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HomeMy WebLinkAbout0313 COTUIT BAY DRIVE - Health U-3 Cotuit:Day.DriveL Cotuit P A = 056 D88 I� f �I �1 If Ili - 'I 1 �y h� J COMMONWEALTH OF NLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS rt DEPARTMENT OF ENVIRONMENTAL PROTECTION > �'H 5 ASSESSORS MAP NO: PARCEL N0: TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: s P Owner's Name: Owner's Addres • .( Date of Inspection: Name of Inspect , please print) A Company Nam • Q Mailing Address. . Telephone Number: CERTIFICATION STATEMENT �- I certify that I have personally inspected the sewage disposal system at this address and that th�-a[rformati ttpofted below is true; accurate and complete as of the time of the inspection. The]inspection was per`li e.d based�on rn training and experience in the proper function and maintenance of on site sewage disposal sy ems. I-arrQ%DEPa approved system inspector purIse to Section 15.340 of Title 5(310 CMR 15.000). Theme stem: .a C Akw �� 1%, ---_4 asses Lp onditionally Passes co ��� " eeds Further Evaluation by the Local Approving Authorify,0 r` Fails f'7 � II p Inspector's ignlr1el1 4 Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. y 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 I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Pk�> - - _ A Owner: Date of I ection: O 7 Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310:CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: &. 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'ouvor'high static water level in the distribution bdx 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: Page 3 of I'l OFFICIAL. INSPECTION FORM - NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION(continued) Property Address: Owner. Date of 6p—ection: dA111. ca 2i'D© 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(l)(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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has 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 coliforin 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: 3 Page 4 of I 1 OFFICIAL.INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: Owner: Date ofWp'yec_tioii: U&= 1 c;00(! D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: . Yes Nq+ 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 UI Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped V 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. V 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.] (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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to.15,000 gpd. You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. 4 Page 5 of l] OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION'FORM PART B CHECIaIST Property Address: /yy Owner Date of 63pedtiow 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? i/ 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? Jam_ 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)] S Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY°ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner:. Date of. pection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):'�. Number of bedrooms(actual): . DESIGN flow based on 310.CvIR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents. Does residence,have.a garbage grinder(yes or no) - Is laundry on a separate sewabe system (yes or no):�.[if yes separate inspection required] Laundry system inspected 9. ilable s.or no):�(� Seasonal use: (yes or no): Water meter readings, if a (last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: Ty COMMERCIAL/INDUSTRIAL./)QY 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: . ,)U lh(-bt W S:!�� 6k<�) Was.system.pumped as part of thJ inspection( or no): If yes, volume pumped: gallons--How:was quantity pumped determined? Reason Tor 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): roximate age of all components,�date.�jnstalled f if.known)and source of information: Were sewage odors detected when arriving at the site(yes or no)--./f X&-- 6 Paae 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1: � V O -)M wne • Date o spection: BUILDING SEWER(locate on site plan) . Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):: i a 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: lP Material of construction:-1zC-0-ncrete_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: . Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ( y yi�"Q �� IA�q. Comments (on pumping recommend tions, let and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert, evidence of leakage, etc.): 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(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 11 OFFICIAL INSPECTION FORD—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PANT C SYSTEM INFORMATION(continued) Property Address: Owne Date of spection. �P 0 D TIGHT or HOLDING TANK:A(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): u Alarm level Alarm in working order(yes or no); Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Jz0f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of �1 age into or out of box, etc.): PUMP CHAMBE (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 INFORNIATION (continued) Property Address- Owner: Date of pectio (� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type Ieaching pits,number: 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. o CESSPOOLSAjr(cesspool must be pumped as part of inspection)(locate on site plan) Number and conf auration: 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);, r Comments(note condition of soil, signs of hydraulic failure,_level of ponding, condition of vegetation, etc.): PRIVY/f (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 71 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PANT C SYSTEM INFORMATION(continued) Property Address: (- �� Y O Owne ICU Date of spection: 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. - ... c� 1 wt -�Ilooni- - 1 C)oo as llon 10 i Page 1 I of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: Owner. (/ Date of pection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water zp 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database explain: You must describe how you established the high ground water elevation: D Il xS 12� Nr tr}r t� t s hl Sty Y 1 3� Z kt h37z 'y, •l i 't Y i ti. � Y ' Permit Number: Date: �xn_6 Completed by: 4 » t HIGH GRQUNDk1I.ATER LEVEL COMPUTATION Sw .y `�'�`�� ;.;::Site Location: ��� / Lot No. Owner: A6` eg!�e ,Address: :Address G/S` � GIc5 V K'.�� 'Contractor: >�}t y Notes: /c9 �'✓/y/ /.S STEP 1 Measure depth to water table � tonearest 1/10 ft. .............. ........................................................:...... .Dale ` C—C Y TaJ r.. month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate a site and determine: /y OA Appropriate index well............_... l OB Water-level range zone ................ STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month/yea; STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment ........... y ................................................................................. STEP 5 Estimate depth to high water by subtracting the water m level adjustment (STEP 4) a . l from measured depth to water level at site (STEP 1) ............................................... Figure 13.--Reproducible computation form. t i?t:a. 1 . ..._.._............... . . i I No. " Fee BOARD OF HEALTH TOWN OF BARNSTABLE Zipprication _for Vern CottsStruction Permit Application is hereby made for a permit to Construct(k)," Alter( ), or Repair( an individual well at: 313 C;rL& T 17G p P Location-Address Assessors Map and Parcel (<d/tv y OwAer ` Address rfle��c S SCa"i•�+eG� <o D t(.r4S3 2j MAJAPe e Mck Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well 40 L Capacity Purpose of Well /,rt l 447-/e•.� Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compl'ance s been issued by the Board of Health. Signed (� Sl/7l,r .— ate Application Approved By Date Application Disapproved for the following reasons: Date Permit No. Issued Z'( Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( Altered( ), or Repaired( ) by ScowA-)c �( �—^ /� Installer at _ 713 COT^,1 I /JCy cDr has been installed in accordance with the provisions of the Town of Barnstable oard of Health Private We Pr tection Regulation as described in the application for Well Construction Permit No. tiV�) -0--Q Dated Z THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector 2 qr , o� No. -___.. ___ Fee BOARD OF HEALTH TOWN OF BARNSTABLc.E� l� Yic t ion for D�P[[ Cowgtrurtion ernut Application is hereby made for a permit to Construct(k);" Alter( ) or-Repair O an individual well at: d 313 c_oT tT ty(s o f c Location-Address Assessors Map and Parcel nn o,J K d/e Owner `` Address ut S_ co,^ (� !a D e G rGSS 2� 6��nP n Mot Q�9 Installer-Driller Address Type of Building Dwelling 1 ` Other-Type of Building No. of Persons-,�l Type of Well Pt)C- Capacity �- Purpose of Well ///I ro a-r/. Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed < . ....X� - -- -------__ _, S//7/J/ Date Application Approved By 5 k• Date Application Disapproved for the following reasons: �1 1 Date Permit No, �r � ''V�3 - � .Issued .. _ t Date e_. ..o._—o_e_de__e—o-maoa<s<v------.._v------msmmmmeom_.._—__o__..._de-__evo------------------obw—e--dee-- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed Altered( ), or Repaired( ) by Installer at 3 C077aIT- &y FJr • has been installed in accordance with the provisions of the Town of Barnstable Board of .,,>Health Private Well Protection Regulation as described in the application for Well Construction Permit No. VIl�L) -03 Dated � Z� t r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Vern Construction Permit No. - L- Fee —, -.-F Permission is hereby granted to SC-CA A)AJ Installer to Construct(`)! Alter( ), or Repair( an individual well at: No. ?/3 C-,2—�t'-F /3ci V Or, Street ,R as shown on the application for a Well Construction Permit No. V"tti '�l>-3 - Dated Date l Approved By A- 0010- /,- 3l3 , Ceara ! � Se0°7�L ��lI t3 Y -------------------------- -I LOCATION l S y 31� SWAGE PERMIT NO. l 7 3 VILLAGE , J / INST LL R'S NAME D RESS t � BUILDER OWNER �l GATE PERMIT ISSUED DATE COMPLIANCE ISSUED -,�j� 7� . !i 3G a No.. Fiz$...,95 .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TQWN...........OF....BARNSTABLE .......................... .......................................... Appliration -for J%gpoiittl Workii C owitrurtion Vrrntit Application is hereby-made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: Lot # 75 Cotuit Bay Drive Cotuit, Mass. ----•------••----•-----------------•---•---------•----•-----•--•--------------------•------------- ---------•-••-----•---------------•-•••------•-•---•---------•---•--------------•-•-----...------ Location-Address or Lot No .-Ka-louilding n.. _...K s.................. 76 Huntington Ave. Scarsdale N.Y. --- ----------------•--. . . ----....... -•---.......-------. .._..... W Owner Address ,a -------- ..-- .......... ------------- ---•-----•----•---......--••-•-•------------•----------•---------•-----------•......-------•------ Ins D? Address U Type Size Lot.....1.08 A XS* t -, Dwelling x No. of Bedrooms..... ___3............................Expansion Attic ( ) Garbage Grinder (X) PA Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow.....50.................................gallons per person per day. Total daily flow........495......................... gallons. WSeptic TankX-Liquid capacity150Q-gallons Lengthl:Q.-6______ Width5_-8........ Diameter-----....- ----- Depth.. -0...... x Disposal Trench—No. .................... Width.................... Total Length.....�....uf�/�tal leaching area_.__ _ . �.' sq. ft.� Seepage Pit No.._�101.10 I Diameter.10-tO _ Depth belo}^ inlet__-1.... fatal Teaching area. sq. ft. Z Other Distribution box (X ) Dosing tank ( ) o0- PC/+l- �` ► ' 7�'� Percolation Test Results Performed by------.-...-an---Jones 1/25/78 A 1 --- -------- Date--------- •---------------- ------------ see --- -- ------------------------- - - ,� see Test Pit No. I................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ attachTgkt Pit No. 2................minutes per inch Depth of Test Pit....................' Depth to ground water--.---.-------..--_-.--. . p4 document Description of Soil-----F.ar-----test---pi-t.--- ,SU1t_ --. nd__des.cr}ption.-o so 1.,____see._ .ocument x attached - U= 2 �---� 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 Article XI 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. Sigd...................................................................................... Date Application Approved BY � b 3 y '1 7-s.--....... -- Date Application Disapproved for the following reasons------------------ --- -•---•- ---------------- ---•--•---------•-•-----------.--- a.t.e-----•-------- ..........--••------------------•--•--..-•-•----------------•-------•--•---------------------••---------•............------------------..---•---•----------.......-------------•------.......------------ i, Date PermitNo......................................................... Issued.------.. ? ................... Date 07f .. No........�° 6...... _ Fly$... . ".."` ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _. . .. __TOWN... -- ..OF....BARNS`.pI BLE. . .... . ............................... Apliliratinn -fur Uiipniittl Marks Tuarstrurtijan Vrrnift Application is,hereby`made for a Permit to Construct (X) or Repair ( ) an Individual Sewage :Disposal System at: Lot # 75 Cotu t Bay Drive Cotuit, Mass. -----------------------------------------........................................=............... --••••----•••---•••--•••---•••-•-••••-••-------•-•-••••--•••-•-•-----•-----------••--•-------••-. Location-Address or Lot No Path n.. - ---•-.-•-.--•_.. ' 6 Hunt_incrton Ave, Scarsdale N.Y. ------ --------------- -------••------ ••••-•••••._....._.......-•---••-- Owner t Address a •. =• ................................... ...••----•--------....--•••-••-••-••••-•....-••---••••-••••----•----•-•••-•-••••••------•--••••••. Ins x6� i Address Q Type o Building ! t� Size Lot..1_r4.8..A...... t Dwelling 4 No. of Bedrooms.--_ ....3.............................Expansion Attic ( ) Garbage Grinder (X ) `4 Other—Type of Building No, of persons............................ Showers — Cafeteria a d Other fixtures -------------------------------------------------------------------------------................---................................................ ... W Design Flow-----�o.................................gallons per Pelson per day. Total daily flow-__--__-- ----__----..------.-.-------gallons. • � 15C10 0-�6 5.7 6 0 W Septic Tank Ltqutd capacity..________..gallons Length............... Width}.___.._....._.. Diameter____.....______. Depth._...:._........ x Disposal Trench No ................ Width-------------------- Total Length .. l_:.. Total leaching area.._. sq.. ft., >/; � Seepage Pit No +�__� Diameter .___._ __ ... Depth below inlet .' .R otal leaching area � .-'::aq. it. z Other Distribution box �c ,) Dosing tank Percolation Test Results Performed b Alan Jones_______________________________________ Date_._.__..1�25�78 Y----- --------------- . . ----------- aSeE� T st Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water__.-----..-_---.--.----- a� tack fs, st Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water-----------._...___..__. document ................. - ------------------------ ----------- Description of Soil----For---test---p?3*.$ .esul't a--,and!,,-dp—,SC1� ption..0 _ sc li----see,',daa ment x attached, V c ------------------ U .. -••• l�=�'T''`--...\ ete. --- ---- /�u=' S � ----------- ----------- W VNature 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 Article XI 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. Sied...................................................................................... --------....................... Date Application Approved BY----- ;' - - -- }' •1 7 r Date Application Disapproved for the.following reasons--------------- ------------------------------------------------------------------------------------- ...... ------------------------•••------------------------------------------------------------------------------••-•--------------•----•---•-----------••-•--------------------:------------------------------ Date PermitNo......................................................... Issued------------ .................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........T4WN...................OF........BARNSTAF3hta............................................. QWfifir tle of fT rm li nre THI 1 O CE Y, That*the Individual Sewage Disposal System constructed (X ) or Repaired ( ) ----------•----------------•••-•--•-----••••-----•-•--••-•-...-•-•--•. b ' Installer at --------- ---- dot No. 75 otuit Bay- Drive, Cotuit,- Mass, t -------- - ------ ---------------- - - --------------------•-----•--••............----•---•••••. has been installed in accordance with the provisions of Ar tale XI of The State Sanitary Code as described in the 1� application for Disposal Works Construction Permit 'A1o.- ._ .__--__•---- ------------------- dated. ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL•F �FTION SATISFACTORY. DATE---------- --- -------- Inspector F---•-•••-•-•••••---•- .............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ^ TOWN BARNSTABLI ...............................O F.............................................................--•-----------......... a-v No. = FEE'S--- •- A i o 1 ork Qlla itrurtion "rrmit A. Permission is hereby granted - ->�- --•-.. -----`------•--------------------------------------•-•--•--------•---------•---.----- to Construct (K ) or Repair an Individual Sewage sposal System at No--------------Lot -NNo.°- 75 otuit BaY..Dx Ve+ - _� ` S s/} a Street 2 i• 7'------------------- as shown on the application for Disposal Works Construction Permit No.____ ____________r Dated.._.`__________. , 7P. --------- �� ��• l!� =1 •----=•---------.-: Board of Health DATE. - ---------- ---- ---------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS } ,s D ES t tt bATA � t='Low z 1tot3 SEP C_ TAU4V =41::�S '4V7 a� _ 7AZ6ka t ur,E I500 GkL ✓187 Z d15POSAL PVT V V6 - G g, 7. 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