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HomeMy WebLinkAbout0072 CROOKED POND ROAD - Health 72 CROOKED POND HYANNIS A = 291-321 o , 0 r a 1 o ,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Volunta Assessments m �t 7d- Cl �-e G Property Address to �C Gl tr A� Cp O✓7 0 Owner Owner s Name information is q required for every A 0/f ✓ � Qd/D � / / �� a-► page. CitylI own State Zi Code 4W P Date of spect' n Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, J use only the tab 1. Inspector: key to move your cursor- not Q I _ /�� use the return (� 0 key. Name of Inspector _ Co�� k�I mpany Name Company Address —--- State fO-�6U- Zip Code Telephon umber License Number B. Certification i certify that I have personally inspected the sewage di r g 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 sm a DEP approved system inspector pursuant to Section 95.340 of Title 5(310 CM 5.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority Inspectors gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owners Name information is / required for every A,i n r j �� ad b 0/ / page. City/Town State -ZIP Code P Date of]1n ectio B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sses: 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: B) System Conditional ly Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C(004-4d Property Address Owner o H 0 o `// information is Owner's Name required for every ✓YID 0� 6 0/ JVE:�:- rtifi page. City/T6eftifta wn State Zi CodeP Date ofB. ion (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed Y ❑ ❑ PJ ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for M Vol71,ryAssessments Prope rtYAddress � J Owner b ki 0 o information is Owner's Name required for every G yf yf IF S /�� 0 a 6 0/ / page. CitylTown State Zip Code Date of spe ion B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ❑Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ L�" Discharge or ponding of effluent to the surface of the ground or surface waters e to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or.cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0;U Cr oo 4,�d / ov 0 �_ J Property Address (i Owner O h 4 O information is Owner's Name required for every �ci �-ff page. City:r own State Zip Code Date of I B. Certification (cont.) pecti Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E1/ Any 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. pp y ❑ ,I s Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ny 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 quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 200 - 10,000gpd. g 0gpd ❑ 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 flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a 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. t5ins;doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r �� —/ sVs` Property Address /'O D B Ci Owner Owner's Name information is required for every A N 41 0j 6 0 page. City/Town State Zip Code Date of i C. Checklist pection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o ❑ ping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ 0:,,. as the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 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: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts rs Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form- Not for Volu70,; Assessments 22 -I Property Address C�o� ��� �C Owner information is OwnePs Name O / required for every G y)4 t ty, page. CiT State Zip Code Date of II specti n D. System Information Description: / Ooo Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage ❑ Yes I'Jo system?(Include laundry system inspection L� information in this report.) ❑ Yes No Laundry system inspected? - ❑ Yes No Seasonal use? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: � Data-" Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9J-- C/o o ire off c� l Property Address (i Owner 0� 0a information is Owners Name /q required for every ✓J 4 f 1 page. City/Town State / Zip Code e D. System Information (cont.) Date of sp ion Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: .-Pa.°.jr Was system pumped as part of the inspection? Yes N❑ o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 o �e � /C C Property Address r,o/ Owner ;Owner's Name 0 0information is required for every Ci VJ� 9 page. rown State 7 Zip Code Date Insp ctio D: System Information (cont.) Approximate age of all components, date installed(if known) n sour e f 7rm ation: Were sewage odors detected when arriving at the site? ❑ Yes Elo Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): i below gr e: feet f construction: crete ❑ metal ❑ fiberglass ❑ polyethylene ❑ ether(explain)ain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate ❑ Yes ❑ No Dimensions: Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Asses ents M OOhTled pN�. Property Address Owner Owner's Name O kq v 0 information is required for every page. City/Town State Zi Code P Date of I pectin D. System Information (cont.) Septic Tank(cont.) !� Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle l- How were dimensions determined? _01 eli/C..a— Comments(on pumping recommendations, inlet and outlet tee or baffle condition, ructural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): U � t✓I o rr '� -P� 00 CAN t Ti o✓1, Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass 9 El polyethylene ❑ other(explain): Dimensions: ' I 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: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yt M � Property Address Owner Owner's Name O 0�/l 0 information is required for every page. City/Town State ZipCode Date of I specti n D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached:? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary As ssm nts 9d- C'/-0 0�6 Property Address Z9 Owner 2 ITt,I information is Owner's Name required for every v1 dJ lS 9- page. City/Town State Zip Code Date of i specti n D. System nformation (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ No* ❑ Yes Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Asse ents PropertY Address �� o Owner Owners Name Oki V1 O information is / required for every 1541 ki O page. CitylTown State ZipCode Date of Ins ectio D. System nforma ' cont.) Type: 6 x -1-1'r leaching pits number: � ""yW_ ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: --- --- ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _W11-�/o l C- Cesspools (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 ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address C/-o o kre cl Owner C o 0✓l 0// information is Owners Name required for every Q✓1 yj 1 t page. City/Town State Zi Code D. System Information (cont.) p Date of I pecti Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Volunta Assessments Pr M operty Address 0-00 4-, 3� c' Owner Co00oi information is Owner's Name required for every a r1 4 l S g) 6 O / page. Citylrown State �V Zip Code Date of I specti n D. System Information (cont.) Sketch Of Se a Disposal System: Provide a view of the sewage disposal system, including ties to at least permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where zUblic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately /VT A Q 3 �oV'Se 4 /AU- - 33 93— S3 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary ssessments .• Property Address ��`� C Ovt Owner 0 V7 �01/ information is Owner s Name required for every G A A ��6�/ / page. City/Town State Zi Code P Date of nspe tion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar L ❑ Shallow wells 7'/ /t/iulv Estimated depth to high ground water: feet _ ---- Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Ci Checked with local Board of Health -explain: ❑ . Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must de c be how you stablished the high ground water elevation, o W �G h t�Ct -Q✓ f I, / /J/� / 'J / V 0 194gA VIE- t (© U P7 w ,� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form -Not for Voluntary Asse sments 7c� Property Address C.�o� �/Q Owner �0 A 4 O information is Owner's Name required for every Gt✓01--f page. City/Town E. RepoState Zip Code Date of spection ompleteness Checklist Inspe ion Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed al-Sys Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BA/R�NSTABLE LOCATION 7�2 6?60 �ed � �( ��( SEWAGE VILLAGE,¢ ASSESSOR'S MAP 6 LOTZ !V., .�?Z/ INSTALLER'S NAME & PHONE NO. .I SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 2— � (size) .✓ NO. OF BEDROOMS A-- PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER � 'Tyl u�'L �(I:etv DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ✓ c � Crt t� Q cT -` `� � � � �f P c ��,_ .,�= No.. ... � Fims..... / ............ aPPRVM THE COMMONWEALTH OF MASSACHUSETTS 6ernst�ht�� BOARD OF HEALTH TOWN OF BARNSTABLE Applira tan fur Diupnittl Worlai Tunitrnr#inn ramit Application is hereby made for a Permit to Construct ( .'or Repair ( ) an Individual Sewage Disposal System at: .............. Z— Loc tion-Address 1 n (/� �/\/;��/ram C������7Jo, ........................................... .......�-!�..._C.sj.v. Se2'S_.-._)�U2t D............................. Owner 0' ,M U -----....late- ------------ - ---------------- --��-�E--- 6G.-----.--------- -------I -.1.. `!-A..... -.7._G V.Y..�...........---"'" •~ "" ...... Installer Address UType of Building Size Lot............................Sq. feet H.Y Dwelling—No. of Bedrooms.......... ........................._...Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.........................--. Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_/L!/vgallons 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. �.��_G.:sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. I----------------rninutes 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 •---•..............................•-----•-•---------------------------••••----------........_------........................................................ 0 Description of Soil-------------------------------------------------------------------------------------- ------------------------------------------------------••-•-•-•-•.............._.. x U ---------•---•----------•-•--------•----------------------•---•-•-•-•-•--•-----------------•-••---------••----------------•-----•--•-----•-------------•-•-•-•---------------------•.........•----•--•-- x ---------------------------------------------------------------------------------------------------------------------------------------------• =- - - ------------------------------ U Nature of Repairs or Alterations—Answer when pplicable... _Cf...i. f` ..... x.....- -...S_tq_.5�-b .�_______________________ --------------------------- -----..i_uc c� � �------`-�-�=�------------------.......---------------......---------------........----------------------......---------- 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 f ther grees not to place the system in operation until a Certificate of Compliance ha been issued by the board o h Signed .......... ... . - � 5..V.... Application Approved B �. PP PP Y ........._.. ...................... y Date '*-----***..... ----------*---------------------------- Application Disapproved for the following reasons: ............................................... ... . .................... ..............-- ---..... ............. ............... .................................... . --................... Dace Permit No. �` 1 .....--................ Issued .... -- Dare No..�V�....... FRs.... ���........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �.-- --.--� ;k-)n�j ITOWN OF BARNSTABLE Appliration for Divi-pusttl lVarkti Cnunutrnrtiun rrrmit Application is hereby made for a Permit to Construct ( , -)-or Repair ( ) an Individual Sewage Disposal System at: ' _ Location-Address I I I Jot_�� oU.Vn v1 ... . (� ..._... ---- Owner/ _ Ad ress pM�e ---.......-:..-._..... w � t' 1= � .. ✓uj -.....---•-=•••I- --- Installer Address PQ Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms._........3-------------------------------Expansion Attic ( ) Garbage Grinder ( ) `4 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 capa6ty.-1 Oz�galIons 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./�G ......q. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 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........................................................................................................................................................................ x V ....._..-•-•-•-•--••---••-••'•..............•••-•--------•-----•"•-•••--•--•"-'••---_._....--•--•-•-•-••--•-----------'--••--"--------•-•-------••-'•••••-•----•••-•----•----•---.._...------•------- W ----•--•--------------------•------•---•--•-•-.....------•--------------•---••---------•-----••---•-----------•---------------•------•-•-----. .................----•••......................---•- UNature of Repairs or /Alterations—Answer when japplicable._._.�_4. G_ ._.. r__,__t ..._S. .._ ^4....................... 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// grees not to place the system in operation until a Certificate of Compliance has been issued by the board o h�ea ' Signed ... .. . .-......0 ....� x� - ..................... Dace f.. A lication Approved B Via. PP PP Yt � ----- ....... - --------- Application Application Disapproved for the following reasons- --------------------- .......::: -f ..................................... - - . ............. ............................................... ...... ...... . .................................. -------------------------------------- Permit No. Issued ..... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certifiratr of Compliance THIS IS TO CERTIFY, That th 'ndiwiduafL�Sewage Disposal System constructed ( ) or Repaired ( � ) by ...---------.----------............-------*............ .-- ------ --- .. ... -� C�G .- �.....-,,,. - at .... .. ...eS............ .._(C)--- -�� described been installed in accordance with the provisions of TITLEiE��CONSTRUED The Stat�nvirondmainttal Code as in P the application for Disposal Works Construction Permit No. _.... �C _... ''.. . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... -------- Inspector' .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.--..._ FEE.:............. .. Uiipustt1 nurkii T.unutrutiun "rrntit Permission is hereby granted -C�----- v�,G.�- ------------------------------------•-------.....---------'--•---•-....•--............... J to Construct ( ) or Repair (v)-an Individual Sewage Disposal System P --_------ Street „r— as shown on the application for Disposal Works Construction Per Dated.._... --.'----34�- _._..1' .a .............................. Board of Health DATE------ f 1 -- •• I FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS 45 3qV L0CAT>ION , SEWAGE PERMIT ND. VILLAGE INSTA LLER'S NAME & ADDRESS B U I'L D E R OR OWNER DATE PERMIT ISSUED DAT E CO-MPLIA :NCE. IS-SUED �7g cam. — c_ G —{ c� \ cis I�z (1 LO CA T.10 SEWAGE PERMIT' NO. VI E LAG E INSTA LLEIll NAME 8 ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED OAT E COMPLIANCE ISSUED �� ,� o i t i Y a - � v .s � RNK 1006�1 e,X, ��� �oiv #�R� C L ►r\l`= � 4 . LOCATION SEWAGE PERMIT NO. .4 2 VILLAGE IN.STA LLER'S NAME & ADDRESS B U I'L DE R OR OWNER DATE PERMIT ISSUED 7-- DATE COMPLIANCE ISSUED fj