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0230 CLAMSHELL COVE ROAD - Health (2)
230 CLAM-SHE LL COtYE ROAD COTUIT A= \ I V Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of pR 2 0 Environmental Protection �,,� 199? William F.Weld Governor Trudy CoTO S.W.y,EOEA n David S. Struhs u Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �CERTIFICATION Property Address: aka C\ �*t'tiShe�� C6�e�1oC Address of Owner: _ Date of Inspection: -LA a`O-� C6�V \ (If different) �� E Name of Inspector. t. G `p Company Name, Address and Telephone Number: 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 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: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: / Date: L'1—JLOs7,7 The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 :U ;r,e sv stern owner and copies seni to the buyer, if applicable and the approv ino authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTE SSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 40 Printed on Recycled Paper 'R I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A r > CERTIFICATION (continued) r '01 Property Mress.c:?-.*-3Nv. CS WAS � 'CO+re. COT"v i 1 Owner:-,li, C<csR��* Date ofslnspection: _ � '�ro � BJ SIN CONDO hON'ALLY PASSES (co SY TE ntinued) 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 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Ihp wsienl haS a septic tanK anu soil absorpUUll system anj is within 100 lcci iu a suliaCE "a,Ei supp!) or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systenl has a septic tank and soi! absorption system and 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 than 5 ppm. DJ SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. 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. (revised 8/15/95) 2 r cA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ( CERTIFICATION (continued) Property Address:-2 5(D Owner �� ,,, j Date of Inspection: '1 -ci7 D]SYSTEM FAILS (continued): —/ l Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ,[j Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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. /L1 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. r� 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: The following criteria apply to large systems in addition to the criteria above: J The design flow of system is 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: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water suppiy well' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 i sK SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property A ress: 3 6 C` p rvl.s�_c k� 60 I-r_ GOB t Owner: y}r�7 Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and 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. t�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, excluding the Soil Absorption System, 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. _L.-fhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. he facilit, o..: c ;a~: ' occupant, if difie..—..1. from ov,ner? were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 11 SYSTEM INFORMATION Property,Z'-, ress:a3 a G, W�Sh��covr— C 5L r COTS, Owner: G%w Date of Inspection: '4 6j -q-7 FLOW CONDITIONS RESIDENTIAL- Design flow: W gallons Number of bedrooms: Number of current residents: a Garbage grinder (yes or no): Laundry connected to system ( es or.no): Seasonal use (yes or no): H Water meter readings, if available: H(A Last date of occupancy:? -St'&P COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day 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: 1-40&-.. System pumped as pan of inspection: (yes or no)_ If yes, volume p,imped: gallons Reason for pumping: C}F SYSTEM TYPE �— 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: V/ 5 Sewage odors detected when arriving at the site: (yes or no) ✓ ` (revised 8/15/95) 5 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyNddress: �O ` �s1�1� C.ov-c— Cc)TvZ l Owner: coj Date of InspectVon: Lk&A-r77 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Sludge depth:. I r Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ �41 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:�t� Comments: (recommendation for pumping, condition of inlet and o tlet tees or affles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) �[cG,eJ�a�TC� l GREASE TRAP: ) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Dktance from bottom N crti t^ hottom of otitlpt tee o• batlle' 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 8/!5/95) 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION (continued) Property Address: __230 �1W►W.�S1r��\�O�re� Owner: 9_e r'V_j Date of Inspe ion: TIGHT OR HOLDING TANKuO (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: . (locate on site plan) Depth of Liquid level above outlet invert:QOOD Comments: I (note if level and distributsuf: eywa , e,*.cience of solid ca;r�o,,er, evidence of leakage into or out of box, etc.) L 0 YI-*Ay0— 3—,&V%xj PUMP CHAMBER: / (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property y dress:&Zo Owner: tge�)r v J Date of Inspection: t{` 'G7 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydrauli failure, level of ponding, condition of vegetation,etc.) C�LwC—�v—i Coa-t��TyoL.JS CESSPOOLS: �f (locate on site pan) 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 grounds+ate : 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 8/15/95) 8 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert ddress:A3 D 1r4)4&% S L I( Cov,--- Coar !E 1 Owner. SS Date of Inspect iorl. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' °moo �C'.V- 0 DEPTH TO GROUNDWATER NbWp`�'� Depth to groundwater:�feet method of determination or approximation: 1S/i�`cz w�- .�� If7r l S /SU�� � td-kC�0,� �E�. i.,�� ��a��I:1 �[�ovci�S�,t4- ��t�. �4.��usT►�isJ1S (revised 8/15/95) 9 BAXTER &- NYE, INC. J Professional land Surveyors and Civil Engineers 812 Main Street • Osterville, Massachusetts 02655 • Tel. (508) 428-9131 WILLIAM C.NYE,P.�S-President PETER SULLIVAN, P.E. -Vice President-Engineering 'RICHARD A_WitTER, P.L.S.-Vice President .mot SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION v Inspector : Peter Sullivan PE Location : 230 Clamshell Cove Road Cotuit Date March 14, 1995 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. Please note the summary of recommendations as presented in this form. ery my yours 1U Peter Sullivan PE d Distribution: Original to system owner or Buyer y � �Seard of Heath y 9 �' SULLIVAN No.29733 MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS 7 SUBSURFACE _SEWAGE DISPOSAL SYSTEM INSPECTION PORN Address of property Owner' s name eoee,TQe_Ee—, Date of Inspection PART A , CHECKLIST Check if the. -following have been done: Pumping information was- requested of the owner, occupant, and Board of Health. WC 'AyA1 L R?.XP. l G ►-lo-r L Tr_ C_ S'TP �— -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, y The site was inspected for signs of breakout, All system components, excluding the SAS, have been located on the site. V 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. L-" The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different Prom owner) were provided with information on the proper maintenance of SSDS. ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 SYSTEM INFORMATION FLAW CONDITIONS If residential 3 number of, bedrooms —� number of current4eo es-idents garbage grinder, or no' laundry connectedo system, yes or no seasonal. use, yes or no . If nonresidential, calculated flow: `33 14?1 OO O 4o3 G?Z Water `meter: readings, , if available: "C}4atc— VS A LA-,L4 tt16A,-viOu • St[STL-y�/L L.ast date of,..occu anc Y o0 �V0-k a ,s s aV-� �.0 us a- GENERAL INFORMATION Pumping records and source of information: e-G o 'iQ_ �ov4�9 ST Pc �• System pumped as part of inspection, yes or no if yes, volume pumped ReaAon E�pumping: Type of system _Q�. .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). Other (explain) Approximate age of all' components. Date installed; if known. Source of information: Sewage odors detected when arriving at the site, yes or no 9 . t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan.) depth below grade;: T material of construction: _concrete metal FRP __:_other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of• outlei tee or baffle distance from bottom of scum to bottom of outlet tee or baffle. 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, reco er)d_atigns for repairs etc. ) —F ©1L1 lr -l�L-V= uL-L. EV D i--, CO ILD 6 L V:E OR Ee" 0.C—C_O , DISTRIBUTION BOX: . . (locate on site plan) L - depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) PUMP CHAMBER:. ae ". (locate on site- plan) pumps in working order, yes or no:.... Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc: ) �,li SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM. INFORMATION continued SOIL -ABSORPTION SYSTEM (SAS) y (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: . Type leaching pits and ntimber tC6D 600-L-(-0" leaching chambers' and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, . condition f vegetation, recommendations for maintenance or repairs etc. ) 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 . condit.ion of vegetation; recommendations for maintenance or repairs etc. ) PRIVY: . (locate on site plan) , I materials. of construction dimensions depth, of solids . Comments: (note condition -Of soil, signs of hydraulic failure, - level of .ponding, condition of vegetation, recommendations for maintenance or repairs,etc..) •''•- 1 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH. OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells .within 100' c C5UT'C' _S C O IV 0 V_t A.7 i DEPTH 'TO GROUNDWATER � 1 el depth, toy groundwater �ti,ate" . ., • - ,. . , meth d of 'determinati or.. approxim tion: 4, la 1 .r. J 1• r ash T f�.1 �. _ 1. .t I+ I r;, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` FAILURE, CRITERIA indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage. into facility? ►`�'� Discharge or pond ing of effluent to the surface of the ground or surface waters? �y ' Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 d flow? �10 Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? • t Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? f"" within 50 feet of a surface water? IVo within . l00 feet of a surface water sup ply or tributary to a surface water supply? within a i hin Zone* n I of a public well . , within 50 feet of a bo rdering vegetated wetland or salt marsh ' (cesspools and privies only, = the SAS) ? within 50 feet of a private water r supply well? da. 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 analysi- for coliform bacteria, volatile grganic compounds, ammonia nitrogen and nitrate nitrogen. 6 TOWN)OF BARNSTABLE 3 0 �h�t r �l C e EWAGE # ��D' Z D LOCATION ; // VILLAGE P r ►+ IASSESSOR'S MAP A LOT INSTALLER'S NAME f. PHONE NO. SEPTIC TANK CAPACITY O LEACHL*IG FACILITY:(t9Pe) , = PRIVATE NO. OF B EDROOMS WELL OR PUBLIC WA?ER BUILDER OR OWNER DATE PERMIT ISSUED: 112, DATE COUPLIANCE ISSUED• VARIANCE GRANTED: Yes - Yt v � P r�r f,� - - - - ASSESSORS MAP NO.PARCEL NO: AA K' Lh THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diopooal Works Tonstrudion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal y /S stem at• ant. LQ- ----------------------------------------------•--------------------------•--------------•--------- -_-Locatio},-Address -----••-•-..•- --•--------------------or.Lot No. ' 6.:2.�C44k1:................................ ...........---•---•--.......................... Owner Addr s Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling=No. of Bedrooms__3.......................... _Expansion Attic ( ) Garbage Grinder (nc) ► t Other—Type of Building p� yp g ........... No. of persons____________________________ Showers ( ) — Cafeteria. ( ) 04 Other fixtures •----------------------- ...................................................... W Design Flow..........31D....12-P-D.........gallons per person per day. Total daily flow.___.._y1 .........................gallons. WSeptic Tank—Liquid capacity.J10-gallons Length._`. 4.... Width-__ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area-.2?S-Z........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I.......2......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........................ P4 ------------------------------------- -------------------------------------------------- •------------------------- ------------------------------------------- ODescription of Soil........................................................................................................................................................................ x V ------------------------------------------ ----------------------------- ------- --------- --------------------------------------------------------------------------------- •--------------- •--------------- W •------•----------------------------------•--------------------------•-----------------•----------•---------••---------------.----- t VNature of Repairs or Alterations—Answer when applicablefix,-'A ..............U-....-6 rhC,� -•-----•----••••••--•-----••••••-------•--•••--••-•------------•-•------•-•......--•..............•••-----•----•-----•--•••••••-------••-----------••--------•-•-•---••---•••--•-•.......--•-------•-•-- 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 as been issued by the board of health. Signed ..... .'50 -------------------------- -----...... ... ..d ...q.0....---- Date Application Approved BY ------ ----------- ------- ---................ Application Disapproved for the following'reasons- ---------------- ------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------...-.....-- --............... . Dare Permit No. '' p Issued -----1---��z G..1✓. Date OD69. Fss..v...... C ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. TOWN OF BARNSTABLE Appliratiun for Diupuuttl Works Tonstrnrtiun .erbti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,p 02 ea",— Wit..$ .c�I....._�°_�_r� a�c�s,Q .................................................................................................. f f Location-Address or Lot No. ......!l..!!L n lfleS ..........��•�CGA' --------------------------------------------------•---....-------•----..........................-- .�..� Owner Addres Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms----3.....................................Expansion Attic ( ) Garbage Grinder (ri d pa, Other—Type of Building -----No,,__�............ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------............................ _ W Design Flow...........1.1.0----9.0.D........gallons per person per day. Total daily flow.........y2�...........................gallons. WSeptic Tank—Liquid ca.pacity..l.2.Qf.gallons Length...1,�n_�_.. 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---°?Y2......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1.__.....�_.__.minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ _ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil...............................................................................-----------------------•--------------------------------------------------------------- W V .--------------•---------------------------...._.........••-•--••-•-••-•-•--•-...•---------••••------.....------------•---••-----••-••••-•-•---•---------•-•--•-••-•-•-•--••--...........------••-••----- W ---------.................................... .......----•-•-----....-•-_... --------------------------- . .------------------ - Nature of Repairs or Alterations—Answer when applicable____xb.,r�--__ ----------t... .....6.CltJ: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 as been issued by the board of health. Si ned .- .... ...�./g te..g.-Q------ A pplication Approved By .� � �/..... ... ...............i�..�,-- - - //,,, Application Disapproved for the following reasons: .................. 1 ' -------------- --------------------------------------------------------------- ---------------------------------------- --- -------------------------------------------------- ---------------- -----........-----------=---- .................................................. ----------- .......................... a / I?ate•yy Permit No. ------- ��" ±--------------------------- r' Date Z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE f C�erttfirate of Tons liance THIS IS TO CE TY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by ......6_4t .---....... �v -R-F-------- \ ----------------------- Installer atA3Q -� e-./1.....-.� .Q.u..0 t---------------------------------------------------------------------------------------------------- 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. ................................................ dated ---------------------------..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. DATE ......... .................................... .................. Inspector ........... .................---------------------.....--- -- ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Roposal, Vorkii To -Itt' ion Prrutit Permission is hereby granted. -•A�-------•-•---•......�1z� .- ------------•--.......------.......-----........................ to Construct (�%r Repair ( ) an In ividual Sewage Disposal ystem atNo. _ .. ......_ -e.��.... Y ------------- ......................... Street as shown on the application for Disposal Works Construction .�fl No. �' !�. Dated.......................................... 1 9 _ .� ...................... !� Board of Health DATE.............. ............................................ ' FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS TOWN OF BARNSTABLE LOCATION ;:56 dhhs4 ,ell C-©Uc VMhEWAGE # C10' 20 VILLAGE e o 1'v i"� ASSESSOR'S MAP & LOT !� )a GG iNS TALLER'S NAME & PHONE NO. Cam/¢IZ 4f 7,* A 12�S SEPTIC TANK CAPACITY /S-O 0 LEACHING FACILITY:(type) �� (size) io a a NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED VARIANCE GRANTED: Yes No `� I � 6�i Y y _ j M I - .�_ .l' ' i I 14 -'t I I I t I i ! I , j ! : I I I : 1 ! .i i 1 f 1-'}�,�__I .� r'I 11•. -�'- s,. I R) I I I 1 . , i j I 1 I ! ( ' � , vjoun�s C OG US /�Af� m IZ Llitilat�l lk ' 2 50 0 C> I I I j , j ,• I;r I j I 1? NI .K7 �CrI�A/r'! °I I� '�i i I, I I I dr'a t , j , Asscso,`s /7�r/p S� ,`�C►,'co/ 6 i i I I I I v►W�, y d bs 'r✓t 11� /rlc,r A �-�+t c�ra.. 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