HomeMy WebLinkAbout0051 REGATTA DRIVE - Health 51 Regatta Dr
TOWN OF BARNSTABLE
LOCATION
- J1 £lr �i� SEWAGE #
�II.LAGE yp,& ASSESSOR'S MAP & LOT�`s4�
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P4T 'S NAME&PHONE NO.
SEPTIC TANK CAPACITY S £ /N S'P£c//,v A�.
LEACHING. FACILITY: (type)' (size)
NO:'OF�BEDROOMS_
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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COMMONWEALTH OF MASSACHUSETTS
W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
�H/y SVB
350 MAIN STREET
& WEST YARMOUTH,MA
CNN KM 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 252 PAR 051X70
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner's Name: JUDGE,KEVIN RECEIVED
Owner's Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Date of Inspection AUGUST 5,2003 S E P 0 5 2003
Name of Inspector:(please print) JAMES D. SEARS TOWN OF BARNSTABLE
Company Name: A&B Cane° HEALTH DEPT.
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infonnation reported
below'is true,accurate and complete as of the time of the inspection. The inspection was perfonned 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 t5.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall su nit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE,KEVIN
Date of Inspection: AUGUST 5,2003
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:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the 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 complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE,KEVIN
Date of Inspection: AUGUST 5,2003
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to detennine 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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,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 I of 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 detennine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coli form
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Fotm 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE,KEVIN
Date of Inspection: AUGUST 5,2003
D. System Failure Criteria applicable to all systems: N/A
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 pit is less than 6"below invert or available volume is less than 'h day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone I of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have detennined 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: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
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 11 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 is 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 CM 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE,KEVIN
Date of Inspection: AUGUST 5,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ 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?
✓ Has 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)has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Detenmined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CM 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE,KEVIN
Date of Inspection: AUGUST 5,2003
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms: 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2002 76,000 CU.FT./2003 89,000 CU. FT.
Sump pump(yes or no) NO ,
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 2000 AND AFTER INSPECTION
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detennined?
Reason for pumping:
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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: i
1996 PERMIT#95-627 1
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
t w
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE, KEVIN
Date of Inspection: AUGUST 5,2003
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 10"
Materials of construction: Cast iron 1D'40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsiteplan): ✓
Depth below grade: 14"
Material of construction: ✓ concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: ASBUILT AND 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.):
MAIN TANK AT WORKING LEVEL.TANK AND COVERS 14"BELOW GRADE. INLET TEE,OUTLET TEE.
NO SIGN OF OVERLOADING OR LEAKAGE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
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 purnping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE, KEVIN
Date of Inspection: AUGUST 5,2003
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(]ocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain) e
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and Float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0 r'
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS 12"xl6",22"BELOW GRADE.ONE LINE IN,ONE LINE OUT. BOX IS CLEAN AND
SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE,KEVIN
Date of Inspection: AUGUST 5,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT 2' BELOW GRADE WITH COVER AT 10".20"
WATER IN PIT.STAIN LINE AT 24".WALLS CLEAN.NO SIGN OF OVERLOADING OR SOLID
CARRYOVER.
CESSPOOLS: N/A (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/I5/2000 9
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 51 REGATTA DRIVE
CENTERVILLE.MA 02632 °
Owner: JUDGE. KEVIN .
Date of Inspection: AUGUST 5,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I c/�
3
c
Title 5 Inspection Form 6/15/2000 10
Page 1 I of I I
OFFICIAL INSPECTION FORM—NO
T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
0
Property Address: 51 REGATTA DRIVE
CENTERVILLE,MA 02632
Owner: JUDGE, KEVIN
Date of Inspection: AUGUST 5,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
./ Obtained from system design plans on record-If checked..date of design plan reviewed:
Observation site(abutting property;obscrvation 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:
TEST HOLE OFF PLAN, 12' NO WATER.
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Title 5 Inspection Form 6/15/2000 ]]
.� TOWN OF BARNSTABLEhdp
1.6CATION /UIC SEWAGE #
VII,LAGE ASSESSOR'S MAP &&
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �/� (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 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 1 g facility) FeeC:
Furnished by l�/� t/'1 /,6
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No. _...... Fps..... .... ��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for i uuttiWorks Cnunutrnr#inn rrrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System.. -- /A
............................. . .......... ---------------J---�. ----•----------------•----••-_----------•-••-------•--------------....--••-----
L t' t• ddres r Lot No.
_....
•----
... . .... ..........D C A
a •-•---••-•--••-••••...
—�� 'G1r��-� Address
Installer Address
Type of Building Size Lot.... ....Sq. feet
0-4 Dwelling—No. of Bedrooms//_______'____e. __Expansion Attic ( ) Garbage Grinder ( )
W i No. of e-rsons......................•----- Showers — Cafeteria
Other—Type of Building _____. _ _. p ( ) ( )
Q' Other fixtures _-.-.-..-_.. .............. . .
-- ------------------------ ------------ -----•---•
d
W Design Flow-----------------------------I�_U.......gallons per persorrper day. Total daily flow.........-�--3-_o-___-_-•-.--__-__-_-_-_gallons.
R; Septic Tank—Liquid capacity-LOQ&_galIons Length................ Width---------------- Diameter---........----- Depth................
W Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing to
'~ Percolation Test Results Performed by------- --.... ....... ....... Date....___ '_..........
Test Pit No. I...)_C':_..minutes 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.------.._--_-_--_-._--.
0 Description of Soil_.L.�C..SI-, t- •. •-•---------•---•---------------------•--...---•-------•......--•---'--'- -----••-- --•--- ---••-'•...........--------•--
x
W --- --------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------•----
UNature 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 Envir mental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian F
ed by th oard of health.
Signed ... .. ---.C./t�.9/0
Application.Approved BY ------------- -.... ram" - - - .®..~.BLS:.......
Dale
Application Disapproved for the following reasons: .............. ....... ..............................*. *
.........................
..--------------......--- .... .. ........... .. .. .. ...._...........................Permit No. .... -.:...... - ..................... Issued .......Date......
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Divi-puittl Enrkii Tomitrnrtiun rrrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at* 4 �t t
.. ............... ---- .................. .................................................
L c. ti 47�ddres (/''� or Lot No.
...:............_....._.._......._.._...._.._..._...---'•--,.._. ................. ......... ..................................................................
av Address
. -_ O, -
J Installer Address //' p�t 7
Type of Building Size Lot---_•.......................Sq. feet
., Dwelling—No. of Bedrooms 11________ ____________ ._--..___Expansion Attic ( ) Garbage Grinder ( )
WOO�No. of ersons---------------------------- Showers
a Other—Type of Building ____ _ _ __ ____________ p ( ) — Cafeteria ( )
dOther fixtures ----------------------------------------&�--------------------------------- ----- .............
W Design Flow.............................f_ .(------gallons per perserl per day. Total daily flow--------�> ..... ._......._______.._.._gallons.
WSeptic Tank—Liquid capacity-/_b.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..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( t _
aPercolation Test Results Performed by-------f -------._/--_ -......---•-------- Date------- _ �..+- _.._...
a Test Pit No. I....G)......_._minutes per inch Depth of Test Pit---------------- -- Depth to ground wat'er..1�� --_ .
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Descriptionof Soil._l.�lJ1 -�r........--------------------------------------------------------------•-------------........----------------------------------------------------
x
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
4
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TITLE 5 of the State Envir mental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliant h as been issued by th 'board of health.
Signed ... ... 1— �.: / a '---------------_---- .(�....z_ �1
to
Application.Approved B .---
$ . ----�-�-.............................................................------------- ->��i�e`�`'�-----
PP Y
Application Disapproved for the following reasons: ..................................................... ............----------------......----------------............
.. .. ................... may' -��.. ...... - - - /
`................. Date
Permit No. "..1�------.-//Qov;..1� Issued --�• .
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Te>rtifirate of Compliance
THI _r I�S-�o.- ERTIFY, That the Ind-vidual ewag. Disposal System constructed ( `�) or Repaired ( )
by .. `' ' 1"�.................... ...> ..... ........ --------------;----
Inst:d�et
- — ------------------------------------.----------------------------------------------
has been installed in accordance with the provisions of TITI_ of The State E vironmental Code as described in
the application for Disposal Works Construction Permit No. - " . . - dated ._...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEMWILL FUN. J
r — )SATISFACTORY. Inspector - �---DATE .. � ��z
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Noq",..[. -.....�/q TOWN OF BARNSTABLE D
Biupnutt1 nrki (goV urtion "pamit i
Permission i5Aereby granted.....\7 --------.1-....
...----------- ---------•------------------------------------..--...---•---•--••............•----........_.
to Constrtjct V) or Repair ) an ndivid 1 Sewage Disposal System '
at No.---- ` �. ��rl...... ; C �' 4' !_ Stree�WVv�
as shown on the application for Disposal Works Construction Permit No.. _ gqated...........................................
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DATE_ ........................................ Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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