HomeMy WebLinkAbout0105 CAP'N CARLETON'S RD - Health 105 CAP C jkR LTONS K04P
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COINBIOIN WEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 17fA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 NQ V 2 7 �oo®
TR Y COXE
��ecretar9
ARGEO PAUL CELLUCCI
Governor
�, DAVI rB. STRUHS
��`""'�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: W S C H P T, C O(;LE I D/1.', Name of Owner :R r 6(41)RI(�
Il1RP 33 P49CrL 3y Address of Owner:
Date of Inspection: �1-iO-G)v ,Name of Inspector:(Please Print) E-D iV A R D C; R)"SPI L c p
I am a DEP approved system inspector pursuant to Section 15.340 of rifle 5(310 CMR 15.000)
Company.Name: Q;i (i'i) C., ax7 5FielD
Mailing Address: L-c cO Ai,
Telephone Number: Zj
CERTIFICATION STATEMENT
1 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 inspection. The inspection was performed based on my training and experience in-the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
/
Inspector's Signature;", -/�/ c �/ Date ,1— -00
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS (���a� �/i1LC�,�j r S P%k 7/4,V,S
I
revised 9/2/98 Pagel orIl
i� Printed on Recycled Paper
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: j C).;) C 0 PT, C il 2LEF 7V st1 R D
Owner: R,Cgp)Qlo
Date of Inspection: 1 I_t -LJ
INSPECTION SUMMARY: Check B, C, or A
A. ✓SYSTEM PASSES:
/l 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health. - -
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
revised 9/2/98 Page 2orii
r .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: i��5 �/}P!, �/}(�(.1`Z,`�U
o��Inspection:R ` tq P�tc
1 t-IS-o�
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH qNp Sq0 CMR 15.303(1)(b)THAT THE SYSTEM
SAFETY AND THE ENVIRONMENT;
Cesspool or privy is within 50 feet of-surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)D
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SA ET THAT
THE SYSTEM IS
SAFETY AND THE ENVIRONMENT:M
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 soil absorption system and the SAS is within a Zone I of a public water supply well.
— The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a.well water analysis 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 to or less
3) OTHER than 5 ppm. Method used to determine distance
—_� (approximation not valid).
revised 9/2/98
Page 3 or 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: C5 C A OT, C 0 P LC TOIL' 13
Owner: �AP12r C
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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 Ievel in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist. .
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 P2ge4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: I D5 C r4 P-1 , C rVL F FD ,
Owner: P,c14PRi'o
Date of Inspection:
Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following:.
Yes No
_ Pumping information was provided by the owner,occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected.for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, have been located on the site-
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)1
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:f!75 C r9 P%, C f9(<'LODIU RQ,
Owner: P.C6PR)o
Date of Inspection:1 i-I�I i�_
00
FLOW CONDITIONS
RESIDENTIAL:
Design flow /L g.p.d./bedr om. _
Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow C-C
Number of current residents:
Garbage grinder(yes orb: l�'C
Laundry(separate system) (yes 'ram:U_a; If yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or :
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or
Last date of occupancy: S�ZL cYC4Pll=p
COMMERCIALIINDUSTRIAL:
Type of establishment:
Design flow: apd ( Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or�6
If yes, volume pumped: gallons
Reason for pumping:
TYFE 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: (!�t'S /L`Fw orT
Sewage odors detected when arriving at the site:(yes or (,
I
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:((✓1 S Cfip%, (f/9"CETDti
Owner: R,(-APPSC)
Date of Inspection:;]_r S-oc
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC_other(explain)
Distance from,private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK:_(
(locate on site plan)
Depth below grade: t
Material of construction:_zconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth: L7
Distance from top�Qf sludge to bottom of outlet tee or baffle:
Scum thickness: y
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 dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) ' 7/91Ui ._It-,�7- C CE/,LL`i 0 U- L1(14;,Q, hi^. Spa/DS
GREASE TRAP:
(locate on site plan)
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 pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cwrtinued)
Property Address: (� C P�I, C 6 f uL 'z/U RD,
owner: ,
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_Z
(locate on site plan)
Depth of liquid level above outlet invert: T 601— C/'')
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into of out of box, etc.)
Oi l /1U SOLr,05 n.-O ';1, 9tC C-000 CCt. .ITT/:rli
PUMP CHAMBER:_
(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.)
revised 9/2/98 P2gesorii
i P
s SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: i (Iq W
Date of Inspection: ��_,%�-0()
SOIL ABSORPTION SYSTEM ISAS);_Ly\
(locate on site plan,if possible:excavation not required,location may be approx?:nated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note•condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
S0 r L r
P(,r- +.I,'r (L itic F+S GF C i<<J n'Sivc: .vFiF C[Ei9L/V
CESSPOOLS:_
(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 (cesspool must be pumped as part of inspection)
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.)
revised 9/2/98 Page 9of11
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: (;S C(APT, C6,CC N rprj 2D,
Owner: ;Z,CAPRw
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
., 30
3
57
1
3°
revised 9/2/98 Page loorn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontiram4l
Property Address:DS ciipl, C94RLMYU
Owner: 9,C—WPR1 0
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow welts �
Estimated Depth to Groundwater.5l 1 Feet
Please indicate all the methods used to Aetermine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed) --.
revised 9/2/98 Page 11of11
=f TOWN OF BARNSTABLE \
LOCATION /o s' SEWAGE #
��lELAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY leo o
LEACHING FACILITY:(type) (size)
i
NO. OF BEDROOMS�PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: � t'7
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ta/`
a
r
• r t
— Fxs.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
App iratiuu for Diiipmal Works Tomitrurthin truth
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal .
System at:
` Locatioion-Address fIQ or Lot No.
.Y__ ..e X.W..L !.._.T,...SpJfW.4-0........................
._
Address
Owne
-----------•-----•. /:. /� c
W l0/rf/ i�.? ......_S�:rr'::(/S�[.................... F /+^ecs- _i!✓:f.....E?? y^�.....e ?� 3vGd✓1_!!Y`'S.---------•
a
Installer Address
d Type of Building Size Lot............................Sq.,feet
Dwelling—No. of Bedrooms.._.. �7.---------------------------------_Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------- --------•--••------_...
WDesign Flow............. ........................gallons per person per day. Total daily flow............................................gallons.
GG Septic Tank—Liquid capacity............gallons Length................ Width................ Dian eter................ Depth................
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........................................
Test Pit No. 1-----------------minutes per inch Depth of Test Pit--------_----------- Depth to ground water_-___ '._......_..
Lz, Test ,Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------•-----------------------•--------------------•------.........----.........................................................
0 Description of Soil........................................................................................................................................................................
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------•-
U Nature of Repairs or Alterations—Ans-wT when a plicable.__ fly^ __.._U¢.... °�:5�•- ,�'��?�.......................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Tii s,.,; of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been ed by the board f health.
Sig ••--- .........................L,t. ............... .................................
^ D t
Application.Approved B - ------- ----------------•--_..... ------......--•- ......,
ate
Application Disapproved for the following reasons:n_:=.:.:—_:::....
-----•-•--•---•------•-------•----•---------•----------------------------•-- --------------------------•------------------------------------------------------------
Date
_"_1
Permit No...... ............................... Issued...
Date
• � THE COMMONWEALTH OF MASSACHUSETTS 'n
BOARD OF HEALTH
..............OF.................... 2..... .... G c7
FEE
Norks Tontriu-tion rrrmit
Permission is hereby granted.....v.LNC .......--------------- ---............................--•-----•...-••--••-•-----,--........--.•--••-
,.to Construct ( or p r ( ) an Individual Sewage Disposal System
�u 1
atNo...... a --------------- -2 •• �
Street /
as shown on the application for Disposal Works Construction Permit Dated.....21 r�,l ............
Board of Health
DATE.......................................----------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
_f
i
(1
7
-7
F
...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF . HEALTH
.............OF....... ................................................................
Appliration for UWposal 1VOrks Toustrurtion jhrmit
Application is hereby made for a Permit to Construct`;( or Repair an Individual Sewage Disposal
System at:
..............................................
Location-Address or Lot No:
..... ....... Z. . :!� .............
....................... ......
.... ............
Owner Address
............................ ..............
installer Address
e4 Type of Building Size Lot----------------------------Sq. feet
U
Dwelling—No. of Bedrooms---..Z............------------_---....Expansion Attic Garbage Grinder
�4 - - __ - - -1 — )�-- -Cda_- ,-
P4 Other--:--Type of Building ..........:................ No. of persons___._.:_____................._.______.__. :Showers eria
QI
Other fixtures .......................................................................................................................................................
Design Flow........... ........................gallons per person per day. Total daily flow...........................................gallon&
1:4 Septic Tank—Liquid capacity____._-_____gallons Length________________ Width_.___._._.______ Diameter__.____.._.__._. Depth_______:______.,.
Disposal-Trench No_ .................... Width'_____...________._._ Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area-----w............sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water_:__" (..............
fi Test Pit No. 2................minutes per inch Depth, of Testiyit..................... Depth to ground water..'....................
P4 ........................................................ ..................
--------------------------------------------------
..... .........
-
0 Description of Soil------........................................................ .......................................................................................................
U ........................................................................................................................................................................................................
------------------- .........................................................................................---------I........................................................... ...............
U Nature of Repairs or Alterations—Answ?F"when applicable-.I,-v,-%*/;, �----- lef�4;- . .......................
......................................................................... ... .......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'7T"IE 5 of the State Sanitary Code—The undersigned further agrees
not to place the system in
operation until a Certificate of Compliance lia� beeg4ifued by the boardi
iof health..
....................................................... ..................e.............
11 te�
Y_
Application Approved By .......... ......... ---------
1—---f----------
ate
Application Disapproved for the following reasons:..............................................................................................................
.........................................................................................................................................................................................................
. 1 Date
—7.
PermitNo......... ........................................ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
V/1j
OF........... .................
. ................................ ....... .............. ...........................
Qwrtifiratr of Toutlifiaurr
TH14 IS O CVTIFY, That the Individual Sewage,Disposal System constructed or Repaired
by--------------VA)
T ............................................................................................................................... ..........................................
Installer? ( . t at----------- _.jE........ . .......t - ------C
S.............C ....... ..................................--------------------
. i 1. . -7---------
has been installed n accordance with the provisions of TILTIE 5-ofThe State Sanitary Code as described in the
_- .. 7...... dated-__:-j-j ....................application for Disposal Works Construction Permit No. .5 ........,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL,FUNCTION SATISFACTORY.-
DATE....................................
.............................................. Inspector..................................I..................................................
THE COMMONWEALTH OF MASSACHUSETTS
A
BOARD OF HEALTH
NP_-7 ...........................OF................. 0.5..............................
................... FEE._........
. ;Bisposal Works Tonstrudion Vprrmit,
..............._::;�........................................................................................................Permission is hfreby granted.....V.L I.Jfc
to,Construct �or R<�ep*_ an Individual Sewage Disposal Svst=
_ j_ - i r. I N
(7 Ayr at No....... •........7.............I...............
...................................... ...................................................................................
Street
as shown on the application for Disposal Works Construction Permit/No.� Dated.... .............
......................
... ....................................................
4Z, Board of Health
DAE...................... ..........t!•-�-.......................................
,FOR%1 1255 HOBBS & WARREN, INC., PUBLISHERS
I
8/2/2021 ShowAsbuilt(1700X2800)
TOWN OF BARNSTABLE
LO ATION le 9 eis/r It— rt SEWAGE#
YLLLAGE 7/v; ASSESSOR'S MAP 6i LOT
INSTALLER'S NAME di PHONE NO. �i c� /nor �'rs�s� 39A•S//9
SEPTIC TANK CAPACITY /Goon
LEACHING FACILITYdcype) (size) 6'
NO.OF BEDRooMS / _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: - 9-7
DATE.COMPLIANCE ISSUED; '3-S' - sJ 7
VARIANCE GRANTED: Yes No r
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https://itsgldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=038035&sq=1 1/1
} FEs ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............T ,v1v.. --......OF........C3mevas;, &�----------------------------------
Allp iratiun for Bi"u,ial Warkii Tunitrnr#iun Daum
Application is hereby made for a Permit to Construct (i,-) or Repair ( ) an Individual Sewage Disposal
System at:
,
..............••-.....----.....---...••---_•--.._..........--•_--_-----•-••-••................----
Location- ddress or Lot No.
L3L'�zr- Cam. .............................o Al /�9 s s. OZ 3�t1/....... ••- ...
r ... .. ....•.....................•••_--•_• ..._.............----•-.............. ....
Owner Address
aJlu .................................... .•----._.........-••---.......----••--•------•--..............._.........._._..---.........•_•----
Installer Address
d Type of Building Size Lot...
Z _ -------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ..................................
W Design Flow............ .-_r. ...................._.gallons per person per day. Total daily flow..........._33c)....................gallons.
WSeptic Tank—Liquid capacity.%bn..gallons Length_j�?.'C"... Width..4..A.'�. Diameter................ Depth.-S-'<9."..
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......: .......... Diameter........A Depth below inlet..............._. Total leaching area...Z67.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by..��?. ?..�.^!YO.................................... Date... ...1`/---77:........
,4 Test Pit No. 1.. _.Z....minutes per inch Depth of Test Pit....z`A" ...... Depth to ground water.......—••----.-_._.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------------------
--------.....
•...
-............
-------------•-------• ----------------............................
...•---------
.......
O Description of Soil...f? a�/c® C A _._-_•-...4."--3G" `Si�iv�/ `SL-,3--So i I—
.......----•- ------------------------------•--...----.....-•---
V ..........�q"•---(4¢„•-•11-1..-•-NlL? ...... ............................................
W
x -----------------------------•------------------•--------------------------------------•-----------....----•----------------------...----------•-....-----------------------........------......_.......
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 TITIE4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
//by�the board of health.
Igned..AV15 Ltt°-[�fGf,,k.L/4,AZ-•-- ,� �...... � a3 ./q ..._
Application Approved By........ -------------------------------------•-•-... (/ t
Date
Application Disapproved f t following reasons:..................................•.......--•---........------•----•--------------......._...•-•----•---___.00�
--------------
- ---------------------------------------------------------------------------------
Date-
v'Wc^..�J'�^✓Jv':d-✓✓'�Z�•.1C1�`���✓'✓JU^�/J✓.f.�Jt/•i':Fv`..�a'J.TJ'✓J'Ca'Tr✓r�Tv v o�.fN✓."✓:.sr'✓::ti ir.�✓�-T.-._�`-.-t�1'Jtl•�PJ'!o v-l�',.-..'v'v.r v a.s-v�.r..✓'✓✓Jr'r'l.J
No.If`fl.�'. .. ..... FEs 0.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.Lyst/............OF.........��f1Z.?_.nZs'? 7/34
AVV iration for Diiiposttl Works Tanstrnrtion amit
Application is hereby made for a Permit to Construct (il--) or Repair ( ) an Individual Sewage Disposal
System at:
Location_Address
or Lot No.
• 7'./ y.......... ................
W Address
r caner
..................
Installer Address
Q Type of Building Size Lot..... G ........Sq. feet
U Dwelling No. of Bedrooms.............. ._.__Ex Expansion Attic►� g— 3----------•-•-----•••- p ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------------------- __--------•-----------------•-•---------------•----•---------------••------••••--••••••----••-------...
W Design Flow.............✓`,_.___..__._._._________gallons per person per day. Total daily flow..___...._.__-330__._____._.._____._.gallons.
W ll
Septic Tank—Liquid capacity_eOp _gallons Length__e.'6 Width__¢.�G_'�_ Diameter________________ Depth_s'8
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------/--.......... Diameter........./P...... Depth below inlet........6........ Total leaching area...zA7.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by--- 2z._ .^!y ____________________________________ Date___.&A../l....e__�177:...._...
Test Pit No. 1_._4__.7-....minutes per inch Depth of Test Pit...... Depth to ground water..____..—___.....-_.
4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --------------- -----------
� _ --•---•--•___.._..--•••--•-••••--
U .......... ...... ------...---•--•--------•----•-••-. ... ----
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 TITLi: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of Health.
•gned...................................................................................... ......... _.._.
Application Approved BY -- ...-•--••_.__:__...-------•_._-••---••----___•----•---•---•-•-•--....-•-------•--_.. 'ti' r
:Dy
Date
Application Disapproved for h ollowing reasons:.................................................................................................................
Date
Permit No......................................................... Issued_........................................................
�fi5^re,
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................Tohini.........-OF.........BA'i?niSTi=3•!,3LL—
........ .........................................
Trrtifiratr of Tontpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (✓'or Repaired ( )
by................................................................................................ ----------_........
.._._..............................................•.--------•-••--•------
Installer
at............................................................................................................................................................................
has been been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code p4 des ib d in the
application for Disposal Works Construction Permit No._�y ,/ ________________ dated_---_ .__ __._._..__.....
THE ISSUANC;X OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WII,Lr F jCTION SATISFACTORY.
__�r._/S�-DATE1..
-•...................................................... Inspector....- ---- -'...................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
y-/yG ..............T!n!n� OF.........B6YlZ{t/STAI�'L.L:�_._.... .:...._._............
No....�................. FEE. ..._.............
Eltopwial Works �onotrorttton rrntit
Permission is hereby granted..... J___' a c,s c o 2 L
.........
to Construct (�'or Repair ( ) an Individual Sewage Disposal System
atNo.....—••••-•40_..r..........f_,S.........
.....................•-•.••----••------------•-•---•-•----••--•-•---._-_-__:;_..__...-----••-•-•-----••.._.__....--•-•-
Street y- /y6 L
as shown on the application for Disposal Works Construction Permit No.�___.._ Dated_._1__..� .........................
.
•-•_•_____________________________ ��"
DATE...... ----------------••---------•--------- Board of Health'
FORM 1255 A. M. SULKIN, INC., BOSTON
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TOP OF FOUNDATION
CONCRETE COVER
Tall CONCRETE COVERS
' 4"CAST IRON 12 MAX.
PIPE 12"MAX. '
, EQU IV-)OR MIN. 4��ORANGEBURG(OR EQUIVA
� PITCH 1/4"PER. PIPE- MIN. LEACH
PITCH 1/4"PER.FT. PIT
PRECAST
o•' NVERT LEACHING
EL•:fq'P.o•• INVERT INVERT e . ; PIT OR
n'. SEPTIC TANK DIST. . w .;.
° INVERT EL..... .�. . . . BOX EL....:?,S' >__ �i' EQUIV.
74.. ��Op. .... GAL. INVERT INVERT w W a: .:�. 3/4 TO I V2•
EL. � G ...
EL'¢8c . ;• U.o �: .;. WASHED
U. STONE
/z'-----►}•-W DIA. -- _
No N6
�• DIA. t`NCoaML'Y2G`D
PROF)LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
SOIL LOG WITNESSED BY :
DATE .!y�jf, /977.. TIME. . ... . . . . ., e''R4�G .C- !�?v/�' BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 Ggf N�/E� c; , ENGINEER
ELEV. .?.7., Zo. . . ELEV .. .. . . . . . .
ME!
lis
WenDloa►-rj . . . . . . . . .
DESIGN DATA :
'"ay NUMBER OF BEDROOMS
30 3 . . . . . . . . . .
M 3LB-Soit�
TOTAL ESTIMATED FLOW GALLONS/DAY
BOTTOM LEACHING AREA ��:�'��? . , SQ.FT. /PIT
CL w SIDE LEACHING AREA SQ.FT/ PIT
GARBAGE DISPOSAL . •/vb (50% AREA INCREASE)
TOTAL LEACHING AREA , Z6 7pU, . SQ.FT
' PERCOLATION RATE A� 77/Al-1•7rVv, MIN/INCH
.N.4.WATER ENCOUNTERED
LEACHING AREA PER PERCOLATION RATE .::9r , SQ,FT.
_,
NUMBER OF LEACHING PITS
APPROVED .. . . . . . . BOARD OF HEALTH � T•�F `Sr° on/ 4-ZZ 5 ion
DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . .
AGENT OR INSPECTOR
n�,lt � p�1H OF �f .
Le/ /S' ��'_ rir R� may STETS
N R.H H
C/-)��N C!-� 'L6TG!1/S �CC►q�7 �a KELLEY ^� °'
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PETITIONER SANITAP\aN
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