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0042 NICKERSON ROAD - Health
42 NICKERSON ROAD, COTUIT _ A= 018 102 ` Commonwealth of Massachusetts Executive Office of Envirolunental Aff-airs Dept. of Environmental Protection One winter Street Boston Ma. 02108 .Tithe Grad ' D.E.P. "Title V Septic inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor rJU SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION p y 42 Nickerson Rd.Cotuit I O� v�0Pro art Address: CV �r Address of Owner:Date of Inspection: 6115198 (If different)Name of Inspector: John Graci Mrs.Anderson 6 1998 11 am a DEP approved system inspector pursuant to Section"15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: a?NJ TABLE CERTIFICATION STATEMENT . I certify that I have personally inspected the sewage disposal system at this address and that the information reported-below i_s tr_ue-�,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 This Inspection Is based on criteria defined In Title V Condition I P sses code 310CMR16.303.Myfindings are ofhow the system is y performing atthe time of the inspection.My inspection does _ Needs F h Evaluation By the Local Approving Authority not Impyany warranty or guarantee of the longevity ofthe Falls septic system and any of Its components useful life. Inspector's Signature: i� Date: 8J15198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: ` B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoThpliance(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 conforming septic tank as approved by the Board of Health. (revised 007197) One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Nickerson Rd.Cotuit' Owner: Mrs.Anderson Date of Inspection:6115199 _ Sewage backup or.4reakout or high static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to 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 leveled or replaced —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: 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 frorn 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: have determined that the system violates one or more of the following failure criteria as defined 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 _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of Offluont to the surface of llto around or surface waters duo to un ovollouded of clouued cesspool. SAS is in hydraulic failure. (revised 0427)97) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Nickerson Rd.Cotuit Owner: Mrs.Anderson Date of Inspection:6115198 D) SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. 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). Numbers of times pumped 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 supply. Any portion of a cesspool or privy is within a Zone 1 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 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"as to each of the following: The following criteria apply to large systems in addition to the criteria: 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 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 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. (reylsed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 42 Nickerson Rd.Cotuit Owner: Mrs.Anderson Date of Inspection:6115198 k Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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 N/A. 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. 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. x _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 0427)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 42 Nickerson Rd.cotuit Owner: Mrs.Anderson Date of Inspection:6115198 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day 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: nla Last date of occupancy: n1a OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)No if yes,volume pumped:0 gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy 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 information: Approximately 16.20 years Sewage odors detected when arriving at the site: (yes or no) No lrevlsed 04127197► I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Nickerson Rd.catuit Owner: Mrs.Anderson Date of Inspection:6115199 SEPTIC TANK: x (locate on site plan) Depth below grade: 4" Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age o1a . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'e'•he•7"w4-10^ Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scan thickness Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 17" 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.) Septic tank and all components are structurally sound.Recommend pumping system every two years. GREASE TRAP:_ (locate on site plan) Depth below grade: Wa Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: r1la Scum thickness:Wa Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: We Date of last pumping;d, 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.) We BUILDING SEWER: (Locate on site plan) Depth below grade: I, Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction lin0own Diameter: nla Qmments: (conditions of joints,venting, evidence of leakage, etc.) , (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Nickerson Rd.Cotuit Owner: Mrs.Anderson Date of Inspection:6115198 ` TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—Other(explain) Dimensions: era Capacity: rya gallons Design flow: rva gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nfa DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rVa PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)—Ye, Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised04r27)97) , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Nickerson Rd.Cotuit Owner: Mrs.Anderson Date of Inspection:6115199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type leaching pits,number: 1o00 gallon leach pit leaching chambers, number:Na leaching galleries, number: Na leaching trenches, number,length: Na leaching fields, number, dimensions:Na overflow cesspool,number:nia Alternate system: nra Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Leach pit and all components are structurally sound and functioning properly.System never had more than 2'of water In it CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: nra Dimensions of cesspool: Na Materials of construction: n1a Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: nla Dimensions: Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 0427)97) �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 42 Nickerson Rd.Cotuit Mrs.Anderson 8115198 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) c � A A (revisedWIT197) Faye ! of 20 •' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 42 Nickerson Rd.Cotult Mrs.Anderson ' 6115198 Depth of groundwater 12• Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revised 04127197) Page 10 of 10 / ct THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applirativit for 11iipnsal Works Tonstrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( %- an Individual Sewage Disposal System at: Location-A dress or Lot No. --•-......VVIII, ✓�1K?,C..... !1.1 �t9!1L' ...�................................................ W Owner f1 O Add_ ----------- b P - --------------•--..._.._ ......---------�-- ,--- � ...................................----- �a `,4 Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___�_________________________________Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building p,� yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------------------------- --------------------------------------------------------------------------- W Design Flow........ ..................gallons per person r day- Total daily flow..... ____..____.._._____gallons. WSeptic Tank A-Liquid capacity__M.gallons Length____ _________ Width__ _______ Diameter---------------- Depth................ x Disposal Trench—No_____________________ Width.................... Total Length........... Total leaching area....................sq. ft. Seepage Pit No------I............. Diameter----j:0---------Depth below inlet____.fa.�........ Total.leaching area.........._.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...................................................... ;_:_: t== Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f= Test Pit No. 2................minutes per inch Depth of Test Pit............:__:.:: Depth to ground water........................ a ----------------------------------------------------------------------------------------------------........................................................ 0 Description of Soil........................................................................................................................................................................ x U W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•------- UNature of Repairs or Alterations—Answer when applicable_- ....... ---- 19`- � '- Agreement: Zolie 7/- P 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 fian�hhasbeen ' sued b the board of h . Signed-..I::.: - - .'C... Application Approved By ............... /' _" --_1-----------------------------------------------------------------..~.... ------..-------------are------------------ �\J J D Application Disapproved for the following reasons- ------------------------------------------ ----------------- --------...------------------....----------------...------.....-- ----------------------------------------------------------------------------------------------------...........................>...----------------------.............--- .................................... -----------------...--.---------- ---------....--- pp� Dare Permit No. /G ` �-------------- --- Issued .........................................------------------------- ---....... Dace +. ..... No....1..Q: Fmc.... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnrtirin Prxntit Application is hereby made for a Permit to Construct ( ) or Repair ( 9"� Individual Sewage Disposal System at: L''('a''r 1 Location-Address or Lot No. -G,,✓n.. .... � _........................ .......................... .............................................. Owner Address R' W c-b P 6:.>_ wunt3 �Sr I --....•••----•• �� o. .!S r� ---- `� ................... --------------------------- - ._ ... ......... .. -- . ... ...... -r Installer Address d Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms......_�__�...................... .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures -----•--•----------------------------------•-•--....--.------------•---•-•••-•--•••------------•----•-----••-------------•....------------------------ W Design Flow......... _......................gallons per person per day. Total daily flow.....�... ..................gallons. WSeptic Tank 4 Liquid capacity....L(PRgallons Length._....��...... Width.... Diameter................ Depth................ x Disposal Trench—No..................... Width........ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......I------------ Diameter.._.. ....... Depth below inlet......f%?.�_.._._. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , aPercolation Test Results Performed by........ -------------------------------------•-••-----•...--------------- Date..................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--__-_-_____•__---__.-. fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ----------------•---•----•----------•-------•-••----------------•--•...---------..._.._..•••-•---•------ :....-------•--•--•-- ......... 0 Description of Soil............................................................................... x .n U ;---------•----------•---------------------•----....•--.....••--•--.....--------------------••••-----------•-----•---•..............................-----------------------------------••-------•------ w U „/N epairs or Alterations—Answer.when applicable_" ,S�w-1(.._.._ 9.at{9-�f_Ko ' ' ' ! ..... .. .../•al. =ST ....... _y Agreement: lf1G G P ;The undersigned agrees to install the aforedescribedjlndividual. 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 -plia®nce has been issued by the board of health. Signed 1 .� :�. .---- -- Application Approved By --- ..---- -------- -------- ------------------------ Date Application Disapproved for the following reasons- ---------------------------------------- ----------------------- ----------------------- ------------------------------ --- --2------........................................... ------------------------------------------------------ - -------........................................................................................................ ................................ Dare Permit No. .......------^1�..........1•,� � Issued Dare THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE Gertifirate of Cumlatiance THIS IS TO CERTIFY, T`hats the �/�Individual �Sewage Disposal System constructed ( ) or Repaired ( by.--------J-�---'.................�+`.:. -.`P ...�.—:KL Wy_.J---- �.-K J��.c alle ........:... ........cnl .A-x---..................... - ------------ .................... has been installed in accordance with the provisions of TITLE 5 #The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...,�Q�.. ...L/.5�... ...... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---1.. ". '` � ............................................... Inspector— THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE No... FEE....z, .............. Disposal Works' Tons#rudilan rrmi# Permission is hereby granted--------G _ .1 ! tQ...:-C, Y3�1<.......................................: ................................................. to Construct ( ) or Repair )—an—Individual Sewage Disposal System atNo.............................. ....... .............. n'T U . ''...................................................... Street as shown on the application for Disposal Works Construction Permit No. Datyed........................................ ........................ DATE_ I/1 1/ V Board of Health FORM 36508 HOBBS h WARREN.INC..PUBLISHERS t w 4 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tonstrn.rtiun 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: ..........-•--_. d.. -..� - Y..1. Ss.�.......................... ---------------OS �� ................................................. �/�Loca�tton-Addreesg` or Lot No. .................. L$:Y:.]!Y.�_ .....a�-fV .g..r.---------._...._.... .----• ------ - ........................................................... Owner Address cP�..�...4+ � -- ... .... -�---...--- ........... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms------ --------------••-__- -Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ` ............... No. of ersons...._..........._........... Showers — Cafeteria Pa YP g ------------- P ( ) ( ) (s, Other fixtures -----•-••---••. ---•-••-•-••......-•----•-•-- d ^ W Design Flow........'�.�•••___________---------gallons per person per day. Total daily flow.......�Z C_......_..........gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-------l------------ Diameter-----I..V....... Depth below inlet._..,�r........ Total leaching area..................sq. ft. Z Other Distribution box ( ) 4 Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 0 Test Pit No. 1----------------minutes per inch Depth of Test Pit---------•---_--•- Depth to ground water.---.................... f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-_.----_--__----. a -------------------------------------------•-----•-----•-------------------..............----•-•--•-......................................................... 0 Description of Soil................................................................................------------------------------------------•--•--......----------------...........••--- x U --•-•-•••••--••••-••--••-•••••••--••-•....---••-........................................................................................................................................................ w x •---•••----•----------------••-•••----•-•-------......-•-•----•-••......•-• �•-•-------....-----•------•---•-••-••-••••--••-•••••--••--••••••-•••--•-_---•••••----••••••............-••••...........••- U Nature of Repairs or Alterations—Answer when applicable........ -�--.-.�a1c(a.....P`!T'.... -CZ s7t 4'e- --------------6445� ....� -kf-)------ s_�06 ........................................................................................................... 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 Compliance has been issued b the board ok health. Signed . - - �:a"oZ� Date................. ApplicationApproved By .........Z��. .. .. - ----------------------------------------------------------------------- ........ Application Disapproved for the following reasons- ------------------- ----------------------------------------------------------- ------------------------------------------------ ----------------------- ------------- --........----------------...---...------------. ----.................---------........---...------------------------ . ........--------------- -------............................ Permit No. (j t ------ ------------ Issued .......................-- te------------------------. Date ------ ----- Date f� No...7/):.Ifs_ Fss...r- d.. ^ ..... t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Workii Tonstrnr#ion "ami# Application is hereby made for a Permit to Construct ( ) or Repair ( %,- an Individual Sewage Disposal System at: O• IA-=7...1/-i•�c .......G;g.rc = -• ........... .............................. t fl ocation-Address -•or Lot No. ,? ,/�, Vv� Owner Address -c lA- L ug S,-1-M.! :. 10L O: 6vk ("t�?......... -. ..... -------•------•- •--• ----�-....- Instatler Address Type of Building Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms....:_3..................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of--Buildili No. of persons............................ Showers — Cafeteria P4 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. r Seepage Pit No........I------------ Diameter....__ ...... Depth below inlet................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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............................................................................... x w x --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----_.... U Nature of Repairs or Alterations—Answer when applicable.........�_p�0....!a u _..._Q!.T___` ,f- _1(__..7 rune.. 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 Compliance has been issued by the board of health. ed / g r. >.. Application Approved B . _ _gate PP PP Y CJ. �-�--- .. 4 Date Application Disapproved for the following reasons- -----------------------...................................----------- ......................................................... --- ---------------------------- --------------------------------------------- ---- -------------------------------------- ...........................------------------------ ---------...... ---------------------- Permit No. %5..-,----.�.- .... Issued s ------------------------ ........... ...--..........-....-..Date ...................----.-Date .... i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fPzttf ra a of Q-1,II>tttylia t.ce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired yb ---------------------------...........-C------A. -.k-..�—. ..... `r` Y - Ins[taller at ....--.............................(a-d......8..A: ..- ---------------------------------------------------------------------- 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. ....... �..-... .�1......... dated ....._........................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.------- �./. - "" � Ins ector `% wr i�� P THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � UU��11 TOWN OF BARNSTABLE No......L ..:..1.7?. �'� FEE----.3 o... ... �to�oottl orko �on�#rnr#ion �rruti� Permission is hereby granted.............. . ................................................ ........ to Construct ( ) or Repaaiir—�( c-)anIndividual Sewage Dis osal System _ IG �T x�i �a /c �E' � fa, at No....................Jn ._......:. k�Y.. ...._._:..t_._.__.._.. ......... ...._--------------------c...---.........._..--------•----•------•---................ Street g as shown on the application for Disposal Works Construction Permit No,; A-.y ..�_ Dated......................................... ............................................................ DATE...... Board of Health --G----9 FORM 36508 HOBBS h WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE . N LOCATION W, H Qa6ovL, SEWAGE #qO 463 VILLAGE Ud4of-1 ASSESSOR'S MAP & LOT �1 INSTALLER'S NAME & PHONE NO. f '��� SEPTIC TANK CAPACITY 1 OCR® �- LEACHING FACILITY:(type) (size)_l(� NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WAT OR OWNER DATE PERMIT ISSUED: /Q " I,D I- - , DATE COMPLIANCE ISSUED:f�"`� / � 4f 1 VARIANCE GRANTED: Yes No �� 7 t -F. � � N a �� � . No........ 6 ••..... FEx.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H TH ApplirFatiun -fur Uiipuual 10orko Cnunitr aiun Vrrmit Application is hereby made for a Permit to Construct ) or Repair ( an Individual Sewage Disposal Syst*Buildin --------- ----------- . . -----------------•--•---------------•--...-----------•--•---•------•----.••---- io .Addre or Lot No. ............. . ........... ----•-----•--------------.------.----- r Address Installer Address UTyp _ Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) p4 Other—Type of Building ____________________________ No. of persons-------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures •---•-------•--------------------------------•----•---------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity__--_._-_-_gallons Length................ Width------- ------- iameter__._._..__...__ Depth.._...____._.... x Disposal Trench—N . __._.... ..... Wi li________ ___ _ _ of 1 L 1 _ __ __ otal leachin ................sq. ft. Seepage Pit No______ _____________ Diameter / epth 1. inley...-_.. otal leacl ' g<t _--..-----.-__-_sq. it. Other Distribution box Dosing tank Z ( ) s gt ( ) � — aPercolation Test Results Performed by-------- ----------------------------------------------------• -------- Date------------------------------------.... a Test Pit No. 1________________minutes per inch Depth of Test Pit.............._..... Depth to ground water..........._-_-_._.-__-- G4 Test Pit No. 2................minutes per inch Depth of ' st Pit-______-__--_______- Depth to ground water-_.--.-..--.--_-----__-- 9 -------------------------------------------------- --- •••.. ...---•----------••••--•••••---- •--•......................................................... 0 Description of Soil--- -----------------------------------------------•-•-•--•--- -•-- - -- ----------- ----------------•----------------------------- x U w 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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued by the b Woh alth. gned ----- D Application Approved By---------- ----------- ------ .... 27 7--- D / � Application Disapproved for the following reasons-------------------------------------------•--• ... ----------------------------------------------------------•-----------------•--------•---•----••-----•---------------------•----•--------------------------------------------------•-•------------------ Date PermitNo......................................................... issued........................................................ Date No.... .7z....... Flmic............................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Apphratinn -for Diipuiittl Worko Cnnn.itrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System.at: AV, � I L / cation-Addre ss' or Lot No. ...."-""""... '' -- a F/I mod`' ._..�/ _ ,�'1 'I ?` = -------f� -------------------------------------•----- dwner "` t pr Address ... Y.._......_ �'............. mow.. Installer Address U Type of Building ( Size Lot..........................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building 0., YP g ---------------------------- No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ---- -----------------------------•----------------------------------------------------------------------- ------------------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. P4 Septic "Tank—Liquid capacity-_---..__._gallons Length---------------- Width...._....._.. Viameter_--.-. .-..-_-_- Depth_-------------- DisposalT Trench—No_ ____________ __ _ Width. of 1 LerA__.(Total leaching lrea_.___._.____..._____s ft. x 1/g' :a� F'N q. Seepage Pit No..... Diameter._.Z'": ._: Depth below inlet____.______ _.:_. Total leachi%g area--.--_--.---_--_sq. ft. z Other Distribution box ( ) Dosing tank ( ) � aPercolation Test Results Performed by------- ---------------------"•-"---•"""•----"•------"--"- " Date-..------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water,--------------.-._-___. L14 Test Pit No. 2_______________minutes per inch Depth of rest Pit.................... Depth to ground water--_-.-----__--.---_---- ---------------------- ----------------------------�--------------------------------------1 ...................................................... 0 Description of Soil-------------------------------------------------------------`- "_------- x �.---.,, 6.1" ' ... —------------------------------------------------- y--------------------------------------------------------------- W -----------------_---- ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of.......................................................... health. ,,�.✓'� Signed; : P ? -" --------•---"-------- Date A lication Approved B —. f,/... . Date Application Disapproved for the following reasons:................................................:*_._.... ................................................ ...................................................... ......................--------------------------•----------•-------•----------------------------------.-------------•----------•---------------- Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r 0�lrrtifirati of fElampliatta �- THI I�,9TO`CER' FYI That the Individual Sewage Disposal System constructed ( or Repaired ( ) bye e' ~......°.'" ---. -... -= .- � - -------------'------- � E/ Installer�� ... d {/ at-----:._.;_,s�`.'_tE_ J--------- I---(, .� .,r•...� � R}"?w "''r' ---/t_ / Y'y°^"'.t>."'<'----•'� •---• ,�� �"_ -a ... ................................. has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----------------4___'_-'o__ .___---_ dated..._..f_f__-,_.7:{/;,, --It__._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF7 HEALTH No. ..... FEE...; " i� n ttl r i TOmitrIJ-ud-b"? n"Te_�, Permission is hereby granted__.... ,',e `__ ✓ .....____.._; !� ..__" ' xr to. Construct ( )!pr repa>/r (r„ an rbndlvtdual Sewage-'Disposal /System ~' r_..._..:t:. A T�s.a�__r'fj s ? d"'f. 6'f Y aC t ;v-h .J ri" f 1 r� at No.�.., r. . r '� ---------------------- Street as shown on the application for Disposal Works Construction Pefi" it No._�___.�.� �C ;ated__.._� r - o oa •--- Boatf Health DATE--"-"".I - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS