HomeMy WebLinkAbout0172 CROCKERS NECK ROAD - Health FLA�F'=019-056
2 Crocker Neck Rd:(C ituit)
rX, TOWN OF BARNSTABLE
LOCATION SEWAGE #
w VILLAGE Gam%CJ�/ ASSESSOR'S MAP & LOTlap
INSTALLER'S NAME & PHONE
SEPTIC TANK CAPACITYd�
t.
LEACHING FACILITY:(type) (size) Lop
,NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: t1 J-5f)5 Tc'4b a--')
z/S77F,v( NE�S ' .A d
DATE CAahfflmaage ISSUED:
VARIANCE GRANTED: Yes No
+ 3
LOCATION /' e`O SEWAGE N
ASSESSOR'S MAP & LOT j
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)/L1i P"/ G��?0 , (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: CO LIANCE DATE:
Separation Distance Between the:
rF
ximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
vate Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of caching facility) Fat
ge of Wetland and Leach} Facility If any wetlands existwithin 300 feet o cac gFeet
nishc y `
1P7 Z Cmc(c�:r Na--k Co-u,�F
R
_ � ti
8/4/01
0 AT
PROPERTY AD ORE S S; Phi 1 Smiley---------_-
. 172 Crocker Neck Road
------------------------
Cotuit,Mass. 02635
--- -----------------
On ►ho above data, I Inapeoted the oeptlo oyflvh at the above address.
This ayslom conslsls of the lollowing;
1 . 1 -1 000 gallon septic tank. RECEIVED
2. 1 -Distribution box.
3 . 1 -1000 gallon precast leaching pit.
eased on my Inspection, I certify the Eollowing oondill naAUG 15 2001
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working order TOWN OFBARNSIABLE
at the present time.
HEALTH DEPT.
6. Pumped the septic tank at time of inspection.
Heavy scum & solids layers were present.
7. Waste water 22" below the invert pippe
of the leaching pit. SfQNATURE?;,/
Company: Joaa2h_P - Hacowber_& Son , Ync,
Address : Box 66----_-
-CencelyiIleL. H6 --02632-0066
Phone' 508- 11_5- 3338---
THIS CERTIFICATION OOES NOT COHSTITVTE A OVARANTY OR WARRANTY
JOSEPN P. MA'0M 'LR & SON, INC.
7+nk�.C.+t�pool���++chll+ld+
Jo
AA
Purnp:d 4 Init+Illd
Town stwtr Connoatlont
P.O. box 6r7S 3+3
8fy71S.64
IZ263
2-006o,,.
Al
.\ COMMONWEALTH OFMASSLACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 172 Crocker Neck Road
o ui , ass.
Owner's Name:Phi I Smiley
Owner's Address: 01
ame
Date of inspection: 8 4 01
Name of Inspector: (please print) J.P. Macomber Jr
Company Name:Joseph P. macomber & Son Inc
Mailing Address: Box 66
Centerville mn n2632
Telephone Number: 508-775-333£i--
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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: .
Passes .
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: —
The system inspector shall Obmit 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.
Notes and Comments
****This report only describes conditions at tbetime 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 same or difiereot
the
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 172 Crocker Neck Road
Cotuit,Mass.
Owner:Phil Smiley
Date OflospecdOD: $/4/01
Inspection Summary: Cbeck A,B,C,D or E/A W complete all of Section D
A. System Passe r
I hin�31�05.304
y information which indicates that any of the failure criteria described in 310 CMR
15.303 or exist. Any failure criteria not evaluated are indicated below,
Comments:
The septic system is in proper working order at the
m
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass"$ection 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 sepric 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:
!!�O 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 pipc(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
Xb 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 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 72 Crocker Neck Road
Co uit,Mass.
Owner: Phil Smile '
Date of Iospectioo:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require hu-ther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,,safety or the environment.
I. 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 bealth, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, Iran y) determines that the
system is functioning in a manner that protects the public health, safety and environment:
D The system has a septic 6M 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 l of a public water supple.
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 w)g90,feet but 50 feet or more from a
private water supple well''. Method used to determine distance Us k
'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
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: 172 Crocker Neck Road
Cotuit,Mass.
Owoer:Phil Smiley
Date of l ospection: 8/4/01
D, System Fallure Crllerla applicable 10 all iyrlem><I
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No /
_ 0,/�ackup 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 he distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool 1,1.. ffly 6 A101 ov"
_ iquid depth in Gcssposl is less than 6"below invert or available volume is less than h day flow
Required pumping more than 4 tirpes in tbellast year NOT due to clogged or obstructed pipe(s). Number
lof times pumped /
�y portion of the SAS, cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
,-,Water supply.
_ y portion of a cesspool or privy is within a Zone I of a public well.
.�y 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 collform 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 3I0 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�
th system is within 400 feet of a surface drinking water supply
system is within 200 feet of a tributary to a surface drinking water supply
— �Fthe
Y �' 8 PPy
_ 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 I I '
x a
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
r
n Property Address: 1 72 Crocker Neck Road
Cotuit,lylass.
Owner: Phil Smiley
Date of Inspection: 4 11
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
K
Were any of the system components pumped out in the previous two weeks 9
_ Ijethe 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,iacluding 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))
5
Page 6ofIl
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 72 Crocker Neck Road
Co ui ,Mass.
Owner: Phil Smiley
Date of Inspection: 8 4 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: A
Does residence have a garbage grinder(yes or no)- 44)
Is laundry on a separate sewage system ( -s or no):V[if yes separate inspection required)
Laundry system inspected(yes or no).
Seasonal use: (yes or no): VA ,Q
Water meter readings, if available(last 2 years usage(gpd)): m
Sump pump(yes or no):
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):--_—J� gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no): AO
Industrial waste holding tank present(yes or no):dA
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: k
Was system pumped as part of the inspection(yes or no): .
If yes, volume pumped: 45�gallons-- How was quantity pumped determined?
n Reason for pumping:Heavy scum & solids layers were present.
TYP F SYSTEM
eptic tank,distribution box,soil absorption system
Single cesspool
44�Overflow cesspool
,VQ Privy
IVP I(/ Shared system(yes or no)(if yes,attach previous inspection records, if any)
aInnovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from syst m owner)
Night tank �Attach a copy of the DEP approval
Other(describe):
ABproximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):efv
6
Pz$e 7 of I I
OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 172 Crocker Neck Road
Cotuit,Mass.
Owner: Phil Smile
Date of Inspection: 8 4 01
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:,&cast iron 40 PVC/tOother(explain): z/,4
Distance from private water supply well or suction line: lO/zl�'
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System is vented
through the house vent.
SEPTIC TANK: Zoocate on site plan) fOOd�/ �dd1S
Depth below grade: y�
Material of construction:�concreteA/0metal.�fiberglass polyethylene
4VQother(explain)
If ta.rik is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):,�)
(attach a copy of
certificate)
Dimensions: 09x,1 4/ �x�%�str/
Sludge depth: _
Distance from top of sl dge to bottom of outlet tee or baffle: C�
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bosom of scum to bonw of outlet tee or baffle:
How were dimensions determined: 1ryll Jill l.Ne 4 > DG -r�1.ty
Comments(on pumping recommendations, inlet and outlet tee or baffle Condit on, structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.): '
Pump the septic tank every 2-3 .years.Inlet &outlet tees are
in p ace.T a tank is structuraliy sound and sriows no evidence
of leakage.
GREASE TRAK&Fvlocate on site plan)
Depth below grade:,//}
Material of conswctioniCA concrete /4metaLVAfiberglass V&olyethylenue4tother
(explain):
Dimensions:
Scum thickness: d_/9
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: IVA
Date of last pumping:—�,4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present.
7
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 172 Crocker Neck Road
C tuit Mass.
Owner,
Phil Sintley
Date of Inspection:
TIGHT or HOLDING TANKy,JA—.'e,(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: �AconcreteViQ_m eta l Ala fiberglass.l0polyethylene 41 4 other(explain):
A�J9
Dimensions: Aid
Capacity: gallons
Design Flow: A64 gallons/day
Alarm present (yes or no): _,d2,A
Alarm level: AM Alarm in working order(yes or no): �
Date of last pumping: _
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX: 2if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has one lateral.No evidence of solids
carry over.No evidence of leakage into or out of the box.
PUMP CHAMBER (locate on site plan)
Pumps in working order(yes or no):A/
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pumpchamber is not present.
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 172 Crocker Neck Road
o ui ass.
Owner:Phi 1 Smiley
Date of Inspection: 8 4 01
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
1 -LP-1000 6 'X10 '
If SAS not located explain why:
Located. Waste wat2r is 22" below the invert pipe.
Type
✓leaching pits, number: 1
mber:
leaching chambers, nu
leaching galleries,number:
d leaching trenches,number, length: <T
leaching fields,number, dimensions: O
overflow cesspool, number: U
innovative/alternative system Type/name of technology:Z� ��O �
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to fine sand,No signs of hydraulic failure or
Ponding.Soils are dry.Vegetation is normal
CESSPOOLSC"cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: ,/�►Q
Depth of solids layer:
Depth of scum laver:
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.):
Cesspools are not presen .
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.):
Privy is' not present.
9
r
Page 10 of 11
OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 172 Crocker Neck "Road
Cotuit,Mass.
Owner: Phii Smi ley
Date of Inspection: 8/4/01
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 rect. Locate where public water supply enters the building.
, _
z.
10
Page 1 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:1 72 Crocker Neck Road
Cotuit,Mass.
Owner.Phi 1 Stni ey
Date of Inspection: 8 4 0 1
t
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water�7`' feet
Please indicate (check)all methods used to determine the high ground water elevation:
O fined frnm c�c�tgm esi fanso n record-If checked,date of design plan reviewed:
bserved site abuttin rope bservation hole within 150 feet of SAS)
ecked with local Boar o ealth-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water contours Map
Ga re y & Mii1er Mo e
12 16 94
11
y,.nrnr+.-n,•rsr.-rrrn.-mr•r.trn�-+.n+�.•rmr:•.r+�er Barnstable „�•'T-r„-..�..r...'
1 TOWN OF BOARD OF 11EA.LTII
SUIISURFACF SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
0•••t••1.r••••. ,-T.III.�.rTT,T,'.'l11',1.•1•►1 rw►,rs'rran'�+r•,•.r-t•f r{tTl't III-T��wr�n�7R� l�lr ..+.rPrr-�• -.
-TYPL OR PRINT CI,EARLY-
PI?OPERT Y I NSPEC7'ED
STREET ADDRESS 172 Crocker Neck Road Cotuit,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Phil Smiley
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.,
COMPANY NAME Joseph P. Macomber V ion Inc
COMPANY ADDRESS Box 66 Centerville Ma 02632
Street To vn or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790- 1578
w
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
omplete 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 ,
Che
�kk stem PASSED
D
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 151303 . Any faililre
criteria not evaluated are as stated in the, FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con toted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature 54 7 A- Date
ne copy of this certification must be prov ded to the OWNER, the BUYER
( where applicable ) and the BOARD OP HEAL'I'II,
w If the inspection PAILED, the owner or operator shall upgrade ' the system
within one year of the date of the inspection , unless allowed or required
otherwise as .provided in 3.10 CMR 16 . 306 .
TOWN"OF,BARNST BL
LOCATION � I�— �1G�/Ll.� j'Jc.�C� / C5, SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT Qj%
INSTALLER'S NAME & PHONE NO.&14 77fT
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) `� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER__
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No `� _
Fizic 0
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
Barnstable Conservation Department
BOARD OF HEALTH
OWN OF BARNSTABLE
Sig Date
Appliratiun for Di►,pimal Works C omitrnrtiun lirrmit
Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage Disposal
System at: /y
� ��Ad—
............ ..... ............. r
... .. ...................................
/L.j ..........................
or Lot No. ------
---`----{/. ......---- ... --....--- r---- //---*------- ------ ................------------......-- ...-........................----,-.......(1.....
W . . ...S...........` f.... ...`n.r.. ...1.G`!_1 �?-1 -_ !�G ` �.I.�i.'.X i...... s!i SSsd .........
1--1 / ..
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.............. .............----------- ....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures -------------------------------- -----------------------------•------•--------•------- ---------
W Design Flow........................................ ..gallons per perso er day. Total daily flow........._..............._.,gallons.
WSeptic Tank—Liquid capacity.. D.gallons Length______.____ 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..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
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........................
a -------------------------------------------------------------------------------------------------------------------------------------------------------------
0 Description of Soil-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W ----------------------------------------------------------------------------------------------------------------- ---
......_U Natn of ars�r ?lterat —Annswr when applicable.1� ___ ___________ .. 13
� .........
... n �...... ---------------------------------------------------
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 a ees not to place the
system in operation until a Certificate of Compliance e uepythe e
l'
Sig ...... .. . . .. ...... ................... ., ...... .....�............. .......-...... .....e.................
Application Approved BY .. ... ............ ... ................................_.. ...;i e I .
Application Disapproved for the following reasons: ..... . ' ....... . ..... . . ..................'. ....................
..... . . ... . .. .... .............................................................................................. Date .. ...................
Permit No. Issued ............ .. to
.............
:. ..
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_/'- TOWN OF BARNSTABLE
Allp iratiun fur Diripagtt1 Wurkq Tunutrnrtiun rprmit
Application is hereby made for a Permit to Construct ( ) or Rcpair(_�—)an Individual Sewage Disposal
System at:
1 Cxam
1" t -, ' /2c� �f,
J
..........�.. -.._ �. ...........,..._..... r•--=•--------•--•---....C•----_..... --•--•-------------------------------------------------------••---•-----•-----............-----_..
or Lot No.
r
a ___
O�rncr AdU'.ess -I
wfrl !l /j Plcc �� (�1 r�5� - c / x-A/f :- 'Ir �� ;
Iustallcr Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-------- ----------------------------------Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ----------------------------
d -------•-••-------•-------------------------------
w Design Flow:-�a...............................`__--gallons per person per day. Total daily flow------ _���........................,gallons.
W \Septic Tank—Liquid capacity__/.Gallons Length--Rj........... Width_.&_-_____-_ Diameter................ Depth................
x Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet..................__ Total leaching area..................sq. ft.
z Other Distribution box ( ) Dying tank (..................---->------..._-•------..._�--:_.._..-•----•-------._._ Date........................................
aPercolation Test Results Performed b
Test Pit No. I----------------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........................
9 -------------------------------------•----------------------------•-•-----------•---........__----••.............................................._..........
0 Description of Soil....................................................................................................................................... ....................._.........
x
V .............•----•--......-----.._._.....---------------------------------------•-----------••-----------•-----------------•--•--------•---------------------------•----............_...._........-
W ------•----•-----------------•------------------•---------------...-----------------------------------------------------------------•--- l
U Nature of Repairs or Alterations—Answer when applicable._f. � t � .__.rU i_:.�f '�._`/....... ....
J/! ----1 c�l..:7.!_5_�` .................................................-..................................................................
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 Compli�has bee'n f/Uuedby the boar-d-o�f h4eaallt1"r
Signed- :.._ /.../..... ....... ..r /�.�%, .A.............. .........
....
--------e
Application Approved B ,4-t'1/yl.�.. � ...........................
PP PP Y .:......-�- ;... ... ........... .._.._--...----- -----. v, ,.
Application Disapproved for the following reasons: . ....... ............................................. ....................
.................................................. ............... 1�................................................... ...................
e
Permit No. .......... ............... ..a .......... Issued .-..:...-....1-� D
;. Dace �......./..+�... ,..........
THE COMMONWEALTH OF MASSACHUSE I I S
BOARD OF HEALTH
TOWN OF BARNSTABLE
(9ez#if rate of (gomplianee
THIS IS TO CERTIFY, That the,Individual Sewage Disposal System constructed ( ) or Repaired
by .....
'`jO�JtPf. T,..... .f �' -E'lCt tr/)._..CfU i��.... lJ.t�r ........._.... .......... .................- ........-
at ........ ...`.7.�.... f' 1L i1 f? (-/ .. � ......... . .....- ------ --------
has been installed in accordance with the provisions of TITLE f The State En 'ronmental Code as described in
the application for Disposal Works Construction Permit I ---- dated .............
TH
E ISSUANCE OF THIS CERTIFICATE SHALL NOT BE tONS UEA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
._..... ....:..._.. ............ Inspector ----------------k r..... a.-----------------------------------------------------------
DATE
..._...............1.. ..-_1...... - d
i
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
j �v� TOWN OF BARNSTABLE
No._--1-- .......-.--- FEE•_..v.-_..........
Permission is hereby granted--------- !'lCJ. 1 /�1 < (-//11-�` --._..•...............
to Construct ( ) or Repair (---')an Individual Sewage Disposal System
at No................. 1 ( /�,P- / � Cl'__----- �`
Street
as shown on the app ication for Disposal Works Constructio Pe)mit No......�1/�/___`I)7ated..........................
•--•-•- Health.. V v
DATE............. •--- ••--�d�_.__...-•---•-------------•-••-•--•- -� � Board of
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS