Loading...
HomeMy WebLinkAbout0364 OLD OYSTER ROAD - Health 364 OLD OYSTER RICOTUIT A - t ii i A ar•. _ COMMO-NWEALTH OF hLaSSACHL;SETTS EXECUTIVE OFFICE OF E\-VIRONT4ENTAL AFF.��RS = e DEPARTMENT OF ENVIRONMENTAL PROTECTION :'"- t r ONE tti7\TER STREET. BOST01 '%L4 O..lU& (617) 29L b T TRUDY CORE tT10 Ila Secretary ARGEO PAUL CELLUCCI d, CID `��� DAVID B. STRLHS Governor Commissio:,er ��+n ©^� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP CION F RAC PART A CERTIFICATION Property Address: CV:k 0gLt�f— Name of Owner <If q-)(—CoTv� Address of Owner: Date of Inspection: ��+ / / , // Name of Inspector: (Please Prim ! [ a a t E 'l EC../'�U 1 am a DEP approved system inspector pursuant to Section 15.(340 of Trde 5(310 CMR 15.000) Company Name: 47'&A, /r 2 Pk � 'ram c, �� +1 f Marring Address:��., a Z :3 yLr. y N(� I'1� ��4-cl Telephone Number: K <7C Z 44 3-;;x CERTIFICATION STATEMENT 1 certify that 1 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 sew a disposal systems. The system: i _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails '�0L Inspector's Signature: Date: V The System Inspector shall submit 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 tfre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS �aU V C, revised 9/2/98 Page Iof11 `� Primed on Recycled Paper . f, f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) *roperty Address: 3�._`{ Ul�l CJJSN Jwner: Date of Inspection: INSPECTION SUMMARY:- Check A, B, C, or D: r A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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. _ 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. _ 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 _ The system required pumping more thari 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 revised 9/2/98 P2ge2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 MR 15.303 (1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA 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 arsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC ATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption syst (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 s stem and the SAS is within a Zone I of a public water supply well. _ The system has a septic.tank and soil absorption ystem and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorptio system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water nalysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine di ance (approximation not valid). 3) OTHER revised /2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: 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 _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the 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). Number 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 I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with 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 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagc4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ?roperty Address: 3L`k o�cS. o s arc Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No A _ 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 •-�c rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N,A. The facility or dwelling was inspected for signs of sewage back-up. 1 _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. K _ 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: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)I - _ The facility owner (and occupants, if different from owner) were provided with information on the propermaintenanco-0f Subsurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 'roperty Address: 3, 6A Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: (-) g.p•d.lbedroom. Number of bedrooms (design):G-�, Number of bedrooms (actual):03 Total DESIGN flow0 Number of current residents: 05 Garbage grinder(yes or no):Js� Laundry(separate system) ( es or no): NJ: If yes, separate inspection required Laundry system inspected es or no) Seasonal use (yes or no): w\\ Water meter readings, if available (last two year's usage (gpd): {y Sump Pump(yes or no):t-111 Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ 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) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of info s{nat ion: � Na System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: F SYSTEM Septic tank ldistribution box/soil absorption system Single cesspool 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 APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) property Address: 3W, o4 Q%TTXL > Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron_40 PVC_other (explain) Distance from private water supply well or suction line 1�}i})C�Qj Diameter Co ments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:\AA­C, (locate on site plan) It Depth below grade: `(o Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: 1500 aer Sludge depth: a tl ` Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ it Distance from top of scum to top of outlet tee or baffle: tl Distance from bottom of scum to bottom of outlet tee or baffle:,_ How dimensions were determined: 1aAinQ c� comments: (recommendation for pumping, condition of i let qd outlet tees or baffles, depth of liqui level in relation to outlet invert, structural integri , evidence o leaks e, etc.) �p W \ GREASE TRAP: (locate on site plan) Depth below grade:_ Materiel of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 9/2/98 Page7orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / 1/ SYSTEM INFORMATION (contirwed) 'ropertyAddress: Owner: Date of Inspection: TIGHT OR HOLDING TANK: •"V1Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: concrete _metal_Fiberglass _Polyethylene_other(explain) Dimensions: Capacity: _ gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: S (locate on site plan) Depth of liquid level above outlet invert: Comments: T� (noI&if level and istnbutio s ual, evidence of solids carryover, evidence of(eakage into or out of box, et;.) � i�rrZ.t 0 U PUMP CHAMBER: CAID (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: NL 0\ , Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excava ion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number. leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, damp soil, condition of ve tati etc.) (� l fC'i CESSPOOLS:n-U (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Oepth of solids layer: )epth of scum layer: 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.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/96 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) iL s 1J 3 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ropertyAddress: Owner: Date of Inspection: NRCS Report name - — --- Soil Type_ --- - Typical depth to groundwater_ _ USGS Date website visited A/7 Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope il Surface water!`3 Check Cellar�K Shallow wells l Estimated Depth to Groundwater 1 ieet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) f revised 9/2/98 Page 11of11 IP. RIGHT SIDE ._ e...... 0 .— ide ° CL. D""" �A6 �/ - - / ,jam• / � IO Ll JI 1 _/ V aaanWil 1 a'-1 BATH O MASTER BEDROOM t OFFICE/ SEWING RObM T A-r REAR - - i Tiny % 1 CJl -_ �• .-. _ FRONT I, y"a La] D P21, ' BEDROOM OM - YlINO[riyBt:HFn,_,_IILF - U .m Unit T R D oath(:It••clxe / 3 - - —1}- - _Y O itri Carbleiaro !'i)Ali•-1•' It"ari" - / - © . O nri O IU/ OeuDrh+q 1'47A'Y4'4• !{"ari' DAB{aLfiN to utnBr Dtr lV N'!{'.11n^ It"ari• 1 B I Mari 2 FO OVJ 1'al^ty'O' wJ I'al N"a 1'L ln^ WA / B'F-I /� avrlYq WA tabt'•q -� ---T-- B'-9' B• a„ _,� u >D 11 - 2.. — +eeq 31.1 1A.l i IN 10 a li 24 REMODEL a ADDITION TO EXISTING RESIDENCE QI ONNW.i1 IWINgDW�vq 1'-11 Yltl t'�L�" 31"a1q^ 1 .Ian alzitm LEFT SIDE rill OnDldup 7'.1A11V" SCALE: t/4•=�' APPROVED By ORAWNBT: dlk OJ M'a II" DATE: ' PEVI9EO: David&Susan Ken 364 Oid O a U. Co ui 02635 S JRAwINJ NUMBER: ECOND FLOOR PLAN A-7 RIGHT SIDE .._....... ..__.. .... ........... ... J1 O .I. �—.' T g 4 a.g• ..� 4'-2/2�10 4'-2/2"-- -. Y',I^ _ -A i a MUD ROOM U j iD / 1 �j a5�1 I .� 444 � i�e�\ • . .J' m _. BREAKFAST ..:•- NOOK (� l\�&� `� � �-..... B'i 9� I B I A n .... .. A CL. CL. n � _ I �E) O LIVING ROOM REAR I .� _ IIr nmoe __ - a C. DINING ROOM 1 KITCHEN a 13 a-- - --- " .f� - FRONT 0 10 4 • X W 6 LL1 S o � CL v i I I �— i _ I o --1---- FAMILY ROOM00 = a I DEN1R .NEnll F ti I Amm TWA Sl:. / �111I u'N ai wpeCp.l Flrt l'-0'1 FV" 1 . LII Il\M tRL mtYIIWrA p�W iV'1/V^ .aLrp 6 � m rI� FrJ] Ul 0"V .a1.w,eF/r�M t114t t'J'1/•J" 1 yy1 j AO IIrt DIDet I O ll-'I /Jnq _ _1_ lil UNY IK a4o0/W p�JyxtN I'�11'1 t'J^ 1 I 0�' I EPA c1 Y, If 24' 2" REMODEL S ADDITION TO EXISTING RESIDENCE l! clove LEFT SIDE Do clo.J Ya r.lt ca..i.4.a F+d no rv'y t'J•' I t/{'_1' ..ovco... d1K L•I: cu.« M.wIN wnr.sw F+rl Iw r-0.1 t.,l•. 4/ti/98 David 6 SUSan Kerr 364 Old Oystw Rd. Cotutf MA 02635 FIRST FLOOR PLAN A• Rlaar s�oE. f.dYfY V o sf�EPS ex�T 2ieM1. eA / 6Vx OWL SPAcQ READ. e&Cj'bq+ (-p**> • snexa %flow& s / �Bctssce L /////////// /// ////////// /// j ;`• a F Rbut f� / sP+RAA srA�a-$��A• / . / up re Ir neoc. Edo�R..r a Z>r4 RceeR"as. s$�I�•C1 � ��� w�uoew Feel• / V, O.G. SPAci '-- - - - - -- - - -- - 21L4 Swb wAm,140ee TAuK• ,,, J/.i with RT SAei ?c►tf. �D�':icTi£ � GAS 3e+uR i --Ati2t-J/kac. wiuDew VA pxlyrtc s��K Belt. . , citcnueA�s�aKt �� `'T�O,WN OF BARNSTABLE LOCATION `� W � SEWAGE # VILLAGE-(a):b ASSESSOR'S MAP &LOT4 INSTALLER'S NAME&PHONE NO.. �� SEPTIC TANK CAPACITY UO"'L- LEACHING FACILITY: g J size NO.OF BEDROOMS Cq-CIS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facilit� Fe Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f of leac - �Iln C-\Q,Peet Furnished by I t. A \V 0 96 _ (4I sy� �im THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di!ipmi al Works Tomitrnrtiun ramit Application is hereby made for a Permit to Coristruct ( ) or Repair ( an Individual Sewage Disposal System at: ................... --- .._. .... ..... ............ ------- ------------•-------------------- ............................................... 1�/ Location:: d ss or Lot No. ns ! __..___._.__ ow W Address j�'i Installer Ada ss UType of Building Size Lot............................Sq. feet ►-t Dwelling— No. of Bedrooms---- ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) � Other—Type of Building __._.... .-.____ o. of persons____________________________ Showers ( ) — Cafeteria ( ) d Other fixtures -_------------- W Design Flow---------------------------------------- gallons per person per day. Total daily flow-------------------------------------,......gallons. WSeptic Tank—Liquid capacity/, IkalIons 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. I----------------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........................ Description of Soil...._ x V --•••••••-•-•-•-••...--••-•••--•-••--•-...--••--•-•••-------------•-•----•---•----••-•--••--•-•----••-•-•-•-----.....---•--------•--•---••--••---------••-••-•---•-•-•-•---------•...------•------•--•-- -----•-------------- ------------------------------------------------- ------------------------ ----------------- ---------- - -- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comph ce h b issue y the board of health. \,Signed . ---------------------- ----- Application.Approved B /.j/___..... -'--!-- ---- -----------....--------------------------------------- .[..../e.�. .[e. ......------- Application.Disapproved for the following reasons- ------------------------------------------------------ ----------------------------------- -------- ------------------------------------------- ----------------------------------------------------------- ------ ---------------------------------------- Permit No. -------- .-T�.......��...2. 2 Issued ----..... Dare No......1..�.......�1� Fiza........ i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratijau for Bi-pmial Works Toutitrurtiun thrutit Application is hereby made for a Permit to Construct ( ) or Repair ("" 7.n Individual Sewage Disposal System at: {��%-:"�� ------------------ .. + 9f� � T ... --d- •.... Locat' -:\ddress or Lot No. I7 ---- •--------•---- •----------•-------•-•--•------------------•--••--- /Ownje_r . Address A � �______F____ _ __________ _______________________________` j = ---- Iuskalle nddress d ' Type of Building q.; ! Size Lot............................Sq. feet Dwelling— No. of Bedrooms._.- ................_----------.--_Expansion Attic ( ) Garbage Grinder ( ) aOther«Type of Building -------.7. _. .__ No. of persons.._-_..._ _.-_ -_---...._. Showers ( ) Cafeteria ( ) Otherfixtures -------------------------------------------•------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow-------------------------------------j.....gallons. WSeptic Tank—Liquid capacity„44.)44 allons Length................ Width_........_.... Diameter---.--------_- Depth-------:........ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... To-al leaching area..................sq. ff. Z ,,,_Other Distribution box ( ) 'Dosing tank ( ) 'e,} ,t ; _ , + , '"' Percolation-Test Results Performed b = �._��.__-�.. `_____________ Date........................................ Y ..... - Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................--. Lz, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water.....__....-__-_-------- .................----------------....--•---------•--••--•---•-••-•-•-•----------•-•----.._.._------......................................................... ODescription of Soil...... : ^ '...............................................-..-.----------- ............................................................... V .•-•----••--...-•-••----••-•••------------------•------------------•-••...----•-•-•---------------••--••-----------••-••--•••----------------------••---•-------••---••-•--•-------........--•---------. W ---------....................................... .................................................. ------� --V--- ____- .. ................................................. Nature I x 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system to oper ation until a Certificate of-Compliance has-be n-issue&by the board of health. `r - - - Signed 17--. t i /!. .. y. (r r. ' Dac APPlication,Approved B / , ee ^ Application.Disapproved for the following reasons: - ...... ....... .......... ................. ........ - - -- ----------------------------------------------//!!-^^-----�----------- .........._................_.............................`.... .. ........ - .............. . � I G Dare -i PermitNo. .............�.............._.................-.....-..... - Issued ............. -......D�.e - .-.... ......... / THE COMMONWEALTH OF MASSACHUSETTS " BOARD OF HEALTH TOWN OF BARNSTABLE Q-1Ertifi atr of Tomplianre THIS IS TO-CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) Yb ................... .._.. f..... --Q. ..-- --------------- at .- � i -L� ---� --------._...- �j.��-�Y/'--- -- --------'�, -------��.t '`'' ..-------------------------------------------------------- has been installed in accordance with the provisions of TITLE S of The State Environmental Code s described in the application for Disposal Works Construction Permit No. �-------�-�..�.. ..0_-2 Z I dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................1-------- .. .. ..: .�✓ ......._._...._... ...-........ Inspector ---------- ......- J..---------.----------------------------------- ......... y + THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 0 a u No......................... FEE........................ Disposal Works �unotru#uan rrutit Permission is hereby granted._-...... !f-_ -.__-(......?�:'.................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst VM —j� --......... at No. �� .[ t✓+,S .RI� �••�'.--------- (`�-"�---•'1"1't . Street /� �1 �� as shown on the application for Disposal Works Construction Permit No._.-.__ .._.._- L)ated.._.._... . ..................... - c .......................................................... .......................,_._........•-•.----- �_ Board of Health DATE............... -•-- �� �� =77n-------------------------------- FORM 36508 HOBBS h WARREN.INC.,PUBLISHERS CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) r e � 1 I, hereby certify that the application for disposal works construction permit signed by me dated concerning the ,,. ., property located at ,� meets all of the following criteria: 1Ale-, • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility . • There is no increase in flow and/or change in use proposed r. ,t • There are no variances requested or needed. 3 ; 4 c } u YA:.`$t SIGNED : }',` DATE• dW1 t F LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE TZER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]: , E . a a , � t 1 w r- o,o � I Ln �r o i Y ✓ 04P S