HomeMy WebLinkAbout0102 BAY ROAD - Health f -
102 Bay Road _
Cotuit
A= 007-023
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t
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
f
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11 29-12
page. City/Town State Zip Code biteof
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:whenfilling out forms A. General Information
OF
on the computer,- �o.\�.�H1..... ys;��ii4
use only the tab 1. Inspector.
key to move your /�j p • �G
cursor-do not James D Sears �/ __'� JAMES ,m
use the return
key. Name of Inspector s 6
:* .
Capewide Enterprises,LLC o o:
Ili Company Name ?lT � �U��
153 Commercial St. % INS?EGA°`°
Company Address
Mashpee Ma 02649
City/Town • State Zip Code
508-477-8877 S1623
Telephone Number 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 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approvingr Authority
11-29-12
pector's Signature. Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 DEPSThe.-original should be sent to the system owner
_ and copies sent to the buyer, if applicable,-an.d--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. !l
t5ins•11/10 Title 5 Official inspection Fonn: ce Sewage Disposal ystem•Page 1 of 17
L `
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A B C D or E/aihva s complete all of Section D
rY Y p
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: .
❑ 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 exMtration 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.
,a
❑ Y ❑ N ❑ ND(Explain.below):
{
t5ins•11M0 Title 5 Official Inspection Fom Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is
required for every Cotuit Ma 02635 11-29-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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:
4 ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system.is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
_ 15.303(1)(b)that the system is not.functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool ar privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address t
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. C4rrown State Zip Code - Date of Inspection
B. Certification (cont.)
f
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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or .
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form:
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into.facility or system component due to overloaded or '
clogged SAS or cesspool.
❑ ® 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 loan overloaded.
or clogged SAS or cesspool
❑ Liquid depth ind is less than 6°below invert or available volume is less
than %day flow
t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.),
Yes . No
❑ ® 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.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or .
tributary to a surface water supply.
❑ ® 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.
El i
z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system faits.I have.determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be "
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
• ❑ ❑ the system is within 400.feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 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 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 T
regional office of the Department.
t5im•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street ,
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. City/Town State Zip Code Date of Inspection
C. Checklist.
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)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential flow Conditions:
Number of bedrooms(design): na Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
f _ '
t5ins-11A0 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 8'6" Block Pool and a 1000 gal Pit
}
y Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® .No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No .
Laundry system inspected? ❑ Yes ® No
Seasonal use? Yes ❑ No
Water meter readings, if available last 2 ears usage na
, 9 ( Y 9 (gPd)}�
Detail:
Sump pump? Y ❑ Yes ® No
Last date of occupancy: na
Date
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No-
Water meter readings, if,available:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
yyY 1221 Main Street -
Property Address
Nancy Walcott
Owner Owner's Name
information as required for every Cotuit Ma 02635. 11-29-12
page. Cityrrown 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: na
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
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)and a copy of latest
inspection of the 1/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11l10 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
JY 1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is
re Cotuit Ma 02635 1 - -
fired for every
1 29 12
required
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Pit installed 1989 Permit#89434
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t
Building Sewer(locate on site plan):
28„
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain)
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4 PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: feet
Material of 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:
Sludge depth:
t5ins-1 IAG rtue 5 Official Inspection Form:SubsuRaoe Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
V;0Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street '
Property Address
Nancy Walcott
Owner Owners Name
information is required for every Cotuit Ma 02635 11-29-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bettom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,*
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: " feet
Material of construction:
• i .
❑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•11110 Tine 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. City/Town State• Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
'
4. .
Tight or Holding Tank(tank must be pumped at time of.inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
• ,gallons
Design Flow-
gallons per day
Alarm present: ❑ Yes ❑,No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date'
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy•attached? ❑ Yes . ❑ No
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I of 17
Commonwealth of Massachusetts.
Title 5 official Inspection Foern
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. CityrFown 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
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.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located,.explain why: `
t5ins-1 U10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection - Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott a
Owner Owner's Name
information is required for every Cotuit Ma 02635 11-29-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type'
® teaching pits number. 1
❑ leaching chambers number.
-
❑ leaching galleries number:
❑ leaching trenches _ ' number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool A number:.
❑ innovative/altemative 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 a 1000 gal Precast Pit. Pit at 58"below grade w/cover at 18".Pit is clean and dry,walls
clean like new on sign of overloading or solid carry over
i.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert
58"
Depth of solids layer 0
_ 4,1
Depth of scum layer
Dimensions of cesspool = 6'x8'-6"
-
Materials of construction Block t
Indication of groundwater inflow ❑ Yes ® No
t5ins•11/10 Title 5 Official inspection Fonn:Subsurface Sewage Disposal System Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '
1221 Main Street -
Property Address
Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma 02635. 11-29-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cone.) i
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Main Pool 8'-6"2'6"water,one inlet no tee, outlet w/tee pool is solid Pool also has a 2"pvc pipe inlet
f
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t 1221 Main Street
Property Address
Nancy Walcott
Owner Owner's Name ,
information is required for every Cotuit ', Ma 02635 . 11-29-12
page. Cityrrown State r Zip Code Date of,Inspection
D. System Information(cunt.)
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
A +�
9
41 C�
C/a
O
p�T
/°®®4_
A a= yy
t5ins•11/10 " Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Offic"al Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
s` 1221 Main Street
Property Address
.Nancy Walcott
Owner Owner's Name
information is required for every Cotuit Ma. 02635 11-29-12
page. City/Town State . Zip Code Date of Inspedion
D. System Information (cont.)' ;
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 2 fe eett
.
Please indicate all methods used to determine the high groundwater elevation:
❑ . Obtained from system design plans on record
If checked,date of design plan reviewed- Date
® Observed site abutting prope 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:
Abutting property drops off 25'+ no g.w. problen`seen
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1221 Main Street
Property Address
Nancy Walcott
Owner owner's Name
information is required for every Cotuit Ma' 02635 11-29-12
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, 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
Y
M
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'17 of 17
TOWN OF BARNSTABLE
LUC�i�'ION i9v2 6(tcf SEWAGE # l/3 I S 3
VILLAGECO k t ASSESSOR'S MAP 6t LOT 60-7. 0�3
INSTALLER'S NAME & PHONE NO. rTMOV 64L_� j
SEPTIC TANK CAPACITY r C
LEACHING FACILITY:(type) /,9 fo b'S (size)
NO. OF BEDROOMS 3 PRIVATE WELL OR-+ UBLIC WATE
BUILDER OR OWNER
DATE PERMIT ISSUED: —
DATE COMPLIANCE ISSUED: / 'g- / S
VARIANCE GRANTED: Yes No
i
p h
Doi
60
c
S r 4
IR -,
�T`�
TOWN OF B RNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT��,(j
INSTALLER'S NAME PHONE NO is V'
SEPTIC TANK CAPACITY e o o `
LEACHING FACILITY:(type) /P !e G�h'isize)
NO. OF BEFDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER tTAjoVW e $
DATE PERMIT ISSUED:
- - T
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes � No
�s-
oil(PL
t
S
N3 1,:500'5 ..........
a
--------------- Fps.... ......_......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH Berne AppR�1�E
DO 1� 3 TOWN OF BARNSTABLE le PPryeti O
Apphration for Di�ipatial Wor1w Tomitrur °�°epanment
Application is hereby made for a Permit to Construct ( ) or Repair (/<an Ind idual Sewage Dispo�te _
Syst at... Q Aw-...... _•--- /11� �' ...
- ................
—or Lot No.
.......... --.!!fs'V fs�.. .._...•..•----- -----------•------- - ......----
wn -• ddress
0
In taller Address
UType of Building Size Lot............................Sq. feet
�. Dwelling— No. of Bedrooms---------------------------------------_...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------- ----- No. of persons----------------...--------- Showers ( ) — Cafeteria ( )
a Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity........-.-.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 tank ( )
►-' Percolation Test Results Performed by---- --------------------•------•..........---•-------...----------------- Date_......................................
as Test Pit No. I................minutes per inch Depth of Test Pit....--.............. Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.--................. Depth to ground water........................
9 ...........................................•--------------------....._...-------••-------._........................----...._....-----•-•-•...................
0 Description of Soil....................................................................................................-----------------•---------------------------------...........-----
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 Compliant ia b issued by board of ealth.
Signed ... . ...� . ..... .... . .. ............ ......................... ..... . ........... 3
Date
ApplicationApproved By ................... � ...�.... .................... . ................................. ........
Application Disapproved for the following reasons: ..... .... .............. . ......................................... ........................................
.................. ......................................... . . ..................... ................... ..... . ... ............................. .... .................... ........................................
Date
Permit No. ..........�.. .-------!.. _3.......I.......... Issued .. --...............................
......:........... ......
Dace
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50 CD
No9 ............... Faa../......�....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{ 00 3 TOWN OF BARNSTABLE
,���lirttti>a,t fux.-�i►��n��1 �nrl�,� Cnngt��r�r#u t� �'r��i#-
Application is_Zereby made for a Permit to Construct ( ) or Repair (/-<an Individual Sewage Disposal
System at-
............
..................................................
/J L4c_bi m/r�ress•f G v- or Lot No.
,rl .r2 .ir. r-------------- _
On n ddress
Ills taller Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ..________________•--._---- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
aI Other fixtures ---------------------
W Design Flow..........................................--gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity........__.gallons Length________________ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area.....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
A+' ` ---------
-----------------------------------------------------------------------------
--•---------
-........
•------------------
•------
•...
.---.............
•
ODescription of Soil........................................................................................................................................................................
x
w -------------------------- -------••--...•------------•--•-•--------------------•--......-----------------... ----•------ -------------------
x ,,� .�
U Nature of Repairs.or Alterations—Answer when applicable.____ . _.. _.1.... ............... ...___ /.i........_.:_._.__7_.__._....
�j�--r... ....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance,_has beet-i-s�sued by the board ofhealth.
Signed .... - —
�'i7' ///✓�— �...... Dace .�
Application Approved By ............... ... .-----------' ..........--........ ........ -.....7�'._��.
Dwe
Application Disapproved for the following reasons: ....................... ............ -' ...................................................................................
............ . .......................................................... ............................. ...................... . . ...................................--............ ........................................
Permit No. .._..... _ Issued
----.....------- --....................................................Dace.....-
----1................... Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
TOWN OF BARNSTABLE
C�>ex#ifictt#E of C�om}�tittnc�
THIS'I -T,O CER- IEY-,sf1hat the Individual Sewage Disposal System constructed ( ) or Repaired (� )
b _............. ...... :....__... .....----...---------------------.---------------- - .._..............................................
.....
y Grf� ✓.....- � � Installer
X
at .--..- / _ ....................................................................................----------------------------
�..-_2-....-..... 7 .....�'�
has been installed to acco ance with the provisions of TITLE 5 off The State Environmental Code as described in
the application for,Disp sal Works Construction Permit No. --_....-/..��--- .f..J.:,?�._. dated .--_......-._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. `
DATE..._._.-.. _-_./�.�-.� ...... --------------_. ....... Inspector .__....A7.......J-----.....--- ---------..------._....-----...-_......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 0
�� - `�� TOWN OF BARNSTABLE D
No.2...... .. ;/�
FED........................
All �
�. -
Permission is hereby granted - "�'
to Construct ( ) or Repair ( � "n Indivir ua1 ke wagbDispos System_
r
at No
as shown on the application forr isposal Works Construction Permit o.�.-�5__�. Date ............................
\\ ; ------- - ------
DATE..","".---------1-- r / •-------------------------------- Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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