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HomeMy WebLinkAbout0544 MAIN STREET (COTUIT) - Health 544 Main Street 037-003 Cotuit vfp P00 a QF COMMONWEALTH OF MASACHUSETTSOr EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS40 DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500, TRUDY COXE ' Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION. Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635 ' Name of Owner BEVERLY DONHEISER Address of Owner: BOX 213 COTUIT MA.02635 Date of Inspection: 2/26/00 1j, z Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: TITLE V SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET MA.02636 " Telephone Number: 608-664-6813 cFRTIFIGATION 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: X Passes _ Conditionally Passes " _ Needs Further Evaluation y the Local Approving Authority, Fails Inspector's Signature: „� Date:2/26/00 ' The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 owner and copies sent to the buyer,if applicable,and the approving authority. , NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO.TWO YEARS FOR PROPER MAINTENANCE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A a CERTIFICATION(continued) Property Address: 644 MAIN ST. COTUIT, MA R037-003 02636 ; Name of Owner BEVERLY DONHEISER Date of Inspection: 2126/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. nla 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;or 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 complying septic tank as approved by the Board of Health. nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced ` nla 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 F M obstruction Is removed, _+ 4 revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635 Name of Owner BEVERLY DONHEISER Date of Inspection: 2/26/00 7 ' C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and 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 nLa(approximation not valid).. 3) OTHER n/a ; revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635 Name of Owner BEVERLY DONHEISER Date of Inspection: 2/26/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No c• . - X Backup of sewage into facility or system component due to an 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 1/2 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 Q. _ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 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 I 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.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"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 X the system is within 400 feet of a surface drinking water supply , - X the system is within 200 feet of a tributary to a surface drinking water supply - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IW PA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9098 Page 4 of 11 L - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _. PART B } CHECKLIST Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635 ' Name of Owner: BEVERLY DONHEISER Date of Inspection: 2/26/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ 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. X _ As built plans have been obtained and examined.Note if they are not available with NIA. X _ The facility or dwelling was inspected for signs of sewage back-up. _ X _ The system does not receive non-sanitary or industrial waste flow. X - The site was Inspected for signs of breakout. X - All system components,excluding the Soil Absorption System,have been located on the site. X _ 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: X _ Existing information,For example,Plan at B4O,H, - X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the•proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635 Name of Owner BEVERLY DONHEISER Date of Inspection: 2/26/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:3 Garbage grinder(yes or no):NO Laundry(separate 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 two year's usage): n/a gpd ' Sump Pump(yes or no): NO Last date of occupancy: n/a CO M MERCIAUINDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) " - n/a GENERAL-INFORMATION - PUMPING RECORDS and source of information: THE SYSTEM WAS PUMPED BY ABCO 2 YEARS AGO r System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a - n TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system. F f ~a _ Single cesspool _ F. _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: BLOCK CESSPOOL OVER 36YRS.WITH A NEW PIT IN 1991 q - Sewage odors detected when arriving at the site:(yes or no), NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION(continued) , Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635, - Name of Owner BEVERLY DONHEISER Date of Inspection: 2/26/00 BUILDING SEWER:X ° (Locate on site plan) Depth below grade: n/a E Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a - Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TWO SEWER LINES ONE IS ORANGEBURGAT3;THE OTHER IS CAST IRONAT 16';THERE IS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 6" Material of construction: X concrete_ metal Fiberglass_ Polyethylene_ other explain: n/a If tank Is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 6'X6'BLOCK CESSPOOL NOT TIGHT" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32 Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED 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.) MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other - Explain: n/a " Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet 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 f 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.) n/a i J revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635 Name of Owner BEVERLY DONHEISER Date of Inspection: 2/26100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) ` Depth below grade: n/a Material of construction: _concrete_ metal Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallonstday Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a . .r Comments: _ (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a - Comments: (note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a } PUMP CHAMBER: _ (locate on site plan) _ 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 revised 9/2/98 Page 8 of 11 I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 544 MAIN ST. COTUIT:MA R037-003 02635 Name of Owner BEVERLY DONHEISER Date of Inspection: 2/26/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) L If not located,explain: n/a Type A leaching pits,number:(n/a)1000 GAL 6 X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a ' leaching trenches,number,length: (n/a)n/a R leaching fields,number,dimensions: (n/a)n/a - overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a „ Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2'OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT.THE PIT WAS INSTALLED IN 1991 PERMIT#91.400 CESSPOOLS: (locate on site plan) Number and configuration: Na 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: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: ; (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a h PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) n/a , revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635. Name of Owner BEVERLY DONHEISER Date of.lnspection: 2/26/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: A include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) + O A AA(y� r - 4 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 544 MAIN ST. COTUIT, MA R037-003 02635, Name of Owner BEVERLY DONHEISER _ Date of Inspection: 2/26/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Y= Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health ` _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data ' Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER IS AT 10+FEET FROM MAPS AND CHARTS I revised 9/2/98 Page 11 of 11 i i �yy: Ygnkee Survey; 1 506 sxd 5553; Apr-8-0-0 11 .3"V; Page °i' RIZXUTI 0 At_LEY At: 7900072 *940 4 X A/7 LOT I A2322MOM w.J" ASIA(AP s� ARM- ;9p tR YAP J A Y J- Opp a vsati+�.-_ i S 11's.t ,� - '�,',�- �� rr roar a►acAts -. zy v_ AUZ=OAr MY J*44 1?,S. ZONE "RF" This MORTGAGE INSPECTION r'7o0I1 ZOJ C" Plaa is For Bank Use Qnly REGISTRY t}WNER,~ DE D RAF: BUYER AA K' PLAN REF` SCALE '°= B29 __.PT t HEREBY CERTIFY TO _ ,THAT THE BUILDING . YANKEE SURVEY iii6,w_lW_dW THIS PLAN IS LOCATED ON THE GROUND AS SHOWN AND THAT I`M PO5MON DOES ____ CONFORM t 6 CONSULTANTS TO THE ZONING LAW SETBACK REQUIREMENTS OF THE '� 143 ROUTE 149 TOWN .OF $d+���T ?I-R �_._. _ ._..___._AND THAT )a JIM errs UU,s UA_ CZS4 IT DOJM_l1 _ LIE WITHIN' THE SPECIAL FLOOD 14A ARD p TEL *n-DO55 AREA AS SHOWN ON THE KU.`Il MAP bfTED FAX 420- 3 A-A TFti PLAN ![Itor Alt A!l IJ TR' tF.N'f 28 12 3 SU I'!E tiSED G s TOWN OF BARNSTABLE L'O('ATION . SEWAGE # ®� XILLA\Gla d/ ASSESSOR'S MAP & LOT 034 003 INSTALLER'S NAME & PHONE NO. C oplrpw lz'xso � ICE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 1,yogq / (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ' BUILDER OR OWNER ;DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No a !rr . m r TOWN OF B RNS ABLE LOC'�,TION � � ` w wcc SEWAGE # ( / 000 VILLAGE ASSESSOR'S MAP & LOT6- 32"`477 INSTALLER'S NAME Si PHONE I CQ,r w ( �1��`�<<L� �� _a 6� x 0. SEPTIC TANK CAPACITY O I LEACHING FACILITY:(type) Via 'i" (size) too O NO. OF BEDROOMS-. _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ,r ® vz e i S e-r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Z VARIANCE GRANTED: Yes No '. �., V ,. may_ � �. ��" '� f _, fi �t. � . � Q � 3` 7 No.....11........_....... F ...._............... THE COMMONWEALTH OF MASSACHUSETTS C�g Car 777O� BOAR® Off" HEALTH �A-60: TOWN OF BARNSTABLE AVVIkation for Ditymial Works Ton rnstiun Vamit i,,3 li ,I Application is hereby made for a Permit to Construct or Repair �) anIndividual Sewage Disposal al System at: ........... ..._...................... .__ ..... .......................... •--... Locat` Lot No. . ........................... '( 'e............'. Adcj�es S `... ^----•......................................---� .............. ....... W L t ��..... -.... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............... No. of persons.........................`. Showers — Cafeteria A4 Other fixtures -------------------------------- . d -------•---••-•------•---------------------•----------- 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 ( ) Percolation 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........................ 9 ---- -------- ------------------------------------------•------------------------•-•--•-••-•.... -------------------------------- •.................. ... O Description of Soil.........._ V ..--•--•----------------------------------•-------------------------. ---------------•-•-•-----------------------------•-----------------------•-----------------•--••--•--------------••-•--------- W --------------------------------------------------------------------------------------•------------------------------------------:-- ------ ................................................... U Nature of Repairs or Alterations—Answer when a iF le----__-- �_'�_��...............r��� 4s................... --------------------------------------------- o� . Agreement: ,The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Envir ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co pli ce h ;been issue bb y"the board of health. Signed .------ . t1�rl GC�\,�X 9 " i ....................... ......................."---................------.................... . .......................... Dace Application Approved By �........................................ .�� -1 Application Disapproved for the following reasons: .......... ........................V---....-------- ................................. .. ..................................... . ---- ---------------------...........................................--...............------------ -----g..........--.--------------------------- Permit No. ..... yCTC�.. Issued . ....^.....(�.................................... te---... +r Dare t G� To t' ®© 'S FR THE COMMONWEALTH OF MASSACHUSETTS _�v"_ �'YZ✓I'�(!D� BOARD OF HEALTH _ s ��; ,�,, C_ TOWN OF BARNSTABLE .V-A Appliration for Biipnaal Workii Ton rnrtinn Vantit 11'3 �; or Repair an 'Individual Application is hereby made for a Permit to Construct '� Disposal g Individual Sewage s osa� ( ) ��"1 System at: - /f ....................... ... ....... -......1..... `L....ion—'A- ddres� S r Lot No. ....... ... a \ W \ S, Addxess� . ----- i ..------ S -v Installer Address Q Type of Building Size Lot............................Sq. feet V�--+ •• Dwelling No. of Bedrooms....13.................................Expansion Attic ( ) Garbage. Grinder ( ) aOther—Type of Building ............................ No.`of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ----------------------- ------------------------------•---•••------••--------•-----...._..--•-•------------•-•--•-..............••---•...........---- 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 ( ) Percolation Test Results Performed bY.......................................................................... Date............................---••------ Test Pit No. 1................minutes per inch Depth of Test Pit--..--..........--.. Depth to ground water................--...... rZ, - Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... a Description.of Soil ----S_: A �- ---.......................................................................,.................................................. U =---•----•--•-----•----------------------- ------- ----------------- --------------------------------------------- ----------•-•--•----------•-----------•---'.. W fi U j Nature of Repairs or Alterations—Answer when a i le.----.---- ............... �. ..�,..^................ 1--Q-0. A Agreement: •. ,The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the'provisions of TITLE 5 of the State Envir ental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co plice h been issued by the board of health. � ,Signed -- 2 `--------------------- ---- - -- ---------- --------------------------------------------- -- ................................. -- Date Application Approved By c— �� ��../.... --------------------------------------------------- --------------------- --- re t Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------- -------------------- ---------------------------- -- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- ... Permit No. ---........0 .7 Issued ../.... l °�--------------- Dare -'-------...._e------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE I Cexttfi a e of Compliance TIWS IS TO C RTIFY, That the Individual Sewage Dispos . System constructed ( ) or Repaired GL ` `'^ ------�'`--�--�--�-�----'�----------- bY................... 1.... staler at ............................. ` L } n---1 ............ . .�.....- ---------------------------------------------------- has S been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- ------------------------------------------------ dated -----------------------------...-.......---.---. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM VILL FUNCTION SATISFACTORY. ., p r • DATE..---------- ... ............................................................... Inspecto ....... ............ ....................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF,BARNSTABLE No. FEE. ...-v �t��n nr�� �.nnn�rn�irr�t rrnti� Permission is hereby granted........... .......Y.-`_.._`.°._ : V C- �L S . --•---------------•-•-------------.....-•-•--.........-----....................•- to Construct or Repair n In Ndual Sewage Disposal rSystem atNo........................ ....... ` ` ..............--------•---..... S h --e- e, s as shown on the application for Disposal Works Construction street ry� a PP P ruction Permit No.:=.,-=---•-----___-- Dated---------.........--..................... Board of Health DATE---- -•-----••-----/----•---•----•-••-----------•----••... FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS