HomeMy WebLinkAbout0944 MAIN STREET (COTUIT) - Health 944 MAIN.STREET, COTUIT
A= 035 094
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bATE•
PROPERTY . ADDRESS:'_ -44, Main: Street
Cotuit
Mass .-02635
On the above date, 1 Inspected 'the septic system at the above address.
This system consists of the following.
1 1-1000'.. 'gallon tank h .'
-Distribution box.
3. '1 1000-: gallon. leach-,pit,
Based on my lns.*ction, I certify the following conditions:
1 This is a title five septic system. ( 78,';06de )
2. .The aseptic system, 1s in proper ,worki`Pi,g order, at , the
pre's.ent,-time.
91GNATUR�: G`'(
Name: J-P_M_acomber _Jr ..
' •P_Macomber_ &_Son 'Inc. .Company:_
Address_ t7�T.
Centerville LMas_ s__0.2.632 ' �. e "
—
NQ
Phone:
THIS CERTIFICATION DOES NOT CONSTITUTE'A GUARANTY OR WARRANTY
VVM
JOSEPH P:' MACOMBER & SON, INC.
Tanks-CeupoolrLeachfleldsg
Pumped & installed '
rG .
Town Sewer Connection: k„
P.O. Box 66` Centerville, MA 02632 0066
, , fu'
773.333$ 77�-5412 . `�'
Jr � ax x.
[ P
Commonwealth of Massachusetts
Executive Office of 3 Environmental Affairs
Department of a
Environmental Protection
Wllllam F.Weld
Trudy Coxe
SKq,.Y.EOEA . • t
David B.Struhs
Commlasfona ., i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM
PART A
CERTIFICATION.
perty Address: 944 Main Street Cotuit Mass Address of Owner:
to of Inspection 9/2 5/9 5 (If different) 2
me of Inspector: Joseph P.Macolnber Jr.
mpany Name,Address and Telephone Number: ` + i
P.Macomber &: Son Inc. Box 66 Centerville ,Mass . .'02632 5.08 775 3338
RTIFICATION STATEMENT
ertify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
d complete as of the time of inspection. The inspection was performed based on my training and experience in the proper'function and
intenance of on-site sewage disposal systems. The system:
•� r
_.L. Passes I
_ Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority y` ;
_ Fails
.4�pector's Signatur �:' .P Date: .
e System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
pection. If the system is a shared system or has a design flow of 10,000 gpd orgreater, the inspector and the system owner shall submit
report to the appropriate regional office of the Department of Environmental Protection, t
e original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
SPECTION SUMMARY:
Check A, B,C, or D:
SYSTEM PASSES:
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15 303. i
LSY
Any failure criteria not evaluated are indicated below•STEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,, k
passes inspection.
irate yes, no, or not,determined (Y, N, or ND).' Describe basis of determination in all instances. If"not determined", explain why not)
Q� The septic tank is,metal, 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 8/15/95)
itt
One Wlnter Street 9 Boston,Massachusetts 02108+ .• FAX(617)556-1049 • Telephone(617)292-5500 L Vie+
SUBSURFACE SEWAGE DISPOSAt SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 944 Main Street Cotuit,Mass
Owner: Edith Crawford
Date of Inspection: 9 2 5 9 5 j
B SYSTEM CONDITIONALLY PASSES (continued)
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
i
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
i
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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
�D 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE }
ENVIRONMENT: I
A� The system nas a septic tank anU suit'absorption system and is within 100 feet to a surface: water supply o 'tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
Al
P The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_AV The system has aseptic tank and soil absorption system and 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^
D) SYSTEM FAILS: t:
f
1 have determined that the system violates one or more'of the following failure criteria as defined in 310 CMR 15.303. The hosts. f
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct I
the failure. }
Backup of sewage into facility oe 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.
(revised 8/15/95) 2 "'s ^ I
1 M+
- l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART A
CERTIFICATION (continued)
Property Address: 944 Main Street Cotuit,Mass
Owner: Edith Crawford
Date of Inspection: 9/2 5/9 5
D]SYSTEM FAILS(continued):
7
d Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. j
40 Liquid depth in cesspool is less than 6" below invert or available,volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to.,clogged or obstructed pipe(s),
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
�l0 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
AO Any portion of a cesspool or privy is within a Zone I of.a public well.
d!0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
�(Q 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. j
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
40 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
4/ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water.supply well`
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
3(revised 8/15/95) �
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a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 944 Main Street Co't•uit,Mass
Owner: Edith Crawford
Date of Inspection:
9/25/95
Check if the following have been done: ;
Pumping information was requested of the owner, occupant, and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal.flow rates i
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.`
built plans have been obtained and examined. Note if they are not available with WA.
The facility or dwelling was inspected for signs of sewage back-up.
/The system does not receive non-sanitary or industrial waste flow
Zhe site was inspected for signs of breakout.
_ZIAll system components,&luding the Soil Absorption System, have been located on the site.
_g4he 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.
_,U/The size and location of the Soil Absorption System on the site has been determined based on existing information or j
app ximated by non-intrusive methods.
7
The facility ov.ne, tanJ occupants, if different from owner) were provided with information on the proper maintenance of Sub.
Surface Disposal System. .
i
RECOMMENDATIONS .
J
1 . Septic tank must' be,','pumped.
I
(revised 6/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 944 Main Street Cotuit,Mass.
Owner: Edith Crawford j
Date of Inspection: 9/2 5/9 5
FLOW CONDITIONS
RESIDENTIAL: a
Design flow:1 gallons
Number of bedrooms:
Number of current residents:,
Garbage grinder(yes or no):
Laundry connected to system (yes or no): E=5 }
Seasonal use (yes or no):_&V
Water meter readings, if available: dJ666 V
/ s /
i
1
• i
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establish ent: yf� r
Design flow: 411,4 allons/day
Grease trap present: (yes or no)A0 i
Industrial Waste Holding Tank present: (yes or no)=
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) /V
Last date of occupancy: /ll
r
. GENERAL INFORMATION. .
PUMPING RECORDS and soAir a oqf� ' formation . . l
A ye- Pdl l¢ B/- 0 Ii
System pumped as part of inspection: (yes or no) 4
If yes, volume pumped. allons
Reason for pumping: A � LiAdy -
TYPE OF YSTEM ,
Septic tank/distribution box/soil absorption system I
Single cesspool
Overflow cesspool
_9 Privy
Shared system (yes 9 no) (if yes, attach previous inspection records, if any)
Other(explain)_
I
APPROXIMATE AGE of all components, date installed (if known) and source of information:
I
Sewage odors detected when arriving at the site: (yes or no) a
i
(revised 8/15/95) S � tM
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
- i
Property'Address: 944 Main Street Cotuit,Mass .
I
Owner: Edith Crawford_
Date of Inspection: 9 2 5 9 5 '
SEPTIC TANK: e
(locate on site plan)
Depth below grader
Material of construction: Lcncrete _metal _FRP other(explain)
Dimensions:
Sludge depth:ld"_
Distance from top of(sludge to bottom of outlet tee or baffle:
Scum thickness: _
Distance from top of scum to top of outlet tee or baffler r f
Distance from bottom of scum to bottom of outlet tee or'biffle:
Comments:
(recommendation for pumping, Condit' n of inlet and utlet tees or baffles, depth of liquid level in relation to outlet invert, structupal
i integrity, evidence of.leaka e, etc.). -
c h
T'
' GREASE TRAP:A
(locate on site p an)
Depth below grade: i`
t
Material of constructto • c ncrete _metal_FRP_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_ l
Distance from bottom of From to bottom of outlet tee or baffler
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 6/15/95) 6
SUBSURFACE.SEWAGE DISPOSAklYSTEM INSPECTION FORM,,.__
PART C
SYSTEM INFORMATION (continued)
Property Address: M in r et -COtuit,Mass . .
Owner: Ehih brave �dr
Date of Inspection: 9/2 5/9 5
. 1
TIGHT OR HOLDING TANK:.t k e '
(locate on site plan)
Depth below grader
Material of construction: oncrete metal_FRP_other(explain)"
Dimensions:
Capacity: al Ions
Design flow: allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
4zli2P
DISTRIBUTION BOX:
(locate site Ian
(oca on pl
an) n Depth of liquid level above outlet invert:
Comments:
(no a if level and distribut;ur, i;a uai, evidence of solids carryover evidence of leakage into or out of box, etc.)
PUMP CHAMBER:A,&
(locale on sit
e plan)
Pumps in working order.(yes or no) ,
Comments:
(note ondition of pump chamber, condition of pumps and appurtenances, etc.)
i
(revised 8/15/95) 7 ���, ; I
a a }
e
I
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM -
PART C
SYSTEM INFORMATION (continued)
Property Address: 944 Main Street Cotuit.,Mass ,
Owner: Edith Crawford
Date of Inspection: 9/2 5/9 5
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required, but ma�be approximated by non-intrusive methods)
If not determined to be present, explain: f i
Type,
leaching pits, numben—L—w a g,446V j 5C7
leaching chambers, number.
leaching galleries, number:_A)D
leaching trenches, number,length: Alt)
leaching fields, number, dimensions: NO
overflow cesspool, number:.&&
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
51 g 4�a,/ri4c/l�L ,RQ i �y��.Ln !b•� �tlegz!%/l/b u 01/s.Qls�
CESSPOOLS: !.
(locate on site pan)
Number and configuration:
Depth-top of liquid to inlet invert:_ 4
Depth of solids layer:
Depth of scum layer: j
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
i
PRIVY:` `
(locate on site plan)
Materials of construction: /�.� Dimensions:
Depth of solids: -
Comme : (note condition of soil, signs of hydraulicfailure, level of ponding, condition of vegetation, etc.)
(revised 6/15/95)
of
49,
SUBSURFACE SEWAGE DISPOSAL eSY$TEM.INSPECTION!FORM
PART C
SYSTEM INFORMATION (continued) y
Property Address: 944 Main Street.'Cotuit,Mass.
Owner: Edith Crawford
Date of Inspection: 9 2 5 9 5 i
5tCH OF SEWAGE DISPOSAL SYSTEM: '. •
Include tiesao at least two permanent references I dmarks or benchmarks
locate all wells within 100.. 71"41 Nl `
9-
9y 111,4/.v Sr col.
DEPTH TO GROUNDWATER �.
Depth to groundwater:p�4- -feet
method of determination or approximation: 44
(revised 8/15/95) 9
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Y 'I'OWN OFBarnstable BOARD OF HEALTH 1
SI(IIS(IRFACF SEWAGE DISPOSAL .SYSTEM INSPECTION FORM —PART D •- CERTIFICATION 1
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-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS _944' Main` Street Cotuit,Mass .
ASSESSORS MAP, -BLOCK AND PARCEL #
•
OWNER' s NAME Edith Crawford
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P. Macomber Jr. � J
COMPANY NAME J.P.Macomber. & Son Inc.
COMPANY ADDRESS Box 66 Ceiiterville,Mass . 02632
Street Toxn or City Stat• LIP
COMPANY TELEPHONE ( 508 ) 775 - 333.8 FAX ( .508 790 - 1578
CERTIFICATION STATEMENT
I certify that I have; personally inspected the sewage disposal system at
this address and that the' information reported -is ;true , accurate, and
complete as of theFtirne 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:
XXXXSysteui PASSED
The inspection which I have conducted has note-found any information
which indicates that ,the system fails to adequately protect public'
health or. the- 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 FAILEll* .�
The inspection which 'I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3,10 CMR 15 . 303., and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 29/95
One copy of this certification must be provided to the OWNER, the BUYER( where applicable ) and the DOARD OF HEALTH.
d >'
* If the inspection FAILED,' the owner or operator shall u MNl�
upgrade ' the system 2 •�within one year of the date, of the inspection, unless allowed or required= ° `
otherwise as provided in 310 CMR 15 . 305 . IRIV
tip-
t.Dartc� r�nn
cc.
mcnwecr,^ c; Maw cc-:tiers
Exewuve vttice cc Envlrcr,?-renTC:
Department of
Environmental Protection
Water Pollurion Ccnrrol Tecnnicet Asslsrcnce and Training cectons
VAULA ,F.Wad
co~nw
Trudy Co:.
SocrwmY.EEA.. .
Thom.&* &Pow*(*
%.ctr'9 CormYr..orr
p
06/12/95
ATTN: Joseph P. Macomber, ;lr.
Joseph Macomber and Scut
PO Box 66
i. Centerville, MA 0263
Dear Joseph P. Macomber, Jr. ,
t _ _
I am pleased 'to inform you chat.;-you have attended training, met` ,
the experience qualifications, 'and have passed .the`Title 5 `System
Inspector exam, pursuant to 310. CMR- 15.340. The passing grade •for
the exam was 39/52 or 75%.
This is an official notification that. you are a Certified Department
of Environmental Protection System Inspector pursuant to. 310 CMR 15 .340. .
You will receive a System Inspector certificate at a later date
If you have any futher questions, please write to me at the following,
address:
Kimball Simpson
D.E. P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very mutt: for �foa: time and consideration .in this mattes:
Sincerely, i
Kimbal'_ ':. 5'.mason,
DEP Training �r recto_
c', �
Di
!2 4 0
Route .n 9 Millbury, MA . FAX 58-755-g251 • - ,n• 508-756.7'0' `7", r
Water
Coris'ervation
sayE Tips . . . .
ME! , .
CHECK FOR LEAKS
Water Loss in-Gallons Due to Leaks
Leak
this loss Per Day . Loss Per Month
Size ,
. 120 3,600
• 300 10,800
693 ' 20,790
• 1,200 36,000
• 1,920 57;600
3,096' 92,880
B 4,296 .128,980
® 6,640 199,200
6,9,84 '• 20Q,520
8,424 ' 252,720
^, 9,888.. 296,640
® 11,324 339,720
12,720 381,600
1'4,952 448,560
L0CATION SEWAGE PEE RXITNol-N
I LL-,�C E
Ty 7`
INSTA L1 ; R'S INANE A ADDRESS
3UILDER DR OWN VI
DATE PERMIT ISSUED
DATA: C0MPLI ,AHCE ISSUES
t
'ram
vi
z '
,c Aj
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X
h
t.
�/ TOWN OF BARNSTABLE
6 or
LCx:A'1lUN ` � + SEWAGE
VILLAGEY ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITX;(tppe) (sue)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
Ob
n
0
i
TOWN OF BARNSTABLE
LOCATION� 1/!� J, !/I� �/. - ' SEWAGE
VILLAGE ��/ ASSESSOR'S MAP & LO'I0
INSTALLER'S NAME & PHONE.NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
a VARIANCE GRANTED: Yes No j
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No.... .......��.�� Fw3.............
-• .. .....
THE COMMONWEALTH OF MASSACHUSETTS SUBJECT TO APP::O'J_�!_ ""'-
BOARD OF HEALTH PAMST BL
CON91V�@SBt���
.................. .......................OF.......................................--.-.... .....................................
-
AVV ira ilan for Biiplaa al Workii Tonstrurtiun rruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--- �1�L......�.1 i .....f` ..........C��.e.7`--------------- ------------------------------------------- .............................................
Location- ddres or Lot No.
a
Owner Address
W-----•------------• -•--------------------------------------------------------------- . ........-----------------••-••.---•-------- -•---------••--•-------•••.......----------
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a4 Other fixtures ............................
W Design Flow............................:...............gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench_L;."No. ......j........... 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........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------•---------------------------..................------------------•.........................................................
0 Description of Soil...............
U •-••--••-•-----•-•• ,r9.f21 -------------------------------- ---------------------------- --------•• ....----------------------------......------...----
W -------------------- ------•-------•--------•----•------------------------•-•-----••------------•------------------------•-......---- ---------------------------•---------------
V Nature of Repairs or Alterations—Answer when4aplicable
...............................................................................................
----------------------------------------------------------------------------- -n-�'------------------•-----------•------•----------•-------------------•------...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be 2i,.ssuedy board of h lth.
Signed•. ---.• ------------------------------- --- +Application Approved By--•••-•---••---•---•----•-----.... . ---- -•-- . -• . -••--•---- . ---------�I.Date
Date
Application Disapproved for the following re ons:---•••---•---------•--•---------------------•---.....-----•-------•••--•----•-••---------•---•----------.------
.....................................•-............-----.....---•-------------•---•---•-•-•--------•--
Date
PermitNo......................................................... Issued........................................................
Date
No................_.....'.� Fs$...........
�_=.... .....
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------.... .. _...................OF...........................................
..... _............
Appliratiun for Uiopoottl Worko Tonotrurtion .rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.......... .t................... .........................•..............•-• •--........_•-----....---.................
Lo cation-Addres ' or Lot No.
-.....Y i, r. =-•- - ` A-................................ . -•---.......•--•------••---...........---------- --........................._•---..............
.. r Owner Address
ac�, .:................... ......... ...
Installer Address
Type of Building Size Lot...................:........Sq. feet
Dwella Other—Type T eoof Building oms..._.._.._._•.-._------i--•No. ofpersons nsion-Attic ( )Showers Garbage Grinder ( j
G4 Other fixtures . -----•-•--•-•-•---...---•......•-----•------ ........-•------••-•--•---•-•--•-•-------••---•--•-------(---•>-......Cafeteria .....•---
�4
d I
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.....--..----.-- Depth................
Disposal Trench J�"No. ......1........... Width..... ......... Total Length_Z; ....•..• Total leaching area....................sq:ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................Sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................---.
a •-••---------•••------•----•-••-•...........-••-...-•-------------------•-......----.............---.........................................................
DDescription of Soih ......L_�.f......................................................................................................................................................
�4 '.` -'1�-'-'•W�'" ----•------------------------------------------•-----•----------
V
W
U Nature of Repairs or Alterations—Answer when applicable............................................................e. ..................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.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 bee, issued;by e board of led lth.
_✓.U' �� 3 X
... ,,Signed. I 3
✓
D x a v
Application Approved B t,i�.�:__ '� :. r r
k t Date
Application Disapproved for the following reasbns:---••------•.............•-••---•--•------------•-•-----•-----...---•--------••--••--•--•----•-•---•-••......-
.......................-•-•-----•-•----•--•-•--••-•-•---------•----.....-------•-•-----------...................-•-•---•-•------•------------------------..............................................
Date
PermitNo---------------------------------------------------- Issued.............-----•-----•----
---- .............•-----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ................OF............A�rr3� ..........................................
(Irrtifiratr of faomphatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.............................................................................................
Instally�
at.................................. ; }�...............................................L ` `. " ..............................................................................................
has been installed in accordance with the provisions of TITLE 5 of � State Sanitary
nita y_ Code as.C ?j��scribed in the
application for Disposal Works Construction Permit No..---.. ? -!........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
'SYSTEM WILL FUN TI N SATISFACTORY.
DATE.................... ..../-QfL........................................ Inspector---•------!•�(......
THE COMMONWEALTH OF MASSACHUSETTS
ti�t�S"I C1^ t , t� BOARD OF HEALTH
Ft N A, OF................................. Ica
No...... .:..:�. FEE...... .` .... .....
-1 t t v r,t c'<',q ^ 41C 13iorvoul Works Timotrnrtion Orrmit
t' .. 1 ;✓
Permission is hereby granted.:.... ._.... ' '...........................................................` :..................................
to Construct ( ) or.Repir ,O an Individual Sewage Disposal S}tst
ff ``l
at No. .................. �a . .....
1"-, ...:..: ..1 p �/ t
Street �
as shown on the application for Disposal Works Construction Permit No.PI..? Dated....... �.. .�. .� ",t....---.....
�- ...................
6 e" / Board of Health
DATE.. �= T....•--1-•. ---'-0.............•------.............--•-•--------
FORM 1255 A.lm. S LKIN, INC.. BOSTON
UPPER CAPE
ENGINEERING COMPANY
7 FERN AVE.
E. SANDWICH, MA 02537
617-888-2027
SPECIALIZING IN:
SITE PLANS
SEWAGE DESIGN
SUBDIVISIONS
HOME INSPECTION
PERCOLATION &SOIL TESTS
Board of Health
Town of Barnstable
Hyannis, Mass
Dear Sir
We have caused to inspect the septic system designed
for Edith Crawford at 944 Main Street Cotuit and find that
its installation was done per plan . That the distance from
the bottom of the trenc to ground water is 2.2ft . That the
existing cesspools were to be filled in and disconnected.
/per y
o`fin Jacobi K.S.
- - O fT. M/N. • /Y07•E : /F E/TNER.TN�'S�cPT/C-TAN_ - i
ZZAC/•I//VC p/y- ,q
/0 Arr M/itl. RE /'9ORE THA./ /2 BELO�/
:rRADE� fi 24'O/.4METER ['pyCR•�T� COVER
FLe✓ 1•a CGNGRETE 4'PYG P/P� S'"LL 8F 6ROUG.HT TO G!7AOE.�.-i 4 .EXTRA
v'• COVERS /N• P/TCN Y 'CA ST /RO/Y Go{/ER ShrAL L (3
IF YB oE,pFT, iF/N .DR/vEwAY .E USED
A E� -s 7 J.4r4
H— G .qaE
SZ fl 62 CIL A' SANG
'• t/Qt//DLEVEL yy k .� _ _• &AC.�F/LL
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q��A i DESIGN
�o ATAW ,..,a DATA
Epp°°��y NUMBER OF BEDROOMS 3
TOTAL ESTIMATED FLOW . O
. GALLONS/DAY
BOTTOM LEACHING AREA /7.� /
SIDE LEACHING AREA r,7-f-
S0.FT./ F
GARBAGE DISPOSAL 410 -(/- )�W .
• SO% AREA INCREASE)
TOTAL LEACHING AREA ,
. 'SQ.FT
ERon oh , PERCOLATION RATE .,>�, MIN/INCH
f/o dsN—
LEACHING AREA PER PERCOLATION RATE
NUMBER OF LEACHING PITS A SOFT.
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