HomeMy WebLinkAbout0012 CLAMSHELL COVE ROAD - Health a 12 Clamahell Cove Read }{
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ASSESSORS MAP NO•.�-- -
PARCEL NO• o a
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 12 Clamshell Cove Road
Cotuit, MA 02635
Owner's Name: Dick Kraus
Owner's Address:
Date of Inspection: June 25, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Ostervi[ie,MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
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
Need Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: June 28, 2004
The system inspector sha\subma 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 to the 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 page 1
3 '
Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Clamshell Cove Road
Cotuit, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section I)
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:
I
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.
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 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..
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:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Clamshell Cove Road
Cotuit, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a 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 a 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 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.
I
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for 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 than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Clamshell Cove Road
Cotuit, AM
Owner: Dick Kraus
Date of Inspection: June 25, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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.
✓ 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.
✓ 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 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.l
No (Yes/No)The system fails. 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 System:
To be considered a large system the system must serve 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-I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 Clamshell Cove Road
Cotuit. MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
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:
Yes No
✓ _ 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(3)(b)].
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Page 6 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 Clamshell Cove Road
Cotuit, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
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): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 1015194-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
1
Page 7 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Clamshell Cove Road
Cotuit, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _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 on site plan)
Depth below grade: 3'
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: 1500 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 5"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
Recommend installing risers on the covers.
GREASE TRAP: None (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Clamshell Cove Road
Cotuit, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
TIGHT or HOLDING TANK: None (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/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: Even
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.):
The D-box was level and clean. No solids were present. The cover was 4'below grade. Recommend installing risers to the
cover.
PUMP CHAMBER: None (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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) ,
Property Address: 12 Clamshell Cove Road
Coto, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 gal.)
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.):
One leach pit(#1) was dry and clean The scum line was approximately 1'up from the bottom. The bottom to grade was
approximately 10' The other pit 02)had 6"of water on the bottom. The scum line was at the same level. The bottom to grade
was approximately 10'. There did not appear to be any signs offailure in either pit.
CESSPOOLS: None (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: None (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.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Clamshell Cove Road
Coto, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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10
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Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Clamshell Cove Road
Cotuit, MA
Owner: Dick Kraus
Date of Inspection: June 25, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
tlsine Barnstable topographic maps and water contours maps, the maps were showing approximately 25'.+/-to Around water at
;errs site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or.guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
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No _�. Fxs............._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Dhi-pngttl Work.5 Towitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (De} an Individual Sewage Disposal
System at:
,
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........ C;o�€
Location e\ ress or Lot No.
��— �i&4v✓l�S�t�- LOrI E C�(T�--v t i
......................-----. ------...... S............................ -•------------------ fir... ._A............-----.........------.
Owner Address
a P�GL.tl ti7 a-.► °7�� ................................................W..4-iLE6 ....... .4. ✓N !�l 5.2.......
................................... .............................. /
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_______________-�e.......................Expansion Attic ( ) Garbage Grinder ( )
4a Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures _....
W Design Flow................ ............gallons per person per day. Total daily flow.............r?._.C/...................gallons.
WSeptic Tank—Liquid capacityeb�_..gallons Length________________ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.--_____v'------- Diameter...... ...... Depth below inlet...... t........... Total leaching area..................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........................
Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
P+ •-•-•--•-•••-----------•--•-•-•---•-•--••••••••••-•--•-•--••••......--•----•----•.......................................................................•-•--
0 Description of Soil........................................................................................................................................................................
x
V ........•-•••-•••-•••-••-...-••••••..............•--•••--••••-•--•-------------•----••••--•-•••----•----------•---••--••------------•-••-••-....•----•-••--------------•-•-----••--...------••-•--------•
W --••---------------------••-•••-••••-••••-••-•------------••-•-•-•-••-•--•-••-••••-------••----•-------•----• -------------------------------...•-----•-•---•-•-•-------------•-----------.
U Nature of Repairs or Alterations=Answer when applicable..../N4...ff-.......
1. ._ .
l47 ---$ 13co. ........s
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 s een issu by t board of health.
igned .......... . . ......... ....... .. ....... .. ................... .......V_ -9./... 'Y.
te
Application Approved By .......................L1z - '� t��. �l«_
Date
Application Disapproved for the following reasons: ........................................................................................................................................
....................................................................................................................................I......................................................... ...... ........................................
Date
Permit No. .... .. _... ..... Issued ....... .`.��'..
Date ..1. .......
` No. ............ 5 Fps... ............. i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Diti-Vw3al Workg Tomitrurtiun rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (.6�-) an Individual Sewage Disposal
System at:
� C' L-A,,-A .s tt—5 t_C C 00, /Z b
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...--•------••-•-•-••-•••••• ••-•. ..................•................... ---•-•............---•--............- °........................................................
Location-Ad ress or Lot No.
.....:....... vs........ .-•••••......------••------.....• ........................................................
Owner Address
W Q i•.G L `' ---- �'-G-''' � ' `7C_75-- W.a 1.Z 6!s`l � --- 10 , ✓ln i 1 L s ,
,.� ---------- --- ------------------- --•--_.... .....-------------•-•--•--• --•• .-•----
Installer Address
CQ
UType of Building Size Lot............................Sq. feet
�. Dwelling— No. of Bedrooms................�_........__._-__..._...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures _----------------------------- - -
W Design Flow..................` -_---- ....._..___._gallons per person per day. Total daily flow........____ ..............gallons.
WSeptic Tank—Liquid capacitv!J>...gallons Length---------------- Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.-__-___�------- Diameter------fO..._..._. Depth below inlet.....A........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by................... ...................................................... Date........................................
a
,a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-...__----_-_._-_---_...
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
n+ --•-----------------------•------•••---•---•-----•------•-----------•---••-•-•-----------._.................•--•-----------------------••-•--••-•-.----.-----
ODescription of Soil...................................................................................................................................................------•--•--••.-•---
V ...........................................................=............................................................................................................................................
W
-----------------------------------------------------------------------------------------------•-------------------------------------•------•---•-------------------------•-------------•--•--••..------
U Nature of Repairs or Alterations—Answer whenp applicable.-.._l
sf'X `., !..Gut). �wC......T .�-'S--•---.. ......... e
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 been issu d by the board of health.
Signed ----------- �----- j.. /�'! ...... 2/1 1..-/�!y-
..--
✓ �' Date
Approved By ....................... �J..-- ....................... ---------------------------------
Application /
Application Disapproved for the following reasons: ...................... .................. .......... . . . ...........................
Date
PermitNo. ....................................................... Issued ................... -----. ------- �.�...........
Date
——————————.———————————————————————,——————————————— ———————————————————--_7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(nEr#ifirat.e of C�omplianee
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �)
by SGiZ�t-.c;?-------------------- -t�u.-- _S-I ycn. u
Installer I
at .-----------------_------------------------------------/1 .----------------- ------------------.._-------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. �.,�..- -. 4.'`r" .. dated ..�-.��ll
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. j
' / r/ ,•y
DATE.........449---- ---- __'. .. ;. Inspector-- Co"', '-"'------=-7.
------------------------'— --------------------------------- - —————————-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��` TOWN OF BARNSTABLE
No /� -, ;z/ FEE... U..r....
%yosal Workii Tunitrudiun "rrmit
Permission is hereby granted _ -...-•----•._.....-- ----------------------------•-----..............---••--••-.••---
to Construct ( ) or Repair (>C) an Individual Sewage Disposal System
c= Lit-. 1�S --......c:�L � G r i
••....•...
Street0
as shown on the application for Disposal Works Construction Permit Noj�<�¢.?�_�Dated...
----------------
DATE.... ------- -•---
Board of Health t
r:-% 1
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
'~ TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ,--e-'ZJ ASSESSOR'S MAP & LOT t3atc--QfU
INSTALLER'S NAME & PHONE NO. V 1-4177 C,Js-' �-- 4 .
SEPTIC TANK CAPACITY /a�U
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL O BLIC WATER'
BUILDER O OWNERS /� �
DATE PERMIT ISSUED: y
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No J
'79 67- -
Y 79
0
TOWN OF BARNSTABLE
-LOCATION a �C IqM �"�'S C OIL R�• SEWAGE # Cf y- Ss(
VILLAGE C�u l t_ ASSESSOR'S MAP & LOT C106- 010
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 01' Ai G (size)
NO.OF BEDROOMS y
BUILDER OR OWNER kt-AUS
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 leachi facility) Feet
Furnished by T-6 D/ d
SOJI,
room
A)
A 4
w 88
a G°� G!!r a O
3 13 °01 3 '
A2J
1 /oy /a(0
y
90