HomeMy WebLinkAbout0003 PASTURE LANE - Health 3 Pasture Lane
Hyannis
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Commonwealth of Massachusetts`
:a=1 Title 5 Official Inispecition l=orm
,-1 Subsurface Sewage Disposal System Form.-Not for'Voluntary Assessments
3 Pasture Ln —� C
Property Address 113
Pat Williams
Owner Owner's Name
information is �Hyannis ��:, ," MA 02601 8-19-,16
required for every y
page. CitylTown >1- State Zip Code Date of Inspection
t
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. ,
A. General Information
1. Inspector: 1• " • , -: <<
Shawn Mcelr6y
Name of Inspector r
Upper Cape Septic Services .r
Company Name
P.O. Box 73 r { r 1 ,, h
Company Address.
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S139.71 -< `
Telephone Number License Number
B. Certification
` I certify that 11fave personally;inspected the•sewage disposal system at this address and that the
='information.reported'below.is true; accurate and complete is of of the,inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of,
Title 5 (310 CMR 15.000).The system:-'` `' J. -,' ' ` , '
0' Passes �,t V ;; ❑ Conditionally Passes '4 9❑ Fails
E :❑ Needs Further n b the Local Approving Authority
.. 8-19-16` t
In ector's Signature Date
The system inspector shall suljmit 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 ownershall 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•3/13 r.?"d - Title 5 Official Inspection Form:Subs6rface Sewage Disposal System•Page 1 of 1/7�-V(�
Commonwealth of Massachusetts
:a=� Title 5 Official Inspection Form
p: ':
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�F
3 Pasture Ln
t�l Property Address
Pat Williams
Owner 11r�l Owner's Name
information is required for.every Hyannis MA 02601 B-19-16
page. 41 City/Town State Zip Code Date of Inspection
B. Certification (coat.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
System is in good working order with no sign of failure.
B) System Conditionally 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposed system-Page 2 of 17
Commonwealth of Massachusetts
la Title 5 Official Inspection.,Form
I,
'I Subsurface Sewage Disposal System Form`-Not for Voluntary Assessments e ,
`�u s{!✓ 3'Pasture Ln
Property Address
Pat Williams t '
Owner Owner's Name ;
information is I
' -•
required for every Hyannis
MA 02601 8-19-16 ,
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)'
❑ Pump Chamber.pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms'are repaired. ` ' ``
M ,
B) System Conditionally Passes (cont.): }-
❑ Observation of sewage backup or breakout or•high static water level in the distribution box due
to broken or,obstructedpipe(s)*or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
. i, a€:, . . 1' •. C ..i 1. •- .,
❑ brokeit. n pipe(s) are replaced ' ' �❑ Yt ❑ N ' ❑ ND (Explain below):
« obstruction"is removed . ❑ Y , ❑ N . ❑ 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)r.Further-Evaluation is Required by the'Board of Health:..laS"
❑ 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 Lis"not functioning"in a manner which will protect public health,',*."=
safety and the environment: r, I•;� ,,
Ej 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.X
t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
�+ f Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name
information is required for every Hyannis MA 02601 8-19-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Suppl'lier, 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 an nit p g d rate 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
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts ►„ , - r+,
.a=1 Title 5 Official., Inspection"F6ft
- Subsurface Sewage Disposal System Form -Not for Vol u ntary.Assessments r
3 Pasture Ln
Property Address
Pat Williams
Owner 3
Owner's Name ,xa
information is ir;l
required for every Hyannis , MA 02601 8-19-16.'r`
page. City/Town State Zip Code Date of,Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection , ❑ Yes ® No
information in this report.) '
Laundry system+inspected? ❑ Yes ® No
Seasonal use? ,, +: ;�' t , + ❑ Yes ® No -
Water meter readings,-if available (last 2 years'usage (gpd))% ;• I
Detail:
Sump pump? f. ., ❑ Yes ® No
8-2016
Last date ofioccupancy:.- k �, .- :, ,,,. Date
Date
Commercial/Industrial Flow Conditions: , ice.
a Y
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gauons per day(gpd)'
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding.tank present? k + El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system?.� �- ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Ins ectlon Form:Subsurface Sewage Disposal System•Page 7 of 17 -
P 9 Y 9
Commonwealth of Massachusetts
la=i Title 5 Official Inspection Form
a' 'N Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name
information is required for every Hyannis MA 02601 8-19-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner--within last year
Was system pumped as,part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
I
Commonwealth of Massachusetts r%,_
�Z Title 5 Official 10ispectio Form!
:-W-I Subsurface Sewage Disposal System form -Not for Voluntary Assessments , >;
3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name :, '
information is
required for every Hyannis, ;a' „ MA w 02601 8-19-16f:- a
page. Cltyrrown ,' y „.3 State Zip Code Date of Inspection
D. System Information (cont.), .,�; -;• _ a , ^, ti
Approximate age of all components, date installed (if known) and-source of information:
1984 �r
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):,-, i
- 2011
Depth below grade: . ;,j � ^�.t ,.a.r,cf. -
. feet
Material of construction:
El cast iron ''' ®'40 PVC Mri • ❑}other(explain): r`
t `y 3�',r t. '�5 ts'4,•L;. p y. . .. a, r •�� - .
Distance from private water supply well or suction line:' feet
a
Comments (on condition of joints, venting, evidence of leakage, etc.): .
Good condition.
Septic Tank(locate on site plan):
1411
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass r ❑;polyethylene ❑ other(explain)
If tank is.metal- list age: ,,,,
years
Is age confirmed by a Certificate.of,Compliance?=(attach,a copy;of,,certificate) . ❑ Yes ❑ No
Dimensions: ,,..... • § 'fr 1000 gal
1211
Sludge depth:_ -
t5ins-3/13 * + Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
lai Title 5 Official Inspection Form
1 ��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3 Pasture Ln
t l
Property Address
Pat Williams
Owner Owner's Name
information is required for every Hyannis MA 02601 8-19-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspecti6n- foft
�01 Subsurface Sewage Disposal System Form Not for,Voluntary Assessments
a
3 Pasture Ln
Property Address
Pat Williams t.
Owner Owner's Name
information is c
required for every Hyannis MA 02601
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,_ a ; . f* ,. : ,, 5
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 ❑fberglass ❑ polyethylene ❑ other(explain):
Dimensions: :
{ Capacity: ,
gallons
+ Design Flow.- .�. �.' aar?'v ,�� t� t` ':� gallons per day ,
Alarm present: - ❑ -Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ .No
Date of last pumping: y Date
- Comments (condition of,alarm and.float switches,.etc.): -
a .. ... . . 4 - +! " - - ➢ is * • ..
*Attach copy of current pumping contract (required). Is copy attached?' ❑ Yes ❑ No.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
a} t( Title 5 Official Inspection Form
! 1If1
' .�If;.} Subsurface Sewage Disposal System Form Not for Voluntary Assessments
_J}! 3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name
information is required for every Hyannis MA 02601 8-19-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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: ❑ Yes ❑ No*
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts _r rf ;
;4 Title 5 Official Inspection form -
r'I Subsurface Sewage Disposal System Form-Not,for Voluntary Assessments
3 Pasture Ln ,
Property Address
Pat Williams
Owner Owner's Name
information is
required for every Hyannis , = MA 02601 8-19-16 :-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers - number:
❑ leaching galleries number:
T❑ - leaching trenches number, length:
❑ leaching fields numberi dimensions: ". ~
❑ overflow cesspool number:
❑ innovative/alternative system •,
Type/name of technology:
t: •� '.Comments (note condition'of soil;signs.of-hydraulic,failure;aevel of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good working.order and holding 24''of water with stain line at 30" below inlet invert.
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•.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of17
Commonwealth of Massachusetts
:a+ Title 5 Official Inspection Form
- I Subsurrace Sewage Disposal System Form -Not for Voluntary Assessments
3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name
information is required for every Hyannis MA 02601 8-19-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5in 1 s 3/3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17
Commonwealth of Massachusetts
1a=1 Title 5 Official Inspection,dorm u
! Subsurface Sewage Disposal System Form:-Not for,Voluntary Assessments° ,
3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name a
information is
required for every Hyannis t i r 'MA 02601 8-19-16, .:r
page. City/Town State , : Zip Code Date of Inspection
D. System Information (cont.),
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately -
• r ., t4�• ,• s
t a f All, r ,
, i:q 111
• i a
° ,4 .y 'i tit ,,� .`•, '"YC..f t, � i ..+�t. .r_ ". .�•,� o d•t � .• - a'
t5ins•3/13 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
R' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3 Pasture Ln
Property Address
Pat Williams
Owner Owner's Name
information is required for every Hyannis MA 02601 8-19-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'
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)
® Checked with local Board of Health - explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
a=1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�Y
3 Pasture Ln
Property Address .
Pat Williams
}
Owner Owner's Name_
information is required for every Hyannis MA 02601. 8-19-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, b, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high-groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
f
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
CERTIFICATE OF -ANALYSIS
Page: 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 7/16/2008
Pat Williams Order No.: G0847535
3 Pasture Lane
Hyannis, MA 02601
Laboratory ID#: 084/5J5-01 Description: Water-Drinking Water
Sample#: Sampling Location: 3 Pasture Ln.Hyannis,MA Collected: 7/3/2008
Collected by: P.Williams Received: 7/3/2008
1
Routine
ITEM RESULT UNITS RL MCL Method# Tested
Nitrate as N`Titregen 3.8 mg/L 0.10 10 EPA 300.0 7/3/2008
Copper ND mg/L 0.10 1.3 SM 311113 7/3/2009
Iron ND mgiL 0.i 3 SLM3111? "3;20CS
i
Sodium 16 mglL 1.0 20 SM 311113 7/3/2008
Total Coliform 0 CFU/100mL 0 0 MF-SM922213 7/3/2008
Conductance 220
umohs/cm 2.0 EPA 120.1 7/3/2008
pH 7.5 pH-units. 0 SM 4500 H-B 7/3/2008
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By:
( Director)
. N
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<r N
N y
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N M
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ND=Mene Detected RL = Reporting Limit MCL=Max;rnum C k,ntaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
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L0CAT10N SEWAGE PERMIT NO.
VILLAGE
Vj IR
INSTALLER'S NAIVE A ADDRESS
�• �- '��:Sca 11
0 U I L D E R (OR OWNER
DATE PERMIT ISSUED Ll L qq
DATE C 0 M P L I A N C E ISSUED s�� .
�I
(N '��
FEs.._..... ............
.:'..
f THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
6 ..--` ..OF:........... .............................
Xpli iration for Uiopoiittl Workri Tontrttrtion Prrutit
Application ' h eby made for a Per 't t Construct ( or Repair ( ) an Individual Sewage Disposal
System at: � �
........... . ................ . ......-__ -_ -........................ ................... 1 ......_..
L io - ddr s ! Lot No.
�11 �i., .....-------•.......... ................... �A e..... 0 -. ...._ ...
`�r Addre
a ,. .... _..... G� .._,_.. `
- ._....._
Installer Address 137,61
�� /
d Type of Building Size Lot....F/ ....Sq. feet
U Dwelling—No. of Bedrooms..............________._.__.__._...__Expansion Attic ( Garbage Grinder
j
aOther—Type of Building _._.._t l T/ __.. No. of persons_________ ______________ Showers (� — Cafeteria ( )
dOther fixtures. --------- ----•--...---•-----•................•-•--------------------------••---...-----•-•--------.....__..._............_.....
W Design Flow............ ................ _gallons per person per day. Total
W
da flow._._._...____ ................gallons.
ank—Liquid ca acitv._/ffkM/gallons . iameter________________ DeSe tic T pth.._ .......
x Disposal Trench—No. idth.................... Total Length.................... Total leaching area._.-Q6.6_.___sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.- tA'k% �,� .. ...... ... Date. �i �/.t
Test Pit No. 1_�aL.._.minutes per inch Depth of es Pit______1_�_._-.___ Depth to ground water_._._. l9/1_�_.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -------------------------------------------t ----,
..................................................................
W
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
-------...-•--•-_...••••••••••••-•----••••••-••-•••-••••-••••-•••-•-••••••••-•-•••••._...•••.........•••.......•••-•••-•-••-••...••-••••-•-••-•••••--•••••••-•-•-••••-_.._.._-•-•-•......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code-- The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee4— ,.O(A
ed by the board of health.
Signed. - ,� .. . .••. . ,1. .......
,�iz Date
ApplicationApproved By-•-•-------•------------•..................:.....•----••�-•-•--•••••MJ-•••••...........--• ........................................
Date
Application Disapproved for the following reasons:.................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo........................................................ .------•---........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA
----.....rlr� OF............... � t........?. ..
Appliraation for Disposal Works Tonstrnrtion 1hrutit
Application is her by made for a Permit o Construct ( Ll or Repair ( ) an Individual Sewage Disposal
System`att
............ J• ................ .... ::... .. (J --.................... ...................... ._._...��. ...-•--••------................_.......--•---.
Locations Address 1 r t No.n
-------•---- v; !`? ....�...i_:......°?::.. ..,...._._..-•-•--•..... .............•-----ft ��`) k���;:. f' ....j!.N;/ 1 ...... ...._....
Ow r Address
w ..................................... ..............................a -,a. _!� .. ........
Installer Address // C/
d Type of Building Size Lot....l_ �L?�....Sq. feet
U Dwelling—No. of Bedrooms______________ ....................Expansion Attic ( Garbage Grinder W o
Other—T e of Building
a —Type g ____._l�3..'7/''i ___ No. of persons__________ _____________ Showers (, — Cafeteria ( )
PAOther fixtuurre�s ---------41a�•�......................................................................................................................
W Design Flow............. 5--— per person pe>;day. Total dail f jow..__._.______ 5 ...............gallo�.
WSeptic Tank—Liquid capacity_/ Gallons Length_,+4..__.._._ Width____..,___. Diameter................ Depth_______..:-
x Disposal Trench—No. ____________________ Total Length.................... Total leaching area...cl?66....sq. ft.
Seepage Pit No____________ ______ Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ���� Date_____ _.Percolation Test Results Performed b �_____ �!_ ' ,�3--
Test Pit No. l._4v_4%_.mmutes per inch Depth of est Pit._._.:1_±�_.`0___ Depth to ground water.......... (!✓t_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---••---...........--•----- --• ---- ...- ---•-•---•-•--•--•••------•..................•••......--•......••-••-_--•--
O Description of Soil.._.____0"` / ___._____ ' .. Q x __
w
•- --- --- «--------------------------------•--------•-------------------
U Nature of Repairs or Alterations—Answer when applicable.............................................................................................
___
-----•-----•--•---•---•-.._-•--------------------------------•------------------•---•-•.....-------•-•-------••-•-•••----•----•-•••-----•---••----•----•--•--•---._....••-•-------------.......------•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of health
Signed r ...._ _... _ _._ f _ -J'
��
• - � 'Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons----------------•-------••--•-•---•--•---...------------------•----------------••-----------------------•-------
•---•--•••--••-------•-•-••--••-•----------•--------••-----------•--•-•-•---•---••-••------------•--...•-•-•-----------------•••--•••--•--•-----•---•--•---••---•••-•--- •--•--------•--------••..._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF................ ...............................
Trrtifiraatr of Tomphaanrr
THIS IS TO CERTI Y� That the ndividual Sewage Disposal System constructed /) orRepaired ( )
by------------------------------------- ............... .. ... ............................................-.....-• ----•-•----.....------•--....-•-------
nst er e
at .....1 t�•-.°_#.__c�-•�--•------ ---- �}. --.. lr -----Z�----- -14 �-��..'•=••••--•----------••-----...---•-•-------------
has been installed in accordance wl" e p sions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANC�/E OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® 0 A GUARANTEE THAT THE
SYSTEM W L F CTION SATISFACTORY.
DATE_:S..2 .-- •--•••---•--------•-------------•-•......._-------......---_. Inspector•-••- -•-= •-•-•-•-•------•••------------------•-••--•--•--•-•....-•-------.....--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ...; ...OF.......... a %- errs
FEE..... _.....trr
Disposal Works Tong ion prrmit
Permission is h by granted -T"-'� ' ----• ............
to Construct ( o Re i ) an ndir Se ag�e,,Drispo al S stem
at No �''�"---l------- 6 - -----_----
DatedF Street
as shown on the ppli tion or Di$ sal'Works Construction Permit No"- _._.__._. -
t
io
...................... --- ................................
oard�6`f ea
DATE-- -•�----•�--��..•.-----...--••--------------------•---------------- i/✓l
FORM 1255 A. M. SULKIN, INC., BOSTON
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CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION Ox0Atos
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EXISTING . CONTOUR ---- p �u �4;
FINISHED SPOT ELEVATION [Q ��, a1 G'I�� gh a4�i P ►�
FIIdI SHED CONTOUR 0 S {
4 IN !
APPROVED BOARD OF HEALTH _L � � + ,
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DATE AGENT 43, SCALES 1 "— .4D � DATES 13 k3
LOREDGE ENGINEERING CQ /AfG CLIENT g ;? I CERTIFY THAT THE PROPOSED I
LENG
GISTER.E REGISTERED =xY, o BUILDING ' SHOWN ON THIS PLAN
JOS.NO. _....
CIVIL
LAND : CONFORMS TO THE ZONING LAWS
INEER RVE DR.BY� �J OF BARNSTABLE MASS
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T12 MAIN STREET, CM. B E''
H YA N N i S,. MASS. SHEET.L:.`pF':2 A E - . REG. LAND SURVEYOR ' '
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