HomeMy WebLinkAbout0010 REGATTA DRIVE - Health 10 REGATTA DRIVE, HYANNIS
A=252-051 LOT 30/30A
't
Commonwealth of Massachusetts
Title 5 O iCial Inspection Fora
Subsurface Sewage Disposal SyMem Form. Not for Voluntary Asses.c;ments C
/p
Property Address --._..-�---
ON ner
Owner's Name 1
information is C / /JQ4 �jg L19
requ�edfor every _
page. Cdyfiown M � State M Zip Code Date 6f Inspec ion
Inspection results muUe submitted on this form. Inspection forms may not be al
way. Please see completeness checklist at the end of the form. y tared in any
f ffmg out forms
Wh
Bing en
A. General Information
out mms �7�
on the computer, lL 7
use only thetab 1 Inspector.
key to move your
cursor- not
use the return -- lyq
key. Name of Inspects
/0 o i�Gib
Company Name
Company Address
J-- /�,4
El1y/Town �o� C�Sc�,2/q/ o State qoy� Zip Code
Telephone mbar" License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 R 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/6L
hs is Signature pate
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER 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.
t5ns•3113 Title 5 official Inspection Form Subsurface sewage Disposal S)mm•Page 1 of 17
f
Commonweam of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage. Di46ial System Form -Not for Voluntary Assessments
�e In �✓
R oPerty Address
Owner's Name D°
Owner
mforrr>ation is �required for every _ / e ms�/
,f&-I (0 3� 6 a oZ
page. CALYi town
State Zip Code Date
�. certification (cor t.) of in pection
Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D
A) Syste Passes:
I lrf. 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 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 ex0ain.
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 t#.at the tank is le
ss than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
f5re-3113
Title 50fficial l spectim Form subsurface 5eviage Disposal system.Page 2 of 17
a.
Commonwealth of Massachusetts
L Tide 5 official Inspection Form
Subsurface Sewage Disposal System Form .Not for Voluntary Assessments
Property Address
ON ner
information is Q"ner's Name
required forevery _ eo Jp,✓Ll1`/.e AYA Qa 6 3� �p a a f�
page. G1tylrown State Zip Code i7at of Ins tion
B. Certification (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 ❑ 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) 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 mannerwhich 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
t5ris 3M3 Title50fficialImpection Form SubsWace Sewage Disposal System•Page 3of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
0-v ner 0001,L1
information is �"ner's Name /
required for every CeH ✓Y/` oa G
page. tzynown State Zip Code Date ins tion
B. Certification (coat.)
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.
ur
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 or clogged SAS or cesspool
Liquid depth in cesspool is less than 60 below invert or available volume is less,
than%day I ow
15B 3/73 Title6officialispeation Form SubsurfaceSevege Disposal System•fte4of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Or-
Property Address /
Owner 00(2
informations Owner's Name // /�
requ'vedforevery �r► t�i l�l-C. / '� 0�(0 3� as /
page. City/Town State Zip Code Date of ins pec' n
B. certification (cunt.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ L'7 '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.
❑ C�/ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any 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.]
❑ he system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails I have determined that one or more of the above failure
criteria exist as described in 310 CM 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 ibliowing, 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.
tans-3113 Title 5 Official Inspection F orm SuusWace Savigle Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo/rm/ -Not for Voluntary Assessments
l7�, oCJr
Property Address l D 4 aI
Owner
QN oar's Name
information is
required for every d Zo3,�
page. G1ty/Town State Zip Code Date Inspection
C. checklist --
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes
❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
u U s 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 WA)
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?
Ly' U 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:
2
Number of bedrooms (design): Number of bedrooms (actual):
. 3 -
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
10)01rI + &/'will -- (oG ;:iA Ile
c�
t9m-3H3 Title50rfidd InspedonFam Sub%Oace SewageDisposd s"m•Page6of17
F(ool, P-1 A 0
0r ` q5Z
Commonwealth of Massachusetts
j Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form -Not for Voluntary Assessments
/0 /ZSa-kl^ Or
Property Address
ON ner
rm
infoation is Ow nees Name
required for every Ile-
page. City/Town State Zip Code Date o spec' n
D. System Information
Description: / /000
/S4rt y �O
Number of current residents: /
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes o
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? 2 Yes o No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: C(.-
Date
Commerciallindusbial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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:
Mrs-3M3 Tivesofficiaflns tionFormSubsurfaoeSe pec wage Disposal Sfslem•Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/o 2e5 .y/�v�
Property Address c,.Doo le
ON ner Ow ner's Nameinfo required for every �e✓� (�6/`G � '/�/
114
page. C FRown State Zip Code Date f Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: (,j7
Was system pumped as part of the inspection? ❑ Yes No
If yes, %ol ume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of Sy
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/Altemative 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 VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ris^3113 We5 Official Inspection FormSubsuface Savage Disposal Systsm•Page 8Of17 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address / /2e� a 41e, �—
Ow ner 00le
information is Owner's Name
required for every Glut�e✓//y Ile /"//1-
page. W/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if nown) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of constructi;-40
❑ cast iron 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):
Depth below grade: /
feet
Material construction:
concrete ❑ metal ❑ fiberglass ❑ 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: Y Y
Sludge depth:
t9n4.3M 3
Title50ffidal IrepeefimFartrt Subsrrfaee SexageDispasal Stem•Page 9of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
Ow ner 0 e
information is Owner'sName
required for every C2v� ✓✓`�i /" /-I �o��i�oZ G �d� ��7
page' CFRown State Zip Code Date dt Inspection
D. System Information (corn.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
si
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? q �� 4,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
a1A►M l h iI7 �-�G PiC
Oki �v A nS ✓► ,.mac'
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
Sm.•3M3 Me50ffidal Inspection Form suuwaace Sewage Disposal system•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
A0
Property Address
Cw ner Cw ner's Name ,(le
information is C' - !l required for every e"r ✓`� C J
page. Cdy/Town State Zip Code hate of In moon
D. System Information (coat.)
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 worldng 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
GSM•3M3 Tille50ffidal Inspectim Form SuWrface Sewage Disposal syslam-Page 11 of 17
i'
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
information is
00 I?
nf ON ner's Name
/ �2✓ `� �� �a6 3� a� l� __
required for every 2� y�
page. Q'ty/I own State Zip Code Date of4rispection
D. System Information (cunt.)
Distribution Box (f present must be opened)(locate on site plan): L
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.):
,/r/o
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•3113 Titlesofficial inspeafion Form Subeuface Sewage Disposal Sptem•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
77-45 z2-
QN ner 00��17
infomlations a^'ner's Name
re4Qedfor every
- ��Mv�Te
page. CSty/Town State Z— Code
Date Inspection
U. SyStem Information (cont.)
/' `Type: � / �'✓� r�� �O
/ C� > !o vcQ
leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovativetaltemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
/
O D H�i✓� f ,.� Z<vie
l01/`1 `j o 0✓`7� �
07'e" 47 44,,, 7<�
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
19ns•3H3
TifieSDFficial Inspection Form SubsWace Sewage Disposal System Page 13of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address - � ---- �
Cw ner 20, /e
information is O,a ne's Name l
required
page-
Gl�ty/ C2in-!e✓���� A 7j
page. Town State Zip Code Date of Ins �
®. System Information (cont.} pection
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.):
tSns•W 3
Title50fficial ImpecfimForm Subsurface Sewage Disposal System*Page U of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Ow ner O0 �
infommtion is Ow ner's Kfarre� / /
required for every
_ .eve Vd f�(/ (o oZo2'
Page- Cny/Town State 56 Code Date of hispection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
Mere water supply enters the building. Check one of the boxes below:
A�pc
etch in the area below
❑ drawing attached separately
-e 4c, 101-1 VC
Ir
f Bye.
P n e°�' f U p
Q (�
3
/��� �o✓F✓ a Wahl✓
142
J--e-A0, 63
f5ins Y13 nue5 Official lnspecticnFarrrc Subswface Sewage Disposal Sysmm-Page 15of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fornn -Not for Voluntary Assessments
Property Address
Owner Owner's Flame Ole
information is
requ'vedfor every
_
C ylfown State Zta Code ;Date:o�f�
D. System Information (coat.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
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
❑ erved site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
le
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must descn a how you tablished the high ground water elevation:
G h�Gu � �a L417
do A V"In o Y ��- 9 Ina /v , Cal
4S 4 C� 0
llvoklF bi4 :::Yo I-'I
Be#ore filing this Inspection Report, please see Report Completeness Checklist on next page.
L4ns•313 Title50mcial lnspwtonFart[SubsvfaceSewageDisposal S)MM•Page 16of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal stern Form-
SY Not for Voluntary Assessments
Roperty Address
/O g ✓r�_
Ow nor �OO
Owner's
hfomnation is Name
requkedforevay Bv►�g✓ri �j� /��} oa 3�? �; a��l G
page. %omp 1 W n She !p Cade Oate'of k�spection
E. �Report Completeness Checklist
0 Nspection Summary:A, g, C, D, or E checked
B b pection Summary D(System Failure Criteria Applicable to All Systems)completed
L7 S em Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page IS or attached in separate file
tem .M3 TM50f8cug trspecoMFoms sumwace sevmeois-d symm•Page v d a
VGG
cc���
No.._./.t:j. 4ft3 Fims..........hs..Y.a......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apptiration fnr Di-ripen i War1w Cnomitrurtivit Permit
Application is hereby made for a Permit to Construct ( v) or Repair ( ) an Individual Sewage Disposal
System at
......./0 /12� _5030 4)
o tion )Aress 1 r Lot No
Address
...........
Installer Address
Type of Building Size Lot-AL/ 7....__Sq. feet
�-, Dwelling—No. of Bedrooms.......3----•-------__-_ -------.--Expansion Attic ( ) Garbage Grinder ( )
a g�0-U.Tf- '... No. of persons............................ Showers ( ) Cafeteria ( )
Other—Type of Buildin .._
dOther fixture 6<-----------------------------------------------------------j------------------.-----•-----*---------
W Design Flow.......................r...17.............gallons per perset3 per day. Total daily flow...........�...0........................gallons.
WSeptic Tank—Liquid capacity-LG:.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing ink ) �j�
Percolation Test Results Per b 4. __ .. .. _.(_.__ --......................... Date_____ _^3��y S__..___._
Y
Test Pit No. 1.... --minutes per inch Depth of Test Pit.................... Depth to ground water_�G'�4'..._....
�L4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil.....rLa.__ ._.
x
V ....._..•-------•-•----•--••---•••--•.....-••---•-•----•--••------•-•-•...............................•--•---------•----------------------•----•
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 TITLE 5- of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com h�. issued by e board of health.
Signed ...'.. ...... ............. .... .............................. ...o.., ��.(�....
Application Approved By ............... ....0_4ts"`�...................................................................... .. 3...= .
Application Disapproved for the following reasons: ........................................................................................................................................
.......................................
Da
Permit No. ......... ................ Issued ........ .....3.......
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certif ra e of Compliance
THIS IS 0 CERTIFY, What then-1 di id al Sewage Disposal System constructed ( V/) or Repaired ( )
by ..... �-�--{;,'. .:.: �.................. ..........0......... ..-.....swiler......... ................................. .............................................-.... .................
�7 � j 3 U/`r y' •�'G l� �t �1.......... '!.. wvu✓)..... .........................................................................
at ........-C,�(y:........:�.... .................................
.�............(�........ ...1
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the.application for Disposal Works Construction Permit No. ...-.L...`....... :..3,......... dated ......... .. L:. ;...:: .� ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................... ...................... Ins ector y _.............. .. � :........................ ...........................
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CATION/19 ef,6PP-M- _ SEWAGE # �3
VILLAGE "r— ASSESSOR'S MAP & O
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY A000
LEACHING FACILITY: (type) �/ >` (size)
NO.OF BEDROOMS -73
BUILDER OR OWNER ���/.C��
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leacbing facility) Feet
Furnished by— )9-
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Uhaipoittl Work,5 Tonitrnrtion ramit
Application is hereby made for a Permit to Construct ( L'�or Repair ( ) an Individual Sewage Disposal
System at:
"..'►. ...-•-"'---L-0 lion-i d ress
- -----•-•- --•----•-- --------•------- •-•----- -'--- - ---- -•----•--- --or Lot No.
---------•...........................••---
Owner Address
Installer Address
UType of Building Size Lot-_--.' ........Sq. feet
Dwelling— No. of Bedrooms.---- 3--------------- ---------------Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building UM2( 'f-4404.. No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
g 1417 _gallons per peeseeri per day. Total daily flow.........3M........................gallons.
w Design Flow----------------------- ---- ------------
WSeptic Tank—Liquid capacity./O."--gal Ions Length________________ Width---------------- Diameter----..-._..-_--- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------_..._------ Diameter-------------------- Depth below inlet.................... Total leaching area.........._.......sq. ft.
z Other Distribution box ( ) Dosing nk )
'~ Percolation Test Results Performed by... --------•----•--•------- ----•--•-•----
�' Date---------------•--------
,.1 Test Pit No. I.... --minutes per inch Depth of Test Pit______ ____________ Depth to ground water_w .......
44 Test Pit No. 2................minutes per inch Depth of Test Pit.-.-_----._--___-_ - Depth to ground water........................
a -- ------------------ -----
0 Description of Soil..... _
- -
x
U •-•••----------•--•----•--••-------•-••-••••---••--••••--------•---•--•----•------••--•--------•--•---•---••----•-------•-••-------•-----•-•.....•------••----------•-•-•----•--•....................•--
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 TITLE 5 of the State Environmental Code--The undersigned further agrees not to place the
system in operation until a Certificate of Compl�aa has b iss\d by e board of health.
Signed -..:;
_...... .... ............................ �� ��
Application.Approved By ----------. � .......... .._.............----------------------------- ....
Dace
Application Disapproved for the following reatonf- -------------------- ------------------------------------------------- ---------------------------------------------------------
Date
Permit No. ---------fir .....""f,L3.................... Issued ............... . ... ._q --
Date
f>, 37
- t
No... ,.....» ---�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN,OF BARNSTABLE
Applirtttiuii for Bi-nVw3al Works C outitrnrtiun Famit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at: A
oc tion-., ddress or Lot No.
,r l owner Address
---------------------------
Installer Address
d Type of Building _ Size Lot..�..! ........Sq. feet
U Dwelling—No. of Bedrooms.__._. 3------------------------------- _-Expansion Attic ( ) Garbage Grinder ( )
IITI_R.f-d_C�._ No. of ersons____________________________ Showers —
p., Other—Type of Building U1 ._. ... p � � ( ) Cafeteria ( )
44 Other fixtures ...................------._-__ .
W Design Flow.......................I�1�-------------gallons per pers,&k per day. Total daily flow..-------a3O........................gallons.
WSeptic Tank—Liquid capanity_/_07P_gallons Length---------------- Width---------------- Diameter---.------------ Depth.............. l
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area_._:U,.............sq. ft.
z Other Distribution box ( ) Dosing t nk )
Percolation Test Results Performed b t __________--------------------------------
Date....-__________:;__.____._____.._____..
Test Pit \o. I___,3_-__ _..minutes per inch Depth of Test Pit____________________ Depth to ground water-..__._...._-_-__.__....
Gi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.(—::..__.__._.....
DDescription of Soil ---1[K-f..............................................................------•--------................................................
x
W
Z. •--------------------------------------------------------------- ------------------------------------------------------------------------------------------------------•-----------------...--.--------
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compih.&Flc has b e issued by the board of health.
Signed 1
Application.Approved By ............... .... ^�...
---........-__-------------------------------------------- ----. ... .._
Date
Application Disapproved for the following 7earonr: ------------........................----------------
----------------------------------------------------------------------------------
•4 {
................................................................................................................................................................................................................ _....`...................................
I Date
Permit No. ........ j >
Az2-- ---------------- Issued .-------------- ? cl...�-.........
•' Date o J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of CIImplianre
THIS:IS 0 CERTIFY, hat thef divid al Sewage Disposal System constructed ( �/ ) or Repaired ( )
Y
Insr.Jlcr
at ...� . Uf 3 U�`}...... .-- X-C-O
_l j<1�f1�,.,........._.j....._Am... ----------------_------------------------------_------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..._7,5 -.��Cj ......... dated ....... .�I'..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ .... - V ' 1.;.�---- .._.... -........... Inspector ..._.... 0. .- _..... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.......g.�..`.. � FEE.........
rn� urk� �u �trV
Verutit
Permtsston t hereby granted =
to Construct (Y) or Repair ( ) an Individ_al Sewage Dispo�s�1 System
at No.- / ?���-!9----._./ C�� G.... . -
7 S0eet
as shown on the application for Disposal Works Construction Permit No----------_-------- Dated...........................................
--•-----•- --------------
•------------------------------------------------------------------------
Board of Health
DATE--------------------------------•-----------•--------------------------------•--
FORM 36508 HOBBS R WARREN.INC.,PUBLISHERS
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TOWN BARNSTABLE '` � }s' 3
I LOCATION/� �iVC�I✓ SEWAGE # �a3
VII.LGE:: "' ASSESSOR'S MAP& O
INSTALLER'S NAME&PHONE NO.
SEPTIC>TANK CAPACITY
LEACHING.FACII.ITY: (type) (size). dQ
I NO.OF BEDROOMS 3 .
BUILDEIt:OR OWNER
PERMITDATE: COMPLIANCE DATE:
- Separation Distance Between the:
' Maximim;Adjusted Groundwater Table and Bottom of Leaching Facility _ Feet
Private:Water Supply Well and Leaching Facility (If any wells exist
on sheaf within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within:300 feet of lea g facility) Feet
Furnisfied;by
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