02632 _ -^ 1��Od� CC/ On the above date, the septic system at the address above was Inspected. This system consists of the following.: �. 1-1000 gaiion zept.ic tank., 2., 1-Dizta.igut-ion Box:, 3., 2-4'X8' Ieow d.i�P-�euzo2.6.1 Based on inspection, i certify the following conditions: 4., 7h.iz .ins a 7.itie Five zept.ic zyztem.l 5., Se/?tic byztem .ib in /22ope2 wo2k.ing 02dez at .the /22esent t.imeo SIGNATUR '- - - r Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 -� Centerville, Mass 02632 i Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 e f I COMMONWEALTH OF MASSACHUSETTS z ExECU'i'IVE OFFICE:OF ENVIRONMENTAL AFFAIRS .DEPARTMENT;OF ENVIRONMENTAL PROTECTION a f< : TITLE 5 OFFICIAL INSPECTION FORM--.NOT:FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: .. 232 Pleasant Pines Avenue Centerville MA 02 2 Owner's Name: Paul Karofsky Owner's Address: Same, Date of Inspection: 7/2 0/0 6 Name of Inspector: (please print) Robrt A Pao.1'ai Company Name: g. P—MacomPIe.¢ I-.Son Inc. Mailing Address: Ce zv7 7 Te, Ra6.6.-02632 Telephone Number: 5 0 87 7 7 5-;3 3 3 8 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 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.l`5:340 of Title 5(310 CMR M000). The system: XXXpasses = Conditionally Passes Needs F Evaluation by the Local Approving Authority F it Inspector's Signature: 1 Date: � ,�Zv o 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 tolhe system owner and copies sent to the 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 page 1 Page 2 of 11 OFFICIAL INSPECTION:FORM—NOT FOR•VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 232 Pleasant Pines Avenue Centerville MA 02632 Owner: Paul Karof sky Date of Inspection: 7/2 0/0 6 Inspection Summary:. Check :A,B,C,D or)E/ALWAY vompletelall of Section.D A. System Passes: qES NO I have not found any information which indicates`that-any of the failure criteria described-in 3 TO CNM 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comme ts: Se/? .ie .dyztem i,3 in paopea woaking oade/t at the /22ezent t.i.meo B. System Conditionally Passes: NO 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. NO The septic tank is metal and.aver 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 a complying septic tank.,iis 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: No 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 br replaced ND explain: NO 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 232 Pleasant. Pines Avenue Centerville MA 02632 Owner:. Paul Karof skv Date of Inspection: 7/2 0/0 6 C. Further Evaluation is Required by the Board of Health: No 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: No Cesspool or privy is within 50 feet of a surface water No . 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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: No 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. No The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. No The system has aseptic tank and.SAS and the SAS is within 50 feet of a private water supply well. No The system has a septic tank and SAS and the SAS is less than 100 feet but 5Q4eet or-more from a private water supply well". Method used to determine distance visual "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: 3 Page 4 of,l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 232 Pleasant Pines Avenue Centervilae MA 02632. Owner: Paul Xarofsk Date of Inspection: 7 2 0 0 6 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no".to.each of the followingfor all inspections: Yes No _ . X Backup of sewage into facility or.systern component due.to overloaded.or clogged SAS or cesspool X Discharge.or.ponding of effluent to the surface of the ground or.surface waters due to:an loverloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available.-volume is less than'/2.day flow X Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply,or tributary to a surface water supply. X Any portion of a cesspool or privy is within a:Zone 1.of a:public well... X Any portion of a cesspool or privy is within.50 feet of a private water supply well. <. X_ Any portion of a cesspool or privy is less than I00.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 to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forip.] No (Yes/No)The system fails.I have determined that one or moremf.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: To be considered a large:system the.system must serve a.facility.with a design flow of 1.0,000 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located'in a nitrogen sensitive area(linterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has 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. 4 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 232 Pleasant Pines Avenue CentervilIe MA 02632 Owner: Paul Karofsk Date of Inspection: 7 2 6 0 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CUR 15.203 (for example:.110 gpd x#of bedrooms)` 220 Number of current residents: u n k n own Does residence have a garbage grinder(yes or no): n o Is laundry on a separate sewage.system.(yes or no):no [if.yes separate inspection required] Laundry system inspected(yes or no): n o Seasonal use:(yes or no): a 2004=17.6, 000 .ga 2 Pons rj%[7-4 82.E 19 Water,meter readings,if available(last 2 years usage(gpd)):2 0 0 5=151, 000 ga i Q o n s r11 D=413., 7.0 Sump pump(yesorno): no S/22.inkeeIL 3y3.tem j,6 /22ersen. Last date of occupancy: unknown COMMERCIAL/IN6USTRIAL NIA Type of estab4sbment: Design flow(bas'ed on 310 CMR 15.203): gpd Basis of design'flow(seats/persons/sgft,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 NCR _— Source of information: Was system pumped as part of the inspection(yes or no): n o If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool _T 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 a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1990 Were sewage odors detected when arriving at the site(yes or no):n o 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 232 Pleasant Pines Avenue Centerville MA 02632 Owner: Paul Karofsky Date of Inspection: 7 2 0 06 BUILDING SEWER(locate on site plan) Depth below grade: 18." Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: 20 f Comments(on condition of joints,venting,evidence of leakage,etc.): ao.cntz aRReaa .tight ,No ieakagn , VDn#vr/ fhnnilrrh hmj6o r)on,t,i SEPTIC TANK:y e-30ocate on site plan)10 0 0 ga i e o n'3 Depth below grade: 12" Material of construction:Xconcrete_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: 8' 6"X5 ' 8"X4' 10" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 4 ' Scum thickness: 5" Distance from top of scum to top of outlet tee or baffler " Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: m e a 3 as ed Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): umI2 .tank evezy 2 yealtzo 7ank.3haued 9.e Ramped n e o-utZe teez ate .in R2ace., Tank .is GREASE TRAP,:NO(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlot.and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): .gaeaze bta/1 .ib not /2ae.eent 7 Page 8ofll OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r- PART C SYSTEM INFORMATION(continued) Property Address: 232 Pleasant Pines 'Avenue - Centerville MA 02632 Owner: pAy,l Karnf Gky Date of Inspection: 7/2 0_/0 6 TIGHT or HOLDING TANK: NO (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 Alarm present(yes or no): Alarm level: Alarm in working order(yes.or no): Date of last pumping: Conegts(condition of alarm and float switches,etc.): �tg t 02 ho ed.ing tank.6 aae not /?,z ent. DISTRIBUTION BOX:.y e.5 (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.): Box .i- Qevei., Kas 1 eateaa2., No .6oiid ca2a ove.¢ o2 out in 0 ox., PUMP CHAMBER: no (locate on site plan) Pumps in working order(yes or no),. Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.) PumR chamtxe2 i oI /2/1D, anf 8 Page 9 of I I OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 232 Pleasant Pines Avenue Centerville MA 02632 Owner: Paul Karofsky... Date of Inspection: 7/2 0/0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If�kS not loc ted explain why: Located .see /gage 10.E Type leaching pits,number:_ X leaching chambers,number:2 Ziow d.il� uzoaz 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.): Loamy .to med.i.um zand.i No h.i nz o a.iivae zo.iiz ate d o /2o.n .cng., Vegetaition .i-s noamaio CESSPOOLS: NO (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.): ce sb/?oo-Ph ate no.t 12aebent PRIVY:NO (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.): l a.ivu .ih not.rzaeZen 9 Page 10 of 11 ` OFFICIAL INSPECTION FORM:—NOT FOR VOLUNTARY<ASSESSMENTS / SU$SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C SYSTEM INFORMATI.ON,(continued)' Property Address: 232 Pleasant Pines Avenue Centerville ,MA 02632 Owner: Paul Karof sky Date of Inspection: 7/2 o/o 6 .SKETCH OF SEWAGE DISPOSAL SYSTEM Prbv�ide 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. 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: .232 Pleasant Pines Avenue . ' . .Centerville MA 02632 Owner: Paul Karnf sky Date of Inspection: 7 2 a I n 6 SITE EXAM . - Slope Surface water Check cellar _ Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans oh record-If checked,date of design plan reviewed: u e z Observed site(abutting property/observation hole within 150,feet of SAS) u e Checked with local Board of Health-explain:a A 0,>; 0 f r n n d n o Checkedwith local excavators,installers-(attach documentation) y e.3AccessedUSGSdatabase=explainAt;6/z.town•'aaznz.tag2e•'ma.,u�s You must describe how you established the high ground water elevation: 11,3ed Cape Cod Comm.iz.ion ldatea 7a�2e Cohtou2z And l ugiie &atea Su.ppiy GJePQ head �sotect ion aaeaz map., Sept 1995 Uatea aezouace.3 o,�eice cape cod commtzt0n 1 -Top of Ground T./ng c feet Groundwater; Feet Below Bottom of Pit High Groundwater'Ad'ustment 1.8 ft per Frim ter Method Therefore,the vertical separation distance between the bottom `T s of the leaching pit and the adjusted groundwater table is � q aD feet. 11 BARNSTABLE BOARD QF HEALTH `TOWN OF y -SUBSURFACK OVAQR DISPOSA1, SYSTPM INSPECTIQN FORM - PART D CERTIFICATION ""'"`^ `'"""""•""�`� �A� -TYPE 01 PAINt CL900- PRO.PEltTY IN,SP50TRJ7 STREET ADDRESS 232• Pleasant Pines Avenue Centerville ' 02632 ff ASSESSORS MAP, DL0,0K AND 'PARCEL OWNER's NAME Paul Kar of gkx.�_ PART. D cFIi11IFI0ATX0N NAME Robert A 'Paoli:n �OF •INSPECTOR - - COMPANY NAME b°senhR marsh COhfPANY ADDRESS I3ox '66 -C$�x .6r-Mlle M.A"'02,6�3-2-0066 Sts• i; Town-or City. 'stao. LIP COMPANY TEGRP 0 H NE t . )� 7.5 - 3338 . . FAX (' 508 ,1790 f 578 5O8 '� CERTTFICATION. STATEMENT I certify that I have persotiai'ly .i,ns-pected -.the Qewage digpo,aa�,. system at this address and that .tti:e' information reported .is true,. aaoUrate-, and w o: e omplete al of the time .a�f��inspeetion.�• The insge4t�. .,Qn as per-formed rm d and any recommendations regarding .upgrade•, .ma•intenAnce,' abd rep4.1r ,are• aon$is'tent with my training and exP.erience in thq proper futTeti-on- and maintenance of on- site sewage disposal systems. B , Check one: V-1hysteDi PAS3*D - The inspection which '.I. have conducted has .,n.at found any information . which indiesteg that- the system' fails to * adequately. protest .public Health or the envi,.ropment as defined io. .3.10 CMR. 1C30.3•, -Any feilure criteria ubt -evaluatwed' are as stated in the FAI'LURM CRITTLRIA ,see.tion e•f this form. System FAILED* ` The nspectioh which I have c6iidttdted 'has- found that *the system fails to protect the public Health And the enV4ronmemt ' in acvord•ance With Title 5 , 310 CMR 15 . 343, and as • specificali.y noted on -PART C . FAILURE CRITERIA of this insj>ect o , rm. Inspector Signature* Date Maw Vncopy of thfs aerti,f ioat•i'or must •be �rovided 'to the .9WNSR., th BUYERre appli.oablo) and the DQARD OV HEA TII, ,. * If the inspection FAxL'E.D., Wo •owner' .Qr'# operator 'a'.h4L13, . upgrnde'•the system. within one year of the dat-e of the inspection, unless. allowed Qr- regitired - ntharw{se. as Provided iri g3io CMR 16 306 . TOWN OF BARNSTABLE i.00ATION�� ems / ine3_�y�� SEWAGE #�d����. VILLAGE J/e _ ASSESSOR'S MAP & LOT 32-4e4-00 p INSTALLER'S NAME &.PHONE NO. �Ce90 3 PTIC TANK CAPACITY Q Gd Ge _ � P I.EACHIND FACILITY:(type)) (si7X)4A' C� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /©✓ DATE PERMIT ISSUED: — / 6 — Fe DATE COMPLIANCE ISSUED:_ VARIANCE GRANTED: Yeses_ h )iv 1 tv P l I 1 \. N0. Y....r�.� Fimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appl ration for Disposal Works Tonotrnrtuan 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S a�I.UU..._._.. -------: o? ....................................... c ton-Address or Lo .. er dres Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._._._._..............................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' 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 ( ) '-� Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water-------................ . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•------------------------------••---------------•----............--•--------......__..._..------.........---------...........................---•-••-•---. ODescription of Soil........................................................................................................................................................................ x �., x ----•--••------------•--•--•------•--------------------•-•----------••------•---•••--•. --------....---- ....................- ----------------- -- - V Nature of Re a' s or Alterations— when a ble__�h'1•�1 _ 1t. G,__..._.... �" 1 n�............... A reement: 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 Comphozrge has peen issued the board of health. g Il Signed 1........at........ ...... Application Approved By C- �" ���---�d Application Disapproved for the following reasons: .................................... .................... ........... --..............-------- ---------.............................---.. . ....... ------------------------------------------- ..............................JJ.�--------......-----......------- ..................---------......................................................te Q....�........-......... r................. .. �Da .. lD Permit No {�r- . ...at....... Ll /HE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH TOWN OF BARNSTABLE Apptiration for Disposal Works Toustrudion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . ----- -- ---------- ----------- L� L1 j}) �L9'c�jii AE dress � ����Ur j� _ O o `....................... /7/ JJ••---- /... -----------------r-------------•----.._..---------------------------------- � Wp ner sz r ----------- �'•� C.� �YV �}�.�. �nstall r� (✓(/��/ � �Gr(/� / r//4 �(/��ess � y/1�i rr! V b Pa (//J Type of Building Size Lot•---------------------------Sq. feet .-I Dwelling—No. of Bedrooms.............. . Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Buildingr --- No. of persons............................ Showers — Cafeteria a 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ P4 ------------------------------------------------------------------------------------------------------------------•---------------------------------------•-- x,. Description of Soil----------------------------------------------------------------------•--------------------------------- ....................................................... V ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------ W x ------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------•------------------- U Nature of Repairs or Alterations—Answer hen applicable.------_ _____ __� .__:__A_tv_._-..__ , '. -- c �. -' _...... ---------------------------- ...........-% -------------�---------- Agry-�e`ment: 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. C Signed ..�.. .... .... . ..... m . --------18 Application Approved BY :v -'--'s : G .< ./l•!ff ' l '". / Dare Application Disapproved for the following reasons- ----------------_----------------------7------------------------------------------------------------------------------------------- -------------------- -------- ............ ---------------------------------------------------------------------------------------------------------...----------------------------------------- ------------------------- -- Dare Permit No. - ---- - -........ � --/ Issued I ... ........... Dare 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cgextifirak of Tompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( by 4� ------' ..1V.-Z'- °.. __;o111---------- -------------------------------------------------------------------------------------------------------------- - -------_---_-_----- } smiler has been installed in accordance with the provisions of TITLE 5 94 The State Environmental Code as described in the application for Disposal Works Construction Permit No. --.--- _ v ' �_4�- - �.�-� PP P _ - -- dated ` ---� ----�k THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE SYSTEM WILL FUNC ,16.N,SATISFACT�ORY. DATE Insp =ior -- * -- 1 ------------------------- �.-� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE......✓�......... ��T� Disposal Works Tons#f ion rrmit Permission is hereby granted.............. ` � s '*' _ 1. � '!! T� ...................................................... to Construct ( ) or Repair ( /-)moan Individual Sewage Disposal System -- .. at No........ =r"'� ---- a ................ Street as shown on the application for Disposal Works Construction Permit N•�Z � 7 Daated......i�" Y B65, �Hea.th f-------- DATE.......-� �' r-� �'......���•-• / FORM 36306 HOBBS&WARREN.INC..PUBLISHERS