HomeMy WebLinkAbout0036 CASTLEWOOD CIRCLE - Health 36 Castlewood Circle
Hyannis. :.:P
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TOWN OF BARNSTABLE
LOCAtk)N (�?*-Rr,1�. -�/ fi e, SEWAGE #
va.,LAGE ASSESSOR'S MAP & LOT
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) J��� GJX� (size)
NO. OF BEDROOMS ys
BUILDER OR OWNER
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 LeaOn'
g Facili (If any w tlands a 'st
within 300 feet f le ) Feet
Furnishe y - i
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DATE: 9/10/02 _
------ RECEIVED
PROPERTY ADDRESS: 36 Castlewood Circle
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xyannis,Mass . SEP 2 5 2002
02601 TOWN OF BARNSTABLE
HEALTH DEPT.
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2. 1 -1000 gallon precsat leaching pit. ( 6 ' X9 ' ) MAP eZ�
inspection, PARCEL
Based on m
y p on, I certify the following condition
3 . This is a title five septic system. ( 78 Code )
4 . The septic system is in proper working order
at the present time.
5. Waste water is 60" below the invert pipe of the
leaching pit.
SIGNATUR
Name :- J .- P . -Macomber-Jr .
-- -- ------- -------
COnlp any : Jos eft Pam- Macomber & Son, Inc .
Address :
-_Qen-t-erv_ -n632-0066
Phone: 508- 775- 3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775.6412
,per
\ COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:36Castlewood Circle
Hyannis�Masq
Owner's NameMaryr Cnnn rty
Owner's Address: Sama
Date of Inspection: c)11 o jn2
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name:J.P.Macomber & Son Inc.
Mailing Address:Bnx hh
Cent-e=illa Macs n2632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
1 certify that 1 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. 1 am a DEP
approved system inspector pursuanCtooSSection 15.340 of Title 5(310 CMR 15.000). The system:
Z" Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: q"d-e),5:1-
The system inspector shall Vbmi't 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 to the buyer, if applicable, and the approving
authoriry.
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.
I
Title 5 Inspection Form 6/15/2000 page I
t� Al
Page 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 36 Castlewood Circle
Hyannis,Mass.
Owner: Mary Connerty
Date of Inspection: 9/1 0/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A ystem Passes:
6 have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.30 or I (:MKT5.3>7 zist. ny failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
*_present time.
B. System Conditionally Passes:
_A49 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.
i
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please
explain.
—A�,Q 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:
A�we Observation of sewage backup or break out or high static water level in the istribution box ue 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:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Add ress:36 Castlewood Circle
Hyannis.,Macs _
Owner:Mar)
Date of Inspection: 9 10 2
C. Further Evaluation is Required by the Board of Health:
AConditions 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
,d26 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
I
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:
,4 LO 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.
l The system has a septic tankand SAS and the SAS is within a Zone I of a public water supple.
�1Q The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
/f The system has a septic tank and SAS and the SAS is less than 10 feet,but 0 feet or more from a
private water supple well". Method used to determine distance p/�
"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:
NONE
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propem Address: 36 Castlewood Circle
Hyannis,Mass.
Owner: Mary Connerty
Date of lnspection:qi/1 olo2
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No
_ �ischaxpe
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
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 istribution box�9bove outlet invert due to an overloaded or clogged SAS or
— � cesspool
squid depth in ca&H)eel is less than 6" below invert or available volume is less than 1A day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped Q.
_ ny portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
— water supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water qualiry analysis. )Tbis 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.)
(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.
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 to large systems in addition to the criteria above)
yes no
_ _ the system is within 400 feet of a surface drinking water supply
yLhe system is within 200 feet of a tributary to a surface drinking water supply
i 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
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
ves" 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 5 of I I
OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properry Address: 36 Castlewood Circle
Hyannis,Mass.
OwneMary Connerty
Date of lospectioo: 9/1 0/02
Check if the following have been done. You must indicate yes" or"no" as to each of the following:
Yes No
mpm- information was provided by the owner, occupant, or Board of Health
— _Z' 11u'ere any of the system components pumped out in the previous two weeks ^.
_ _/Has the system received normal (lows in the previous two week period ?
_ ZHave large volumes of water been introduced to the system recently or as pan 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 ?
1/ Were all system components;Xluding 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 ?
Was the facility owner(and occupants.ifdifferent 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 noJ
d Existing information. For example, a plan at the Board of Health.
v _ Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
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Page 6 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 36 Castlewood Circle
Hyannis,Mass.
Owner: Mary Connerty
Date of Inspection: 9/1 0/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):—1 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):c V iG0 r
Number of current residents: j
Does residence have a garbage grinder(yes or no): .6
Is laundry on a separate sewage system ( es or no):.( a[if yes separate inspection required)
Laundry system inspected�)/ie--s or no S
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage(gpd))2001 —1 3, 500 gal lons=36. 99 GPD
Sump pump(yes or no):// 2002-30, 000 gallons=82. 20 GPD
Last date of occupancy:
COMMERCLALIMUSTRIAL
TNIpe of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):&4
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no)/!/o
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): .lJJ9
GENERAL INFORMATION
Pumping Records
Source of information:1 1 /2 4/9 5 Tank only
Was system pumped as part of the inspection(yes or no): -10
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
OF SYSTEM
Septic tank, fox, 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
ined from syste owner)
Iob a Tight tank _Attach a copy of the DEP approval
/0 Other(describe):
Ap r ximate a e of II comp ne date installed (if known) and source of information:
Were sewage odors detected when arriving at the site(yes or no):
I
6
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Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:36 Castlewood Circle
Hyannis�Ma�� _
Owner:MarV rnnnari-v
Date of Inspection: 9111 (T p2
BUILDING SEWER (locate on site plan)
>I
Depth below grade:
Materials of construction: cast iron A,)640 PVC zther(explain):Lite wieght 4" PVC pipe.
Distance from private water supply well or suction line:
Comments(on condition of joints, venting, evidence of leakage, etc.):
,Tni ntG appear tight No evidence_ f leakage The system—is
vented throw7h the house vents.
SEPTIC TANK: Y (locate on site plan)/OOo,,0d�0-03
�<
Depth below grade:
Material of construction: ✓concrete.[/0 metalAV fiberglass4_polyethylene
li:?!other(explain)
If tank is metal list age:lfld is age confu-med by a Certificate of Compliance (yes or no):4/D(artach a copy of
certificate)
Dimensions: '6`;rC
Sludge depth�j�
Distance from to2_2f.�ludge to bottom of outlet tee or baffle: Ae44tz-,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee pr ba e:
How-were dimensions determined: Sdf/A2
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump the septic tank every 2-T' years.Inlet & outlet tee sre in
place.The septic tank is structurally sound and shows no evidence
of leakage.Liquid level at the outlet invert is 51 " .
GREASE TRAPlocate on site plan)
Depth below grade: 414
Material of construct ion:concrete4/Am eta W,0fiberglassApolyethylenet/V other
(explain): 4114
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: 4i9
Date of last pumping: 1100
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Grease trap is not present.
7
Page 8 of I I
OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address36 Castlewood Circle
HyannisfMass _
OwnerMarW rannertW
Date of Iospectioo: 9,11 (),In?
TIGHT or HOLDING TANK4�-.r/4(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: to
Material of consrruction: ;00/9concrete tI4 metal.?),4 fiberglass de polyethylene,09 other(explain):
AM
Dimensions ,V
Capacity: A14 gallons
Desien Flow: IVA gallons/day
Alarm present (yes or no): Jx—
Alarm level: A2,j Al,ar9md in working order(yes or no): IM
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOXtk/e,(if present must be opened)(locate on site plan)
Depth of liquid level above outlet inven: _
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.):
Distribution box is not present.
PUMP CHAMBER(locate on site plan)
Pumps in working order(yes or no):LtM
Alarms in working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present.
8
(,fir f
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:36 Castlewood Circle
Hyannis,Mass.
Owner: Mary Connprty
Date of lnspection:q 11 fl j fl 2
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
1 -1000 gallon precast leaching pit. ( 6 'X9 ' )
If SAS not located explain why:
Located: See pane 10
Teaching pits. number:
xl,� leaching chambers, number: 0
leaching galleries,number: D
leaching trenches, number, length: �9
leaching fields, number, dimensions: 0
doverflow cesspool, number: C, /,
innovative/alternative system Type/name of technology: i�T�e �'$ C
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic failure
or Ponding.Soils are drv, vegetation is normal .Waste water is 60
below the invert pipe.
CESSPOOLS4& 4cesspool must be pumped as part of inspection)(locate on site plan)
N'uhiber and configuration:
Depth—top of liquid to inlet invert: r�
Depth of solids layer: AM
Depth of scum laver:
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.):
Cesspools are not present
PR VY/.&C(locate on site plan)
Materials of construction:
Dimensions: 4
Depth of solids:
'Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy i G nest' nrPSPni
9
1
Pagc 10 of I I
OFFICLAI fNSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM iNSPECTION FORM
PART C
SYSTEM fNFORNLATION (conllnvcO)
vIop(rT_� A001c11:36 Castlewood Circle
Hyannis.Mass
O�ocr: �, �, rnnncr+ v
Olio of Inlpcclioo: � Q,��12
5KITCH Of SCWACE DISPOSAL, SYSTEM
P10,10C I Itcich of Ir,1 Icw1 tc Oilpolll lyllcm including IIcI IQ
II Ic"I rwo pCrmincm rcrcrcncc IsnCmc,xi o
orncrvnvtl lo(m III -(Ili `+ilnln 10O (cc1. LQcm what pvblic wllcr Ivpply cnl<rl Inc bvilOing.
�� Gas-�1c,Nao�` C';c��•� , µy�����
wATt R
i
IO
Page I I of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem Address:36 Castlewood Circle
Hyannis,Mass_
Owner:Nary Connerty
Date of lospection: 9/1 0/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Esumated depth to groundwater 40 feet
Please indicate (check) all methods used to determine the high ground water elevation:
plp_ Obtained 6'om system design plans on record - If checked, date of design plan reviewed: NA
y_FS Observed site (abutting property/observation hole within 150 feet of SAS)
NQ_ Checked with local Board of Health-explain: NA
YES Checked with local excavators, installers- (attach doctunentation)
YES Accessed USGS database-explain: http//town_harnstable.ma. us.
You must describe how you established the high ground water elevation:
3ed: Gahrety & Miller Model. 12/16/94 . Ground water elevations above sea level
3ed: USGS: Qbservation well data.June 1992
3ed: USGS: Technical bulletin. 92-000-1 Plate #2 January 1992 Annual ranges
of around water elevations
rouna — -
t eaching 3
Pit 19 •eet
Q.,oundwater, Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom `
Of the leaching pit and the adjusted groundwater table is
feet.
11
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1 TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CER'rIFiCATION
•••�:•••r••.•:: -�.11��.�T1.r.^.1•fl:fTt TT.T.STTTTTI't�•.1 TtJ1T.1 ST'R1T-TtR.nc�.ar RTR�R'.9'T'1LT7 fRI.n'mrtmsm*rr�*r•r�.•.:r rr r--,.
-TYPE OR PRINT CLEARLY- _
PI?OPERTY INSPECTED
STREET ADDRESS 36 Castlewood Circle Hyannis,Mass . 02601
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Mary Connetty
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son incw.4'
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Town or Clty State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that tiie inrortnation reported is true , accurate , and
omplete as of the time ofeinspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one ;
,�i�System PASSED
The inspection tihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA sectio►1 of
this form ,
System FAILED* \
The inspection which I have con rcted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Signature - bo Date
one copy of this d rt.ification must be provided to the OWNER, the BUYER
Inspector
where applicable ) and the 130ARD OF )IRAL7'1(.
* If the inspection FAILED , th`e owner or*"operator shall upgrade ' the ayetem
within one ,year of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 ChIR 15 , 305 .
partd .doc
TOWN OF BARNSTABLE
LOCATION 3(p CCeS7- LU J Cif-" SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 7 "'
INSTALLER'S NAME & PHONE NO.AbeY '�r (�CC�Q10'.A4 77
SEPTIC TANK CAPACITY C'2�S( �6l-Q!� I C00
LEACHING FACILITY:(type) � (size) 65�Ce-
NO. OF BEDROOMS •PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER b&f
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No.... - F.Es..,. ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Applira#inn for DiipugFa1 Worku Tons rnr#inn f rrmt#
Application is hereby made for a Permit to Construct ( ) or Repair ( individual Sewage Disposal
System at:
Location-Address or Lot No.
.........v2a."m�.r...
�,(O�tw,n/e,T �,p,/ ,Jn/ Adder
Installer 1 Address
Type of Building Size Lot............................Sq. feet
.-� Dwelling—No. of Bedrooms...... ..............................Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—T e of Building ........... No. of persons............................ Showers
YP g ------------------------------•-••--------.P ( ) — Cafeteria ( )
Other fixtures ------------------•--- ---.-----•-•-•--------
w Design Flow..............S._*CS�....._......._--gallons per person per day. Total daily flow........._d_3Z�?...................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-------1............ Diameter.....L.tt..... Depth below inlet. ............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date........................................
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......--................
04 ..........................:............................. -------
••••--------
-------------------
___-------
....--•---------__----
0 Description of Soil.........................
x
U -•••--•••-•--•-••--•-----------••-••---•-•••-•-•------•---•---......•-•-------------------------------•---------------------------•-•---------- ------------------•---••------ _------
w
U Nature of Repairs or Alterations—Answer when applicable------ lti�- - ----� --. �--- 'r'�„-,,,,,,,,,•,,,-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Cqmplianrue has bee issued by the boar of health. ^^���`�
Signed ........... ... .. .. ...... ......... ............. -" --........."'......... ......�..0'L�-.L.�
Application Approved BY ............ ..... '
Due
----'-----"----"----................--"----"................... ......3..r:.�0.......e L
Application Disapproved for the following reasons: .................................................."----..........---'--------..............................----........."'............
.............................................................."----........----......................------....----...................---.................---..............----................................ ........................................
PermitNo. 2-2-..U......"".......... Issued ......................................................... ...
............. ..
Dace
No... :. � Fps..>. ...�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tonutrnr#iun Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( �_)_an"ndividual Sewage Disposal
System at:
p Location-Address or Lot No.--
........
Addr
aW � .. y�� l� Inswtanlele�}r
. . �.. eO ......... ............... .Address ..... �✓.:..: °/���/(
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......_..3-------.--.-•.--.-.•--.---.--.-Expansion Attic ( ) Garbage Grinder ( )
a04 Other—T e of Building No. of persons............................ Showers
YP g ---•--•-•------------------- P (..-)--- Cafeteria ( )
� Other fixtures ...................:....--------------------------•---'----------•----------------------------------------•--• ------.
W Design Flow.............. .. :.................gallons per person per day. Total daily flow.........."�Acl..................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.......I------------ Diameter.....L.D----.--. Depth below inlet..(,2............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. I................minutes per inch Depth of Test Pit---.--..........--.. Depth to ground water......--.............--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ........-.................:..................................................................................................................................
0 Description of Soil......................................................:.......................................-........................................................................
W
V .......................•--•••-•••------••-•---•--•-...._......---•--•-•--•------•---•-•--•------•-••--••---------•••••••----•-•-•--•-•-•-•----••-----...................................................
W
..--•-----•-••......---••--••----•••--. -••---•••••--•--•---•-•---•---•--•-----•----....•••-•-•-••-----•----•----------------•----•••--•---•--•--••-......•--•--------•.
x �� = �� " -" --•-••---
U Nature of Repairs or Alterations—Answer when applicable.......�-D-0--- ----••...___.___.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comphance has beep issued by the board"of health.
-Signed � c)3 .... - .............. .
I
Application Approved B� gre
ApplicationDisapprove 'for the following reasons: .......................................................................................................................................
.................. .....
\
�................................................................................................. .....................
Date
Per�it-No�............. Issued i Dace
THE COMMONWEALTH OF MASSACHUSETTS
�o
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ertifirate Df Contylia iCE
THIS IS TO C' R <IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
E �
by............ 7 pt.: V:�...... S.Z .. �'...... ----------------------------- ----------- ------- ---I——--------.........
J ...... Installer ..... .............................
at ......... � .. ........ ----..��.��'� ..... < .��:.......................��� �
.......
has been installed it accordance with the provisions of TITLE 5 oLThe State Environmental Code as described in
the application for Disposal Works Construction Permit No. .........'//..... ...... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....-` ' ...-........... �.:... ...... Inspector ..:... .. ........................................................ .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Disposal Vorks, Tunu#rnr#iun_ thmi
Permission is hereby granted ............................................`----- - -------- ---------••---•----•-.............
to Construct ( ) or Repair (�,.)_an Individual Sewage Disposal System
at No.•-----•--•............. -. ?�. � u� Q1
.............................................................
Street
as shown on the application for Disposal Works Construction Permit No d_ r .. Dated..........................................
- ¢---- .........................................-................_
)Soard of Health
DATE =._. ..."....� ......----••......--••-••...
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS