HomeMy WebLinkAbout0023 JOHNS PATH - Health 23 Johns Path i
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COMMO11MIEALTH OF MASSACHUSETTS
EXECUTIV1 OFFICE OF ENVIRONMENTAL AFFAIRS
EPARTMENT OF ENVIRONMENTAL PROTECTION VED
EI
DJ
OCT 3 12002
TOWN OF BARNSTABLE
o,
e`� HEALTH DEPT.
1
TITLE
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 23 JOHN'S PATH M ARSTONS MILLS, MA 02648 O
Owner's Name: GIORDANO .
Owner's Address: 72 COHASSET,ST WORCESTER,MA 01604 91
Date of Inspection: 10/21/02
Name of Inspector: (please print) JOHN GRACI
Company Name: s.. SEP'tiT iC. INSPECTIONS la '
Cap
Mailing Address: ;' P.O. BIOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX; �`08-564-7270
CERTIFICATION STATEMENT
1 certify that I have personally inspected the'sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the-time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of T Ale 5(310 CMR 15.000). The system:
1�8 �pa� xr } c,,�j7 �� -P� ,
'A Passes �n � remon� ,,,r
X Conditional -'asses b /vM,,Cc,��.✓' ,A�/
_ Needs Furt E,aluation by the Local App�oving Author ity
Fails
Inspector's Signature: Date: 10/21/02_
The system inspector shall submi a cope of this inspection report to the Approvint,,Authority(Board of Health or DEP)within
30 days of completing this inspection. It the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall s&-iiii the report to the appropriate regional office ofthe DEP. The original should be
sent to the system owner and copies sent;o th..buyer, if applicable,and the approving authority.
Notes and Comments -
SYSTEM CONDIT1 NALLY'PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFUL LIFE:
****'Phis report only describes conditions at the time of inspection and under the conditions of use at that lime. 1'hls
inspection does not address how the,system will perform in the future under the same or different conditions of use.
iL
'I'll1v 5 Incnrrlinn I'nrm A/I S/7n(HI
Page 2 of I 1
OFFICIAL INSPECTIONFORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 JOHN'S'`PATH MARL TONS MILLS, MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
Inspection Summary: Check A,B,C,D•or E/,ALWAYS complete all of Section D
y
A. System Passes: & `Y
_ 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 notevaluated are indicated below.
,.#T
Comments:
SYSTEM CONDITIONALLY PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS
TO PROLONG THE SYSTEM'5 USEFUL.LIFE.
B. System Conditionally Passes:
X 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' epair,as approved by the Board of Health,will pass.
x
Answer yes, no or not determined(Y,N,ND) in"the for the following statements. If"not determined"please explain.
aar, �
n/a The septic tank is metal ail&pver'20`years o'Id* 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,a'vailable.
ND explain: n/a
n/a Observation of sewage backup Sorll break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or.uneven distribution box. System will pass inspection if(with approval of Board of
Health): '
_ broken pipe(s)'are replaced
_ obstruction'is removed
X distribution box is leveled or replaced
ND /a n pi-v
ex lain: e p � `��q /sysr!
n/a The system required pu nping more 1ian 4,times a year due to broken or obstructed pipe(s).The system Zil pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_ob'struction is removed
Z � g
ND explain: n/a
y .
3E t
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
w, PART A
�'ttii s CERTIFICATION(continued)
Property Address: 23 JOHN'S PATH MARSTONS MILLS,MA 02648 +
Owner: GIORDANO
Date of Inspection: 10/21/02
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.jhe,environment,
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is withm 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 surfac'e'°water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septiclh,nk`atid SA°S and the SAS is within 50 feet of a private water supply well.
�4 6!
_ The system has a styptic tank and SA§and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used'rto'deter'mine distance n/a
"This system passes if&well water`analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds'ndicates fh'at 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'Iorm.
... - •8�: 'elf,.. Y '. - -
3. Other: e
n/a = k
s
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Page 4 of I I
OFFICIAL INSPECTION;FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
4 13
Property Address: 23 JOHN'S PATH MARSTONS MILLS,MA 02648
Owner: GIORDANO r r
Date of Inspection: 10/21/02"
D. System Failure Criteria aI Aeable to all systems:
You m.usl indicate"yes"or"no"to each of the following for alLinspections:
Yes No '
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa. 1,1,
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy imithin 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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. IThis system passes if the well water analysis, performed at a DEP
certified laboratory, forrcoliform bacteria and volatile organic compounds indicates that the well is free
from pollution from tliat.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 forma
(Yes/No)The system faits..) 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's'ystem 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet'of a triburt'ary to a surface drinking water supply
Y
X the system is located iii 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 tailed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section DPslfall'upgiade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
•
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Page 5 of 1 1
F }
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART B
CHECKLIST
Property Address: 23 JOHN'S PATH MARSTONS MILLS, MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No ,
X _ Pumping information was provided:by the owner,occupant,or Board of Health
t„ � >
X Were any of the system components pumped out in the previous two weeks`'
X Has the system received normal ,lows in the previous two week period
X Have large volumes of water bee, introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were n,,available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of creak out?
X _ Were all system components,exciading the SAS, located on site 9
X _ 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 ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposa[systems? '
g
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.. For'eza' le;a plan at the Board of Health.
X _ 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)]
f•
`t
5
III _.
II Page 6 of
OFFICIAL-INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 JOHN'S PATH MARSTONS MILLS,MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02 t.
FLOWXONDITIONS
RESIDENTIAL `
Number of bedrooms(design): 3 Number+of,bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: n/a t
Does residence have a garbage grinder(yes cr no): NO
Is laundry on a separate sewage system-(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no)',:.,NO, `
Seasonal use: (yes or no): NO
Water meter readings, if available(last-2 years usage(gpd)): n/a
Sump pump(yes or no): NO '`_, , s
Last date of occupancy: 10/12/02„ ` s';„
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a" 'N'. ;• " # F
Design flow(based on 310 CMR 15.203):,n/agpd
Basis of design flow(seats/persons/sgft,etc.):.n/a
Grease trap present(yes or no): NO s
Industrial waste holding tank present(yes or,no): NO
Non-sanitary waste discharged totthe,Title 5 system(yes or no): NO
Water meter readings, if available:kn/a
Last date of occupancy/use: n/a`
OTHER(describe): n/a
r CEINERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspectic.n(yes or no): NO
If yes, volume pumped: n/agallons-'-',.Howwas quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool A '
_Overflow cesspool '
_Privy
Shared system(yes or no,)(i:f yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a I copy of the current operation and maintenance contract(to be obtained fi•om
system owner)
_Tight tank Attach a copy o'f�the DEP,app`roval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of infor�iiation:
1986 BY OWNER
Were sewage odors detected when arri:v.ng at the site(yes or no): NO
Page 7 of I 1
f'
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 JOHN'S PATH MARSTONS MILLS, MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
BUILDING SEWER(locate on site plan)
Depth below grade: 9"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
WELL WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:3" ,
Material of construction: Xconcrete .metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is ak&6*6f rtned by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS"
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet teeor baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY'TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan) , (;
Depth below grade: n/a
Material of construction:_concrete_metal f berglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top ofoutlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
y tY., .,� f -
to outlet invert,evidence of leakagev ,e'fc.)
n/a t
fit( . 7 t
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM ENSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 JOHN'S PATH MARSTONS MILLS,MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a + '
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explair): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be,opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX IS STRUCTURALLY UNSOUND:"
PUMP CHAMBER: _ locate on site ,Ian
( plan)
S.
Pumps in working order(yes or,no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
I. .
L R
Page 9 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE'VIAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 JOHN'S PATH 11/iARSTONS MILLS, MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a ieaching trenches, number, length: n/a
n/a ,,aching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a fi;.i s € ° 'raiovative/alternative system
h k /pe/name of technology: n/a
Comments(note condition of soil, signs of E.ydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE LEACH PIT. PIT APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. RECOMMEND KEEPING TREES OFF OF SYSTEM.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a.
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or-r-o): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a '
Dimensions: n/a '
Depth of solids: n/a
Comments(note condition of soil,signs;of hydraulic failure, level of ponding coG:'. ion of vegetation,etc.):
n/a
4
1
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 JOHN'S PATH MARSTONS MILLS,MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page I 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 JOHN'S PATH MARSTONS MILLS, MA 02648
Owner: GIORDANO
Date of Inspection: 10/21/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local`excawators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+ FT.
-. •r
� � F
06/14/1994 00:13 508-790-1578 J.P.MACOMBER & SON PAGE 02
JOSEPH P. MACOMBER & SON, INC.
P_O.Box 66
CENTERVILLE.MA 026U.0m
77SS3338 7754412
Thomas Mckeon February 6, 2003
Barnstable Board Of Health
RE: 23 Johns Path Marstons Mills Ma, 02648
On 11/7/02 we removed all roots from distribution box. Cemented&
reconnected all joints. Distribution box is now in proper working order.
Sincereley
6--
Joseph P. macomber Jr.
Joseph P. Macomber& Son Inc.
Septic Inspection Information
" 10/31/ 00 I>I :tic irr>:.;:''>ct l i 2 2ps .:. 876
sesSOFS.':?[ap 027 # r '> ------------
124n# 98
<' tkr 23 a Johns Path
Marstons Mills
>an r John Grad
€.fin:>::» # te> rs rr a a s C
:::: . 0/21/2002 ......................:... P/R
igiisrel Originally CP due to D-Box; Macomber removed roots and
reconnected the joints in the d-box on 11/7/02. Distribution box is
now in proper working order according to J.P.Macomber,Jr. The
e# ti spar[.aa€e 11/7/2002
fiC 1 E at I`l rsfa#i 7
> �e�at D �lne�aes
JOSEPH P. MACOMBER & SON, INC.
Tanks - Cesspools - Leachfiields
Pumped & Installed
Town Sewer Connections
P.C. Box 66 Centerville, MA 02632-OM
775-= 775-6412
INVOICE
JohnOordano 2-65,�.2
,
72 Cohassett Street 11/13j02
orcestet MA 01604
Job Address
°TE;RMIS 23Johns Path
Cash 1.5% every 30 days MarstonsMilis MA 02648
y�
,4 9 F
srr# r.4 1�x4.
E--:g
11/7/2002 Removed roots& reconnected joints on d-box. $150.00
Notes CHARGES SUBTOTAL: $150.00
CREDITS SUBTOTAL:
BALANCE DOTE:BaknceDje
i
%11
No.._.. . FE:jc ..........
.......... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7_e,"V.,0V................OF......
... .....................
Appliration for Diaposal Workfi (filtutrurnatt Vamit
Application is hereby made for a Permit to Construct (W/Or Repair an Individual Sewage Disposal
System,at:
.........................................
,gc...........
a Address or Lot No.
d
........... . .. e-- ...... ..............
....................*"*"*'*....... --------------------
---------------
---------jwn Address
7.. ...... 4W ........... ........................................................................
Installer Address
-----7-'-7
.. . . ......... ...
Type of Building Size Lot...1_3.i�.....Sq. feet
U
Dwelling—No. of Bedroot ns.......:3................................Expansion Attic (�/p Garbage Grinder (
P4 Other—Type of Building ... .............. No. of persons_........._................. Showers Cafeteria (
Other fiVures ------------------------------------------------------------------------------------------ ..........
-----------
Design Flow........ ............................gallons per person per day. Total dailyflow.._........13..42.....................gallonsW .
Septic Tank—Liquid capacity/,O&v.gallons' Length AR:..47.. Width..!�-.5:7_ Diameter................ Depth.._t
Disposal Trench—No. .................... Width.................... Total Length....... Total leaching area.__..........c.....sq. ft.
Seepage Pit No... V-4� ----
> Diameter........12..... Depth below inlet........... Total leaching area.2..!IL3sq. f t.
4 -----
Z Other Distribution box Dosieq_tapkn(_7)
...................................... Date....
Percolation Test Results Performed by.......a............ . :41- Z
x t/��r�
Test Pit No. I................minutes per inch De h of Test Pit.................... Depth to ground water.___................,__.
Test Pit No. 2................minutes per inch Depth of Test Pit.._.._........._._.. Depth to ground water.:...._..._.........___.
.............................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
x
U .................................................................................................................................................................................................
.......................................................................................................................................................................................................
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 TL I Ti LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ed y the board of health.
Sied..6:11.1 .. ......... ................................. ..........................
e
7 ./,D�t.e
ApplicationApproved By...... . ........ ............................. . .. .............. .................. ................
Date
,/ffolWIowEg re
Application Disapproved for he .......... .. ...............................................................................
............................................................................... -------- ............................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
------------------------------------------------------------------------------
r
No.......................... FEz............._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...Z.r'A/V et.✓................OF...... ✓ !� .0 .-•.......................
Appliratiou for Uifipwial Workii Tomitrurtiott thrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
11.......... ...Gd>! ........... �1'............---......------....-----------............-------------••--•------.........----
m L ation-Address or Lot No.
...... . p / �_yA Owne y� �, • �......................
Address
a ....._5.�..C. L........L,::Uf.r�,,.__ .. ------------7
Type ..__......._....._......--••---.....•.• ^........^----
Installer Address
of Building Size Lot...,1-3...je25�-:G.....Sq. feet
U Dwelling— No. of Bedrooms.......3............. .---__---_-Expansion Attic (Z/p Garbage Grinder ( )
a Other—Type of Building .__ -------------- No. of persons............................ Showers ( ) — Cafeteria ( )
_._�5
dOther fixtures ••------••----•-••-•••------•----••••-•...••--•-•-•••-----------------------------------•---.--------............----......---...---•----••••--------
W Design Flow.......9.. ............................gallons per person r day. Total daily flow.........3_�_.c....................._gallons.
WSeptic Tank—Liquid capacity/&avgallons Length Width__�-..5---__ Diameter................ Depth.._........
x Disposal Trench—No. ._..y.............. Width.................... Total Length.......
'........... Total leaching area.._.......�.....sq. ft.
Seepage Pit No...NGO�=___- Diameter........12----- Depth below inlet........... ...... Total leaching area.2..--- 3sq. ft.
Z Other Distribution box ( ) Dosi )
�" Percolation Test Results Performed by............... ...�. .�a-14---.---_------.----------•------•----- Date.....
Test Pit No. I................minutes per inch De th of Test Pit.................... Depth to ground water........................
Gti Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------------------------------------------------------------------••--.........................................................
0 Description of Soil........-................................................................................................................................................................
U ---•....---•----•-----•-•---•-•••--•-••--•-••••-••-••--••-•-••----•-••.....------•-••-•-•--......••••-••---------••••-•......_..•---••••---•••-----•-••••.....•--•-----•-------••---•-•------•-----•-••-
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-----------------------------------------------------------------------------------------------•-•------•-------••••••---••-•---•••••---•--•-•'•--••--•---••...._....••••••••-••--•----•••--•.......-••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal SIstem in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned.further agrees not to place the system in
operation until a Certificate of Compliance has been ' ed y the board of h th.
Sig d...l .. ........
.- Date �T Zl
Application Approved By....... = ....-•--•---••- ---•••......�a d_J..............
l f f ,, _✓ Date
Application Disapproved for fthe following reasons:. .....................(...----------------------------------------------•-------------:..---------------..
-------------------------------------------------------------------------•---......-•---•.,.....-•••••....••••-•••--••-------------•--••---•••---••-••-•••......----•-• •••---...............•••.---
Date
PermitNo.................................... .................. Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,I ...... 1 /V..............OF............. ? 1✓ .l..lJ.. ......................
l�
r_ t Trrtif irtttr of Toutpliatta
r TICS IS TO ERTI Y, That the Indiv'. - al ewa a sal S-s m cons ruc.ted or R aired
g ( )
.....--
Installer
at..... ....... '-•---------------------------------------------------•---------....._.......----•---•------•-----•-•------- _ ------
has been inst, ed in accordance with the provisions of TITLL `,of T State Sanitary Coe described in the
application for Disposal Works Construction Permit No. _.._: .Z dated_.. ---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL-FUNCTION SATISFACTORY.DATE................ .._�.1 - �-•---••---•-•---------=-•--------- Inspector...-•-- '" ................................................................
THE COMMONWEALTH OF MASSACHUSETTS
l
BOARD 9F HEAL H
.............................................................
No. !
:................ FEE---•••---:......�....
J10#— g
Permission is hereby granted --------- -------, L = ...•-----� -•-•-......... `..... .
to Con
stn r� o;,Rycpair an IndividualeC; e Dis o�lV
at No......�v.. ->• - lY . ///.. �i.. �jf/
Street
as shown on the application for Disposal Works Construction Permit No.....�-56�.. Dated.._....... ....A ......................
................
•.................•.......... . ............
..�.._...._.... ...............
.....---•-•...
7r of Health
DATE-----....------------------!/-- •----.....•-•-----/-- •!� [.--
-• --- ---
FORM 1255 A. M. SULKIN, INC., BOSTON
r.
Upper Cape Engineering
P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617) 362-6281
w _ Sept . 17, 1.986
Board' of Heal th
Town of Barnstable
397 Main St .
Hyannis-, Mass. -
Dear Sir ;
This letter i-s to certify that the Septic System on
Lot 98 John- s Path was installed in accordance to- the plan
submitted bythis office , and further , that the well to
septic distances meet or exceed those as deliniated -on the
p l an C 1 of 1037
..- , *Thaon ou
Vic..
n Jacobi
r =
p
t
L
e TOP OF FOUNDATION
CONCRETE COVER
.,• CONCRETE COVERS
4"CAST IRON 12"MAX,
OR SCHEDULE 40 12"MAX. RM"'""''
P.V.C. PIPE 4 SCHEDULE 40 P.V.C.(ONLY)
• � PITCH 1/4"PER.FT PIPE- MIN. LEACH
PITCH 1/4"PER.FT. PIT
PRECAST
�I�N7 .T .... ��/ iy ! Q :•.. LEACHING G
•e Te
INVERT INVERT �' d•;' PIT OR
SEPTIC TANK BOX ELF... . ..•e INVERT
EL.33Xy DIST. w EQUIV.
...... GAL. INVERT "
EL. � INVERT a ww �: 3/4"T011/;
.'.
,'• EL.1W. C\ WASHED
'• Z� � ... FS2gX�
/�—►-��--W DIA. —►-I �-
0 0 ' '• �-- /7--D I A.--► }
PROFILE OF /V GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
:-NO SCALE
SQ1 L LO WITNESSED BY :
/ �
DATE .X r ,... TIME., ,, ,,,, /•��� ✓, , , BOARD OF HEALTH
TEST HOLE I TEST HOLE 2
EL-EV. �.1�a. . . . . . . . ENGINEER
ELEV. ..... .. .
DESIGN DATA :
NUMBER OF BEDROOMS , ,. , 3
TOTAL ESTIMATED FLOW . . 3 , , , GALLONS/DAY
BOTTOM LEACHING AREA /�. , , SO.FT. /PIT
SIDE LEACHING AREA . . ./. �. . . . . SQ.FT./ PIT
GARBAGE DISPOSAL . . �. ..(50% AREA INCREASE)
TOTAL LEACHING AREA �� . . . SQ.FT
PERCOLATION RATE 4 5 , , , , MIN/INCH
.... WATER ENCOUNTERED
Ao LEACHING AREA PER PERCOLATION RATE .. . . SQ.FT.
NUMBER OF LEAC�JNG\ PITS
APPROVED . .. . . . . . . . . . . BOARD OF HEALTH 7'e•�- 3:
DATE. . . . . . . . . 7o7W
AGENT 'OR INSPECTOR a
OF Mgsrq�4',
J, GO BI
.�V . f g �. . . . . . . . . . . �
S1 .
•/J� Y. . . o �gNATAV,\;
PETITIONER: • ' ' o _
ASSESSOR'S MAP NO PARC EL`� � a t -
LO C A T ION S I A G E PE RM�IT NO.
L.o 7' cra fj rr S 2 i47W
VILLAGE
`
I N S T A LLER'S NAME i ADDRESS
S U I L D E R OR OWNER :
�/I-C-4Fcl H6"k 'Fs
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
,� �, ��i�
97
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ASSESSOR'S MAP N0 PARE '�6, a .
LOCATION SEWAGE PERMIT NO.
P 19 7-54/
VILLAGE
INSTA LLER'S NAME i ADADRESS
s 'U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE C0IdPLIANCE ISSUED
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