HomeMy WebLinkAbout0017 KEELA ROAD - Health 17 Keela Road, Cotuit _
I A 018 - 062
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DATE : 1 /23/98
PROPERTY ADDRESS : 17 Keela Road
Cotuit,Mass.
02635
F
On the above dale, I Inspected the eeptic system at the` above'9 re667 -
Thls system conslsts of the following: 9;� T
t y oFe jg
1 . 1 -1 000 gallon septic tank. yoaST 8
�(T q9
2 . 1 -Distribution box. F'l9B�F '�A'
3 . 1 -1000 gallon precast leaching pit
packed in stone.
6aseo on my InPc�ectlon, I certify the following condltlons. �_9
4. This is a title five septic system. -*( 78 Code )
5 . The septic system is in proper working order
at the present time.
6 . The leaching pit is "dry.
7 . The house is vacant at this time.
• SIGNATURr
Name : J . P . Hacomber Jr... i
------ .---------------
Company: J . P_Macomber &- Son_Inc , ,
__Centervi 11e `Ma9s__02632
Phone : 5gZ__27y�338_______ I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
.)OSEPN P, MACOMBER & SON, INC.
TAnki-C.upooli-Lerchflelds
. Pumprd L lnilllltd
Town Sower Connectloni
P.O. Box 60 ' Centerville, MA 02632.0066
715-3 3 38 7 J 5-6-412
I I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
_ DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIAM F.WELD TRL DY CO>
Govcmor Sc:rcu
ARGEO PAUL CELLUCCI DAVID B STRUI
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission
PART A
CERTIFICATION
Property Address: 17 Keela Road Cotuit,Mass . Address of Owner:
Date of Inspection:) /2 3/9 8 (If different)
Name of Inspector: ,Tmsecah P_Ma camber Jr.
I am a DEP a proved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15,000)
Company Name: J.pP.Macomber & Son Inc.
Mailing Address: BOX 66 Centerville Mass. 02632
Telephone Number: 50 -775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: � �j •� , Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owne.
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15303
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
- t 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.
Indicate yes,nno, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not
1120 The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; of
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Avww.magnet.atate.ma-us/dep
0 Printed on Recycied Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Keela Road Cotuit,Mass .
Owner: Nickerson
Date of Inspectional /2 3/9 8
BJ SYSTEM CONDITIONALLY PASSES (continued)
&V Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
-v The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
.11Q The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance _(approximation not valid).
3) OTHER
(revised 04/25/97) P&9. 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Keela Road Cotuit,Mass.
Owner. Nickerson
Date of Inspection: 1 /2 3/9 8
D) SYSTEM FAILS:
You must indicate ewer "Yes" or "No" as to each of the following:
A)0 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CHAR 15.303 The bass
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correc
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the di;,tribution box above outlet inven due to an overloaded or clogged SAS or cesspool
4,a&A r r' C 4-/7
Liquid depth in c 4i9wI is less than 6" below inven or available volume is less than 1/2 day flow
Required pumping more than 4 times in the last year NOT doe to clogged or obstructed pipe(s)
Number of times pumped U.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation
Any portion of a cesspool or-privy is within 100 feet of a surface water supply or tributary to a surface water supple
Any ponion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with nc
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist
Yes No ,
/1,1�11'1 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 i1 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information
(r.vi+.d 04/25/97) P.g. 3 of 10
v \
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 Keela Road Cotuit,Mass .
Owner: I Nickerson
Date of Inspection) /2 3/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No f//
_ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for ssigns of breakout.
_ All system components, e4cluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Peg* 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:A.p. /bedroom for S.A.S.
Number of bedrooms: I
Number of current residents:-
Garbage grinder (yes or no):_V_V y
Laundry connected to syst m (yes or no): LZ��
Seasonal use (yes or no):l°1 7
Water meter readings, if avai ble (last two (2) year usage (gpd): fo " �'y
Sump Pump (yes or no):� `r'fi1%i
Last date of occupancy:
COMMERCIAUINDUSTRIAL•
Type of establishment: Abf
Design flow: A)p Rallons/day
Grease trap present: (yes or no)�
industrial Waste Holding Tank present: (yes or no)A,&f
Non-sanitary waste discharged to the Title 5 system: (yes or no)A`
Water meter readings, if avail ble:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy: !U
GENERAL INFORMATION
PUMPING RECORDS and so r e of information:
P, 16
System pumped as pan of inspection: (yes or no),�
If yes, volume pumped: gallons
Reason for pumping:
-
TYPE OF P,5TEM
Septic tank/distribution box/soil absorption system
106 Single cesspool
Overflow cesspool
Privy
Ve Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other / //
APPROXIMATE AGE of all components, date installed (if known) and source of information: !/Y�
Sewage odors detected when arriving at the site: (yes or no)'!i5l !
(revised 04/25/97) Page 5 of 10
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LOCATION SBWA #CIO" f
VILLAGE_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME A PHONE NO
SEPTIC TANK CAPACITY r o 1-
LEACHING gACILITY:(type} -� --
NO. OF.BEDROOMS r - -PRIVATE WELL OR UBLIC CATER
BUILDER OR65jER%
DATE PERMIT ISSUED:
DATE COZIPLIANCE ISSUED: �, - -
VARIANCB GRANTED: Yes No
C BOX66
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TOTRL ='.al
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Keela Road Cotuit,Mass .
P Y
Owner: Ted Nickerson
Date of Inspection: 1 /2 3/98
BUILDING SEWER:
(locate on site plan)
Depth below grade:L
Material of construction: _ cast iron J_ 00 PVC _ other (explain)
Distance from or.vate water supply well or suction line
Diameter
Comments: (condition of oints, ventin , evidence of leakage, e(c.)
n
klolu"Ily' IF
01
SEPTIC TANK:
(locate on site plan)
Depth below grade:(�
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age
& Is age confirmed by Cenificate of ComplianceILA(Yes/No)
Dimensions:
Sludge depth: Zyake
Distance from top of sludge to bonom of outlet tee or barfle: le C.e_
Scum thicknees:T(^/f2C
Distance irom top of scum to top of outlet tee or bah'le:�L4L
Distance from bonom of scum to bottom of outlet r baffle: .T..gSe
How dimensions were determined: YzL4�i Itee
Comments:
(recommendation for pumping, condit'M of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of lie ,kage, etc.) 2 5, Y
GREASE TRAP:Z2A fJe
(locate on site plan)
Depth below grade: 0(
Material of con struction:4//koncrete,%&tnetaLvAFiberglass.c,- Polyethylene42yother(explain)
Dimensions: Ad
Scum thickness:—Idze!�
Distance from top of scum to top of outlet tee or baffle:��
Distance from bottom of scum to bottom of outlet tee or baffler
Date of last pumping: till_
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) ?&g• 6 of 10
I LT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Keela Road Cotuit,Mass .
Owner: Ted Nickerson
Date of Inspection: 1 /23/98
TIGHT OR HOLDING TANK:&ZK�YjTank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:Aj
Materrai of con struct ion:44 concrete A&4metal lam/Fiberglass.liPolyethyleneU�other(explain)
eJ,Q
N�4
Dimensions: A)A
Capacity: .4)6 gallons
Design flog.. A gallons/day
Alarm level:. Alarm in working order Yes;A)A Nu
Date of previous pumping: AW
Comments
(condition of inlet tee, condition of alarm and float switches, etc.)
J
DISTRIBUTION BOX:1--�
(locate on site plan)
Depth o: lewd level above outlet invert:���
Comments.
(no a if level and distribution is eq al, evidence of soli s carryover, evidence of leakage into or out of box, etc.)
eWe-
/L/ g r4rJ^
B
PUMP CHAMBER:&ye—
(locate on site plan)
Pumps in working order: (Yes or NO)-A.Z/Q
Alarms n working order (Yes or No),&A
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r.vl..d 04/25/97) Pig. 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Keela Road Cotuit,Mass .
Owner: Ted Nickerson
Date of Inspection: 1 /2 3/98
SOIL ABSORPTION SYSTEM (SAS):
;locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Tye. !
leaching pits, number:
leaching chambers, number: Q
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:_
overflow cesspool, numb r:n
Alternative system: AM
Name of Technology:
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding condition of vegetation, etc.)
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inven: ,,4>f4
Depth of solids layer: 4222
Depth of scum layer: AJA
Dimensions of cesspool: &%
Materials of construction: 414)
Indication of groundwater: All'
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: .(J/if Dimensions:
Depth of solids:-Jl11
Comments:
(note condition of soil, signs of.-hydraulic failure, level of ponding, condition of vegetation, etc.)
(r.vl..d 04/25/97) P.g. 8 of 10
�1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Keela Road Cotuit,Mass .
Owner: Ted Nickerson
Date of inspection:1 /2 3/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
V.
' ?J bFn-�
(revised 04/25/97) Page 9 of 10
l
I
SUBSURFACE SEWAGE DISP,. I. SYSTEM INSPECTION FORM
I . C
SYSTEM INFOI: :ION (continued)
Property Address: 17 Keela Road Cotuit,Mass .
Owner: Ted Nickerson
Date of Inspection: 1 /23/98
c
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater 0&-a:ion:
Obtained from Design Plans on record
-Z Observation Site (Abutting�pro_p_rty, observation hole, baserntni s imp etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Grounc}../a-irzr•Elevation. (Must be completed)
Grounwater Contours are based on Gahrety & Miller Model
1 2/1 6/94
of 10
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-
TOWN OF Barnstable BOARD OF HEALTH
SUIISURFACF SEWACF DISPOSAL SYSTF,M INSPECTION FORM - PART D - CEI(TIFI CAT ION
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 17 Keela Road Cotuit,Mass .
ASSESSORS MAP , BLOCK AND PARCEL # � d C�
OWNER' s NAME Ted Nickerson
PART D - CERTIFICATION �
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & S.e'n' Inc.
Box 66 Centerville Mass . 02
COMPANY ADDRESS � 632
Street Town or City StatI ZIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true , accurate , and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one ;
�7stem: PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 15 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have cony rcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection folim .
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the DOARD OF 11EAL1'II.
* If the inspection FAILED , the owner or"*oporator shall u
Yatem
within one year of the date of h owed O required
e eared
the inspection , unless allowed or
otherwise re wired as provided in 310 Ch1R 15 . 305 ,
q
partd . doc
1 c �'
cn v
ti
THE COMMONWEi ALTH OF MASSACHUSETTS
DEPAR` NIENT OF ENVI[RONIIMNTAL PROTECTION
BE IT INN O WN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CER i i D TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
lunc B 199S
Acting Oicccior of (tic �) ( toll Ur W21cr {'UflutiUn Control
i
t
LOCATION? SE AG ii
VILLAGE ASSESSOR'S MAP & LOT
—D
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS ,
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
\ r .
ram\
TOWN OF BARNSTABLE
LOCATION + �„ SEWAGE #.CIO O .
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME Cz PHONE
SEPTIC TANK CAPACITY
r
LEACHING FACILITY:(type)
NO. OF BEDROOMS ��PRIVATE WELL OR P� UBLIC WATER
BUILDER OR XN.ER�
DATE PERMIT ISSUED: "
DATE COLIPLIANCE ISSUED: ��—�77
VARIANCE GRANTED: Yes No
r
A7^ J •Y .. Y
F' �I r/
J
ASSESSORS MAP NO:
PARCEL NO:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplirFatinn for DiupuuFal Workii Tonutrur#inn Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
System at: ���-
,- .................................... ...............•-•-•--•••••....__•--....... ---•-•---•--.............__:________------
Lo t' -A d ss .. or Lot No.
!�1 ddr ----•-• --•.............
Installer Address
d Type of Building Size Lot............................Sq. feet
U
., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
4 Other—T e of Building ____- No. of persons•-•---•-_-__-___-_-._ Showers — Cafeteria
04 Other fixtures ---------------------------------------------•••-- --. -------------------------------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- 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 ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date------.
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
G%t Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..........-...................................................................................................................................................
ODescription of Soil...............................................................................----------------------------------------------------------------------------------•-.••.
x
U
w
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U N f Repairs or Alterations—Answer when applicable______...�..r� a:PnU__......... .- �"-
-------------------------------------------------------------------•--_----•-•-----------•--•----•-------
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 Co ianc b eS sue board of health.
Sign --- ------,. ----------------------------------- ...... .............. .............. 7 90
.e.� to
Application Approved By ............. . U--....---- .. �`�-------------------------------------------------------------------_- --------�
bete
Application Disapproved for the following reasons- ..........................------------------------------------------------------------------------------------------------------------
-------------------------------- ----- -------------------------------------------------------------------------------- -----------------------------------........................------------- .................................
PermitNo. .........%�------ 1-------_------------- Issued .........................................................
....-...
Date
Woo
No.»_?e. �6 r F:c$..... _
E THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratilan for Disposal Works Tnnstr urtio n Prrmit
Application is hereby made for a Permit to Construct,( or,Repair(+,�) an Individual Sewage Disposal
System at*
r .. ---- ------'................
.................... l�
».....__».»Lo 'or Lot No.
Rd`C`.... -------------------------'---._ � .. .`..c k ��Q-- V` a= �'4-•
Installer �f Address
d Type of Building Size Lot----------------------------Sq. feet
Dwelling-No. of 'Bedrooms............................................Expansion Attic ( :) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................
Showers ( ) — Cafeteria ( )
a
Other fixtures X ----•-----------------------------------------------•---
w Design Flow....... !• ' fJ�._�---___--gallons per person per day �T ta°1 daily�ftow____________________________________________galIons.
P T Total Length Lf-1 dth................ Diameter.----------••... Depth----------•-----
9 Septic Tank—Liquid capacity............gallons Length 1__i
,t-�
w Disposal Trench—No..................... Width..A_..A ___ � ength....._.__........... Total leaching area--------------------sq. ft.
x V �� Cf
� Seepage Pit No-------------------_ Diameter.__t,_._.__...._._._ Depth below inlet.................... Total leaching area..................sq. ft.
u
Z -Other Distribution box ( ) f Dooss}ng tank ( )
'-. Percolation Test Results Performed by ............::................................. Date........................................
Test Pit No. 1............s---minutes perinchf Depth of�Test/,Pit........ f/--__-- Depth to ground water........................
f=t Test Pit No. 2................minutes per inch Depth of T<e /___------ Depth to ground water------------------------
---------------------------------••-------............-.............................................................-......................................
O Description of Soil..................... J
x
-- -•-------•-------------------------------------------------------------------------------------------------------
w
UNature�of-Repairs or Alterations—Answer when applicable.______.�`7_ ff 16 ............. .
�� - -`---•----•-•---•--------------------•--............-----.......----------------------------------------•--------------•---•---•-•--•-......---------•--.
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 Cor<pliance as beefiissued by-th board of health.
(Signed - t". � ----... --- ---- -�d
Date
V- V----.---.- 7APPlication Approved BY ems .-.... te
Application Disapproved for the following reasons- ----------------------- -------------------------------------------------------------------------------------------------------------
--------------_-----------------------------....................................... ...---- ----...----...----------------------------------------......................... ------------------ ----------------------------------------
�j Date
Permit No. ........7f"..--- ' -------------------------- Issued .............................................................
---.------.. ----------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(.9Ex#ifirate of Cfumpliance
T TS-7S TO CE TIP`Y;That fliie Individual Sewage Disposal System constructed ( ) or Repaired
by. �1 ...� -- -- ------ ...................................
---Installer ------
at --------........................ ---....------..�.�.- .:.t 1 - ...------------- ......-..... "y....
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ............ %2...-.- .e-1.-..... dated ---------- ................------------..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A5 A GUAR TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- .3- �c 7------ -----------_. .............. Inspector ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...., .:... . � FEE...."`..(�_
Disposa-1 oaks Tons#rudion rrmit
E�Permission is hereby granted.--------�= -`Q —�--� ,- ---•--•• •-----...-•---•---•-••.....................
to Construct ( ) or Repair (��n Indivldual Sewage Disposa Y.Pem
at No............. .. ..........�.P_D, " - �_-Flu ice—"
........ •.............. -...-..--••••----•------••--.....u.............-•...................................................
Street
as shown on the application for Disposal Works Construction Permit,No.._/.47 L Dated..........................................
L.. — / / ' / . Board of Health
DATE....................... ....-•..............................•--•-•--------..._�..
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS