HomeMy WebLinkAbout0082 CARLOTTA AVENUE - Health 82 CAROTTA AVE, HYANNIS
A =
i
0
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTA AFC 0��®
DEPARTMENT OF ENVIRONMENTAL P ' OTECTION "x R
Inv, 01 2001 '
TOWN OF BARNST
HEALTH DEPT.
a
yev
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE lSEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601 �p� �� Lc�3
t..
Owner's Name: MICHAEL WOOD
Owner's Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Date of Inspection: 10/23/01
Name of Inspector: (please print) ,, JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P' UOX 2119 TEATICKET,MA.02536
Telephone Number: 508m%4-6813.FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is K
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 j.
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes f FJ
s..
_ Conditionally'Pa ses
_ Needs Furthe aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 10/23/01
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 1
e.
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 t#
�.
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be c
sent to the system owner and copies;�sent to the buyer,if applicable,and the approving authority. h
Notes and Comments I s
THE SYSTEM PASSES TITLE,V IN, SPECTION.RECOMMEND RAISING INSPECTIONS COVER TO LEACH FIELD �..
RECOMMEND PUMPING EVERY TWO YEARS.
****This report only describes coldi.tions at the time of inspection and under the conditions of use at that time,Thie
inspection does not address how the,system will perform in the future under the same or different conditions of use + ,� +
'X.
is
Ti11r 5 liicnf rtinn Form (/1 Sl�flfl(1
.
Page 2 of 1 I
' k
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
h.
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 ..
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND RAISING INSPECTIONS COVER TO LEACH
FIELD.RECOMMEND PUMPING EVERY TWO YEARS.
B. System Conditionally Passes:
Y;
_ 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.
n/a 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 a 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: n/a
n/a 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
disrribution-box is leveled or replaced
ND explain: n/a
n/a 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 x
{ ND explain: n/a '
f
c4¢e
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
C. ,Further Evaluation is Required by the Board of Health: k
_ 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 a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplie ,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ and soil absorption system
The system has a septic tank (SAS)and the SAS is within 100 feet of a surface water s
supply or tributary to a surface water supply. ` ..
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a 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 n/a
**This system passes if the well water analysis,perfofacility and rmed of a DEP certified laboratory,for coliform bacteria and r
volatile organic compounds indicates that the well is free from pollution provided that no other failure criteriaeare triggered.ammonia presence of opy $
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,pro
of the analysis must be attached to this form.
3. Other:
n/a
w
'N
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 CARLOTTA AV. HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
f sewage into facility or system component due to overloaded or clogged SAS or cesspool '
X Backup o g ty
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
X Required pumping more than 4 times in the last year NO due to clogged or obstructed pipe(s).Number of times
T
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or;orivy is within 100 feet of a surface water supply or tributary to a surface water supply.
ortion of a cesspool o
X Any pr privy;is within a Zone I 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 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 1,
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.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
4•�
t.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply tb 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(Interim Wellhead Protection Area—1WPA)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 systorn has failed.The owner or operator°nce with 310 CMR 15f any large system s304 ell e significant sy tern own r at a"
under Section E or failed under Section D shall upgrade the system in accord
a
should contact the appropriate regional office of the Department.
t
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 82 CARLOTTA:AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No � `:^:_ :`,
X Pumping information was provided by the owner,occupant,or Board of Health
X. Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
,;
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site?
S :
X _ Were the septic tank mahlibles uncovered,opened,and the interior of the tank inspected for the condition of the 4
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any.of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
n
. =r
1.
S
.4
Page 6 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
FLOW''CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents:3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO ,
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a 4
Design flow(based on 310 CMR`1�5.203):.n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a t
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a "
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soih'absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology,F Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
4
_Tight tank Attach a copy of the'r.DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1995 PERMIT 95-1563
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
4"-
PART C '.
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
BUILDING SEWER(locate on.site plan)
Depth below grade: 18" '
Materials of construction:_cast iron,X40 PVC other(explain): n/a
t.
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a �n
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate)
Dimensions: 150OG L 10'6" H 5' 6" W 5' 8""
Sludge depth:2" ;r,
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness:2"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED `
- j
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND "}
FUNCTIONING PROPERLY:' RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S :? :>?
USEFUL LIFE
,
GREASE TRAP:_(locate on site pla S n)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness:n/a 4 `
Distance from top of scum to top of outlet tee or baffle: n/a ...
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related A .
to outlet invert,evidence of leakage,etc.): `
n/a
i..
' F
1
it
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 2•.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction: concrete metal fiberglass_polyethylene—other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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 IS STRUCTURALLY SOUND:
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
s
d 4
F
R
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: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
INFILTRATORS leaching chambers, number: 5
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system '.
Type/name of technology: nla
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH FIELD IS FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE-SOIL PROBED
DRY.RECOMMEND RAISING INSPECTION COVER.BOTTOM AT 5'
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a `
Dimensions: n/a
Depth of solids: n/a ="
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
Page 10 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
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.
E
cell r�
Deck
C � - M
-------------
IIA -7
IBC a3
p a
6C 113
in
Page i l of I 1
A „
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS,MA 02601
Owner: MICHAEL WOOD
Date of Inspection: 10/23/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER WAS DETERMINED BY AUGER- NO WATER AT 12'
}
Gr� f
' L
e �
. ... COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
+
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
�2
Property Address: 82 CARLOTTA AV. HYANNIS MAP 248 PAR 208 L 43
Name of Owner MARY WALSHE c
Address of Owner: 9 EVERGREEN CIRCLE WESTFORD MA.01886f
Date of Inspection: 10/29/99 NO
r
Name of Inspector:(Please Print)JOHN GRACI 1999 ,p
1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: n/a p�
Mailing Address: n/a
Telephone Number: n/a
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpectlon is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Ev lu ion By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: �� Date:11/1199
The System Inspector sh I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
r
revised 9/2198 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed 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
n/a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Heath):
_ broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP.248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance llld (approximation not valid).
3) OTHER
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10129199
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 I 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 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
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(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of t 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10129/99 -
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 4 Number of bedrooms(actual):I
Total DESIGN flow: 444
Number of current residents:11
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):.J1LO
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NQ
Last date of occupancy: 911199
COMMERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: Wit
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or.no):NQ
Water meter readings.if available:n&
Last date of occupancy: n&
OTHER: (Describe)
nla
Last date of occupancy: nla
GENERAL INFORMATION
PUMPING RECORDS and source of information:
DLd
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa- gallons
Reason for pumping: nla
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nta
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1996 PERMIT#961683
Sewage odors detected when arriving at the site:(yes or no) ALO
revised 9098 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V 6
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n(a
Comments: (condition of joints,venting,evidence of leakage,etc.)
n&
SEPTIC TANK: X
(locate on site plan)
Depth below grade: X
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n(a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
n(a
Dimensions: L 10'6"H 6'7"W 6'8"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3r
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: V
Distance from bottom of scum to bottom of outlet tee or baffle: Wa
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: n(a
Scum thickness: n(a
Distance from top of scum to top of outlet tee or baffle:_n(a
Distance from bottom of scum to bottom of outlet tee or baffle nLa
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.) a
n(a
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n&
Dimensions: n/a
Capacity: nla gallons
Design flow: n(a. gallons/day
Alarm present: NO
Alarm level:jita- Alarm in working order:Yes_No_: MO
Date of previous pumping: n(a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms In working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 9/2198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number: 111/A
leaching chambers,number: 10.INFILTRATORS 5'WX8li'LX2'13
leaching galleries,number: _n/a
leaching trenches,number,length: n[a
leaching fields,number,dimensions: nLa
overflow cesspool,number: n&
Alternative system: n(a
Name of Technology: ji&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY.THE SOIL PROBED DRY,SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n&
i Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: n&
Materials of construction: n(a
Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: n(a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
�r1ClL.
Ag
Pc
�F-
o b
0
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 CARLOTTA AV.HYANNIS MAP 248 PAR 208 L 43
Owner: MARY WALSHE
Date of Inspection:10/29199
NRCS Report name: n&
Soil Type: n&
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: NAQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
I
revised 9/2/98 Page 11 of 11
TOWN OF BARNSTABLE
Srt>
LOCH"PION b r 1 `� SEWAGE # aS� l l
VILLAGE 'nS ASSESSOR'S �LO�" C L� 3
INSTALLER'S NAME&PH NO.
SEPTIC TANK CAPACITY
I LEACHING FACILITY: (type) (size)
f NO. OF BEDROOMS
lil BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
` Separation Distance Between the:
fMaximum 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
e
f�
is tj o
TIT
TOWN OF BARNSTABLE
LOCATION SEWAGE # 9C5�-
VILLiAGE fqIV141-11-i LJ ASSESSOR'S MAP & LOT-,Xyr-Xd r
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ® ,
LEACHING FACILITY: (type),1�-f 6�'e . /® (size)
NO. OF BEDROOMS
BUILDER O OR��
PERMIT DATE: —r 4/ COMPLIANCE DATE:
—
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
l Furnished by
CA
N
i
i
� 1
!\D
1 ,
• J
No. ..............................
THL".C6MMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Bi_tipwial Works Towitrurtion ramit
Application is hereby made for a Permit to Construct or Repair (b4 an Individual Sewage Disposal
System at:
....! �........4� g C_ I
..... ....... ........ ..........
............. ..................................................................................................
Location-Addrcsp or Lot No.
......... .....
.............................................................................. ................................. ......................I..A..M..............
UW7 &J-k, Address
..................... ..................... ( J ................(..... ..............
Installer Address
U Type of Building Size Lot............................Sq. feet
ooms----------- --------------------------_Expansion Attic
Dwelling—No. of Bedr Garbage Grinder ( )
P4 Other—Type of Building ............................ N6. of persons---._-.-----.-_-___--_-_._. Showers Cafeteria ( )
P4Other fixtures ------------------------------------------------------------------------------------------------ ....................................................
Design Flow......._...S_,'�-—------------_-_-----gallons per person per day. Total daily flow--------------Y_YQ...................gallons.
IYO Septic Tank—Liquid capa6ty/� ---zallons Length__/4p'�. Width---------------- Diameter................ Depth................
Disposal Trench—No- ------/------------ Width...:-��------- Total Length.....4909._./.... Total leaching area....................sq. ff.
Seepage Pit No.---__-_-_--__.-_ Diameter----------I...... -. Depth below inlet_...i;;��....... Total leaching area..................sq. f t.
Z Other Distribution box (i0 Dosing tank
Percolation Test Results Per-formed by............ ---------------------------------------- .................... Date........................................
Test Pit No. I-----------_---minutesperinch Depth of Test Pit_:.................: Depth to ground water---------------------
Test Pit No. 2................minutes per inch Depth of Test Pit--.-_-----____-_-_-. Depth to ground water........................
.............................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
U ......................................................................................................................................................................................................
............. ----------- ----------------------------------------------- ------------------------------------------------------------------------------- ...................................
__40..ix cleove—
U Nature of Re.2airs or Alterations—Answer when applicable t hJC'JAV� A-._10
I........../ --------- ......i��------------------------------- roAd-040 ---------
�IrS.1 Oa U7WJr- W4 .'
...................................... ....
Agreement: V1rAjU_'E4_ .
The undersigned agrees to install the aforedescribed li-idividual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmenta� Code—The undersigned further agrees not to place the
pli ce
-
system in operation until a Certificate of Compliance
b n issue e board of health.
Signed .............................. ------ fY
................... -------- .... ................
Application,Approved By .................. ------- --- ------------------ - ------ --------- _Z:.......................------------- ------
Application Disapproved for the following reasons: ............................................----------------------- .... ...................................
.::�(��: � -
-------------------------------
------------------------------------------------- -- ---------------_-------------------------1--------------------------
............
Permit No. _1...........:�7�---- Issued ------------- .... ............. -----------
No.- - Fm$......'20.............
THE COMMONWEALTH OF MASSACHUSETTS
.. = BOARD OF HEALTH W
TOWN OF BARNSTABLE
ApphrFativaa for DiipoiFal Work,i Tontitriirtion Vatnit
Application is hereby made for a Permit to Construct ( ) or Repair (el—) an Individual Sewage Disposal
System at:
....ES ....� � ........ -••---•--•---------•----•----•----•-•-------------••---••-•-•-----•----.....--------•------...
-------------
Location-Addres or Lot No.
�(Jd IAJ
Owner Address
�_%ttn1S77V,L/C—�aN 7(a C^�}IL `1 •ICD ✓�'? ,mil l
a -•---••---- ... • -• ----•----------- ----
Installer Address
UType of Building Size Lot............................Sq. feet
., Dwelling— No. of Bedrooms...........y-----------------------------Expansion Attic ( ) Garbage Grinder ( )
Pk
Other—Type of Building ---------------------_-.--- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ------------------------------------------------------ -----
W Design Flow...........43_�. .. ....................gallons per person per day. Total daily flow..............`J'you__-_----__.._____--gallons.
R: Septic Tank—Liquid capacitvl�__gallons Length-.ley+ _ Width---------------- Diameter.-.____-_.-._..- Depth......
W f� /
x Disposal rT\ encli:,-'Z No. ..t _ i`4�_-,-,Width-......... Total Length.___ _1.-_--- Total leaching area....................sq. ft.
3 Seepage Pit No--------:............. Diameter-----------_------ Depth below inlet___-5�!:!........ Total leaching area..................sq. ft.,
Z Other Distribution box (p() Dosing tank O//
W
Percolation Test Results Performed by_-------_------- ................................................... Date........................................
Test Pit No. I................minutes peni i Depth of Test Pit-------------------- Depth to ground.water........................
G14 Test Pit No. 2................ inutes per inch`/'-Depth-lof Tegd Pit-___l._'._1 1.ADie�th to ground water........................
_ {
ODescription of Soil........................................................................................................................................................................
---...................................... ....................... ----- ...._..------------------------------- ---------------------------------------
U Nature of Repairs or Alterations—Answer when applicable_ _ � -- �L/Lcr YJ
� ` ... J -T/ISN--a-L-
_ ... ....
` � Ii W D
Agreement: Ij3�NF•r�bl
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmentaj Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has b n issue y,t e board of health.
Signed
e AA V7�
Application.Approved By ...� C. .r.. ... .........
Application Disapproved for the following reasons: ...._... ....__......................................................................... ........................................
.� '
------------ -- --------------------------------------------------------
.. - -- -- ---'Dare
Permit No. _...�.. .....`.. ` - Issued - --------
Z
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
TOWN OF BARNSTABLE
C e rt>ifirate of Compliance
THIS IS TO CERTIFY, TTfiai the Individual Sewage Disposal System constructed ( ) or Repaired
by ........... � -O 64^j4-1-A v<. 7 v ram►
- - ...... -( ------------------- --------------------------------------------.....-...------------------------------------------
I, at .......................... .......................--... -- - - - L -- ----1 -- /------ /`----J
- -- _
has been installed in accordance with the provisions of TITLE f The St t . nvi onmental Code as described in
the application for Disposal Works Construction Permit No. _.. dated ...------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONS RU A GUARANTEE THAT THE �!
SYSTEM WILL FUNCTION SATISFACTORY. '
DATE --- ----- Insp t --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE _
No............. FEE.._.•`
? ` ..........
_ �io�roottl orko �uaiotr�rtion 11nmit
Permission is hereby granted-------------------_------- ---------------------------------- ....w�
to Construct ( ) or Repair (/Z) an Individual Sewage Disposal System
at No.. �rd�' ` ' L r1..........................3 - ��� -- --------- --
----- - ------ -----
f' Strcet
as shown on the applica 'on for Disposal Works Construction P m> No"l __ Hate ___ - �. _ � ...0
;.. . ''�---------------------- --- ------r��_:��
/ / Board of Health
DATE.__...... n�
f / `
FORM 36508 HOBS 8 WARREN-INC..PUBLISHERS
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated it y/9s- , concerning the
property located at F..)- Z A-OLL.&7 721 A-^J L , �/4fJ AJU meets all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no increase in flow and/or change in use proposed
`�• There are no variances requested or needed.
SIGNED : DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
E
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
♦ V� - i`1 Jib R - I
nq�PQ J-1
Y
000
I�
i
U'