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HomeMy WebLinkAbout0044 SAMPSON HOUSE NOB - Health 44 Sampson House NOB 102 ;r I Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund& Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 August 12 2014 required for every g , page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any . way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms , on the computer, use only the tab 1. Inspector: key to move your fff��,��1 VVV I cursor-do not Kevin J. Sullivan use the return key. Name of Inspector Ready Rooter, Inc.. Company Name P.O. Box 371 Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-888-6055 SI 13517 a Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system'at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further..Evaluation"by the Local Approving Authority /' August 13, 2014 Inspector's igrr?atu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 6/L I Commonwealth of Massachusetts Title 5 Official. Inspection. Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments r� 44 Sampson House Knob Property Address Edmund& Estelle Trzcinski Owner Owner's Name information is required for every COtUIt MA 02635 August 12, 2014 C' page. �Y/Town . State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the.failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 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 ne to be replaced or repaired. The system, upon completion of the replacement or repair, s approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined'(Y, N, ND)for the following atements. 1!f"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(w her metal or not) is structurally unsound;exhibits substantial infiltration or exfiltration or tank failur s imminent. System will pass inspection if the existing tank is replaced with a complying septi ank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structur sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y rs old is available. ❑ Y ❑ N ❑ ND(Explain be w): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund& Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 Au ust 12 2014 required for every 9 , page.. Cityrrown State Zip Code Date of Inspection B. Certification(cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or breakout,or high,static water level in the distribution ox due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. ystem will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N . ❑ ND(Expl ' below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND( plain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ (Explain below): ❑ The system required pumping more than 4 times a ear due to broken or obstructed pipe(s). The system will pass inspection if(with approval of th Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) /teifsa aluation is equired by the Board of Health: ❑ exist wh' h require further evaluation by the Board of Health in order to determine if is faili to protect public health, safety or the environment. wil pass unless Board of Health determines in accordance with 310 CMR b) at the system is hot functioning in a manner which will protect public health, he environment: sspool or privy is within 50 feet of a surface water sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts . Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob `. Property Address Edmund& Estelle Trzcinski Owner Owners Name information is COtUit required for every MA 02635 August 12, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and.Public Water Supplier, if y) determines that the system is functioning in a manner that protects the lic health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS nd the SAS is within 100 feet of a surface�water supply or tributary to a surface water sup ❑ The system has a septic tank and SAS and the SAS is wi n a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SA s within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS.and the SAS * ess than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water anal is,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n ther failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure.Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to 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 Y2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 August 12 2014 required for every 9 , page. Cityrrown State Zip Code Date of Inspection B. Certification.(cont.) Yes No ® 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 SAS, cesspool or privy is below high ground water elevation. E ® Any portion of 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow.of 2000gpd- . 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E) Large Systems: To be considered a jarge system the system must serve a f ility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,,you must indicate either"yes".or"no"to each of the lowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a s ace drinking water supply . ❑ ❑ the system is within 200 feet a tributary to a surface drinking water supply ❑ El the system is located in itrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a m ped Zone II of a public water.supply well If you have answered"yes"to any que 'on in Section E the system is considered a significant threat, or answered"yes" in Section D abov he large system has failed. The owner or operator of any large system considered a significant th at under Section E or failed under Section D shall upgrade the system in accordance with 310 R 15.304. The system owner should contact the appropriate regional office of the Depart ent. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund& Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 August 12, 2014 required for every g page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® E] Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site.inspected for signs of breakout? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered; opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of.liquid, depth of sludge and depth of scum? El Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the.Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the.Board of Health. ® ❑ Determined in the .field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System 'Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 330 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund&Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 August 12 2014 required for every g , page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Water meter readings for2012-198 gallons per day 2013- 110 gallons per day Sump pump? ❑ Yes ® No Last date of occupancy: August.12, 2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): ons_per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap.present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No ` Non-sanitary waste discharged to t itle 5 system? ❑ Yes ❑ No Water meter readings, if av ' le: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments '< 44 Sampson House Knob Property Address Edmund& Estelle Trzcinski Owner Owners Name information is 9 Cotuit MA 0205 August 12 2014 required for every ; page. Cityfrown State Zip Code Date of Inspection D. System. Information (cont.) Last date of occupancy/user Date Other(describe below): General Information Pumping Records: Source of information: Ready Rooter Pumped October 2012 and August .2014 after inspection. Was system pumped:as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000 , gallons How was quantity Sight tube on truck q y pumped determined? Reason for pumping: Maintenance Type of System: Septic tank,.distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owner's Name information is COtuit required for every MA 02635 August 12, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: , Sytem was installed in June of 1985 Certificate of compliance on file at Board of Health Were sewage odors detected when arriving at the site?' ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.50' feet Material of construction: El cast iron -®40 PVC ❑other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below,grade: 2'feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'x 4.5'x 4.5' 1000 Gallons Sludge depth: 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 44 Sampson House Knob Property Address Edmund& Estelle Trzcinski Owner Owner's Name information is Cotuit required for every MA 02635 August 12, 2014 page. City/rown State Zip Code Date of Inspection D. System Information cont. Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 37„ I Scum thickness 2" Distance from top of scum to top of outlet tee or'baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments(on pumping.recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC inlet and oulet baffles. Grease Trap(locate on site.plan): Depth below grade: fee Material of construction: Elconcrete ❑ metal El fiberglass ❑ polyethylene ❑.other(explain): Dimensions: Scum thickness Distance from top of.scum to top of tlet tee or baffle Distance from bottom of scu bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 44 Sampson House Knob , Property Address Edmund& Estelle Trzcinski" Owner Owner's Name information is required for every Cotuit MA 02635 August 12, 2014 Ci /Town page. ty .State Zip Code Date of Inspection. D. System Information (cont.) f Comments(on pumping recommendations, inlet and.outlet tee or baffle condition, struct al integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspec' n)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fi rglass . ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: d Yes ❑ No Alarm level.' Alarm in working order: ❑'Yes ❑ No Date of last pum ng: Date Comments(c ndition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments " 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 August 12 2014 required for every g , �Y C' rr page. own State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): New H-20 Concrete D-Box with one inlet and one outlet. D-Box 2'deep with riser to within 6"of grade. Old D-Box was corroded and needed to be replaced. Certificate of compliance on file with BOH and a copy attached. Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No Alarms in working order: 0 Yes ❑ No Comments(note condition of pump chamber, condition of pu s and appurtenances, etc.): Soil Absorption System (SAS)(locate n site.plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owners Name information is required for every Cotuit MA 02635 August 12, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6'x6'5'with 2' of stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number, dimensions ❑ overflow cesspool number: ❑ innovative/alternative-system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit 2.5'deep with riser to raise cover to within 6"of grade. 3 courses of holes are visable above existing water level with a high stain 3"above existing water level Cesspools (cesspool must be pumped as part of ins p ction) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwate Inflow 0 Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owner's Name information is required for every COtUIt MA 02635 August 12,2014 page. City(rown State, Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of,v etation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs o/ulfic re, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski k1p Owner Owner's Name information is Cotuit MA 02635 Au ust 12 2014 required for every 9 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Of =sue ' -4a- ry rAeA&6 a o 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owner's Name information is Cotuit MA 02635 August 12 2014 required for every g , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells <13' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: June 25, 1984 Date ❑ Observed site(abutting property/observation hole within`150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Two test holes done June 25, 1984 to 13' no ground water found. Base of soil absorption system less than 9'deep. Before filing this Inspection Report,please see Report Completeness Checklist on next page. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Sampson House Knob Property Address Edmund & Estelle Trzcinski Owner Owner's Name information is COtUIt required for every MA 02635 August 12, 2014 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria.Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file No. F Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplitation for 33isposal .pstem Construction permit Application for a Permit to Construct( ) Repair(,;,<Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. w y L7Am P sa Al FIotjS cf kva Owner's Name,Address,and Tel.No. Assessor's Map/Parcel G d 7(J T T m LrDP0viD T Zit tJSKTr Installer's Name,Address,and Tel.No. /�d, &7 x 3 / Designer's Name,Address,and Tel.No. 'RERov Roora-r- n/<. �$/�h'oa/oC �/r► 1v Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) cis 6 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /0 OB B P-P(91✓ Type of S.A.S. 4 lfbl<.H P t—Y J/ jfo d')(r Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9k�v­✓s Awo j,XFza<1r V,s;Ac 8J7-,'a0 ►jdcj H-za D- Qo x., Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date 7n Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 4 Date Issued No. r Fee /D v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISIONa- TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Misposar *pstrm Construction 3permit i' Application for a Permit to Construct( ) Repair(kUpgrade( ) Abandon( ) ❑Complete System Individual Components ? Location Address or Lot No. Q q JAM f sd 1J Nov5 e- 0 Owner's Name,Address,and Tel.No. r ® . CDMUNo Assessors Map/Parcel L 7 fJ T 7- Installer's Name,Address,and Tel.No. pd. &b x 3 7 / Designer's Name,Address,and Tel.No. RCRUV for an rwr_ �5frtiwo�/,c�t,/h Type of Building: `K Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 336 gpd Design flow provided gpd Tlan Date Number of sheets Revision Date Title Size of Septic Tank /0 00 G tr('(7+✓ Type of S.A.S. 4 e#9<H P,�f f iJ/ ,STD n)C' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Rkw»vs PYw6 <ll V S711 C ByTi om) [F)tUX I,' t, ltil ace) H- D- Qo s Date last inspected: y Agreement: The undersigned a' grees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date - "� Application Approved by Date Application Disapproved by Date for the following reasons _ Permit No. �—�i t_� Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V Upgraded( ) Abandoned( )by R c A 0Y V-8 v To►� 1 W G, at y Y E/I w)P 3L,-z K&ut d L too Q has been constructed in accordance ` with the provisions of Title 5 and the for Disposal System Construction Permit No;�-Dl dated Installer Designer #bedrooms Approved design flow �,l ,•7� �/ gpdThe issuance of tthis/permit stealll not lie construed as a guarantee that the system will f inctiioonn as desiigned. GDate /1 / / Ins ector Iki'" ,/1�1/ I ll �lh✓ iJ1"/ (tlJ )•• -------------------------------------------------------------------------------------------------------✓------------------------------- No. ^ Fee b THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit s x Permission is hereby granted to Construct( ) Repair(✓� Upgrade( ) Abandon( ) Systemlocatedat �� cskMpSaH) HOy�I- X00R and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co plete within three years of the date of this p rmit. Date ' L Approved by Zz-day /07 /d 6 A AVCAION SEWAGE PERMIT NO. VILLAGE /7- �° INSTALLER'S 'NAME a ADDRESS ef�v,AALdZe Re h Wlclq 0 U I D E R OR OWNER ZA :z c/A" ,"S/< DA T E P ERMIT ISSU E D DAT E COMPLIANCE ISSUED 1 r �� �� E; � � � j i .�, i� � � j No. .......;...._.... Fi$............................_ -Ti E COMMONWEfALTH OF MASSACHUSETTS 4-tf b� . BOARD OF HEALTH aa -............. ...... ................OF...-..-..--..........-.... Appilratiun for DiupuuFal Workii Tunutrurtiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: &A........................................ --------------------le,61'_4-------...-----...........--------......----........._...-•--- Location-Address 4 ft or Lot ® Owner A W a ; '� e ddress ry . Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms__________ ________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building �L &A�._ p ______._._.. Showers ( — Cafeteria ( ) yp g _ __ %`No, of persons d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/d#__gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fTq Y Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------•-----------------------------------------------•...------------------------------------•---........................................................ 0 Description of Soil........................................................................................................................................................................ W x ---------------------------------------------------------------------------------------------------------------------------------••------------------------------•------------•--------._...._.._------ V Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -------------•----•-------------------------------------------------------------•--------------------------------........_..----- Agreement: The undersigned agrees to install the afore scribed Individual Sewage Disposal System in accordance with the provisions of LI 1E 5 of the State Sanitary ode—The undersigned further agrees not to place the system in operation until aaCCertificate of Compliance has ben issued by the b and of hea`lthh.. ;PP11ication Approved 1/ ---- ---•---------------••-----•-------------••-•----- -------•------ ........*------ Date Application Disapproved for the following reasons---- --------------------------------------------------------------------------------------------------•--------- --------------------------------------•-----•---•-----------•--•----•-••------------------=............................................................................................................. Date PermitNo....................•--....-----•---•------••----------. Issued_....................................................... Date e No �... f C) F�$-5 C; =i;�iE COMMONWE;%XLTH OF MASSACHUSETTS BOARD OF HEALTH ............... ....----------------.OF............................. ApplirFation for 14fivooaal Works Tontrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �"f.!� 4.i1...t �1 -••-�Y ........................................... ..................... AA...-----------•---------•-------=-•----------.......---.....--- Location-Address or Lot No. ..... R,U•[�:s 1e4-----------------------••---•-----..... j. t_.. 0-fit�.0.�---��o 4.0-----31:G?%).... 1.4...eL.27-J:7 Owner Address W j .................................................. Installe Address •0.1 RW UType of Building Size Lot............................Sq. feet I-1 Dwelling—No. of Bedrooms........ ............. ...............Expansion Attic ( ) Garbage Grinder ( ) allo. Other—Type of Building i4!�, .,. , of persons........, .............. Showers ( — Cafeteria ( ) 04 Other fixtures ......................................................................................................................... --•-••..................•--- WDesign Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity/0-0..gallons Length................ Width................ Diameter...........'.... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below-;inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank0-4 ( ) W Percolation Test Results Performed by................................ ................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit..__...........___.. Depth to ground water..................... ._. 44 Test Pit No. 2................minutes per inch > Depth of Test Pit.................... Depth to ground water----____-----------•_-_- P4 :.................................•••......................................................... 0 Description of Soil.............................................................................................-............................................................................ W 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 TITI:r; -5 of the State Sanitary Code—,The undersigned further agrees not to place the system in operation until a Certificate of CojnMiance has b ri issued by the board of health. * o(� �� .. •--•••---------•--• .-• igned " --------------- pplication Approve 3'-- `w �. . -- -•---•- ------ .................... ----- Application Disapproved f r thefollowing reasons-........... -------------•--------••--------•----------••---•--•-...---•••--•---•-------••--•-•--------••-------•.------ • -------------------------•--••-•----•---...--•-----------•---------......••-•----..._•-•--•......._,. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH *. d=Ai I- ................................ ....OF............................................................... (9rdifirFa#r of TontpliFatur T IS T �CiR IFY, That the Individual Sewage Disposal System constructed (,.-- Or Repairedop ( ) by.. - ,�,c --------------------•-----•-----•----•-- Installer f r at--- --------- ----------- f ---•---•-���-cA�y ail .,has been installe in accordance with the provisions of TI"',� 5 of T eE/State Sanitary Cod as s ibed in the application for Disposal Works Construction Permit No.___..... .-_.. ........ ......... dated-- ;*--`�_. ._ .._......_._............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST D AS A AN EE THAT THE. SYSTEM WILL F N TI N SATISFACTORY. y..,. DATE . ._ .. ....................... ....... Inspector__...:.. THE COMMONWEALTH OF MASSACH TTS BOARD OF/)HEALTH ...... O F............Nol,`` � � .... . ........................... 7 ..•---•=A. .. .... ..FEE. Dispo Ivory 4 notrudion Prrutit Permission is hereby granted.... to Construct ( , or Rer ( ) an Individual Sewage Disposal st• <f at No. � ..... ', .......f� _. ��.. �...ors / Street as shown-on the application for Disposal Works Constructibfi Permit No................. at d.......................................... ".. ............................................ .......................•......•.—� L•Cr--------•--•-•-•----.-----•------•------•----•---- oard of Health DATE.............. aZ .. _......--•---------------------------- f FORM J2gp 'A. M. SULKIN, INC., BOSTON C, s,-r PITS 1,2 C "Gty • for G Ir a ci 0 c 1.00 IUA 1 -7 AVE'.(�E'c.KaUit. i � I I �.. .. ._;C)r i,.D�- 10 (� A � 5�1rYl.L:SQ/l �-iUl).�E? -Z Coi /-V nc� A AJ T CO/V,,7- LW k C)0, Ho Hap xcz-\Vo,�-c?r , -beor"\-, �-�C�Q PSt1 OF EARL -41 ERY, JR. Z4 C- I oc,c) E26�75 (A' 4/ONAL Env di° FIN, GR.E -ToP vTWA 9 9.0 97 X-V ?qc Ser T cyi 66, f\\j J i ------- t�,a K ��+.o o,e '� '; t'.C,Cone I � � j I � �',ry, � , '; „ �:, -� ,-, 176 Y�.' (sev C', w �-4 VV z to)1 IC), C'l- On TP J J-' T/ T.0 r h I-T F A /V 'fie/ ---- - --- ;J C 6- OF 41 � L EARL NTERY, JR. No. 657 p /ONAI y 1, Pr�z I,000 CW` - -- Q D�s�oszL S _ r. it � z 9 0.2 ----- — —------_ 1 Tf- �� AV 1 lit SIC t 4 �13 �.�o��� ' J I coo C)0 A✓K +c,) c l SA:, D -rr 5 x r. g x ----- A W a do .. --- F>�s.............................. �"�=�E COMMONWE LTH OF MASSACHUSETTS ,b�' BARD OF HEALTH - l 0 / O F......... ..... .............=---------"------=........................ . p iiration for Dhip i al Work.5 Tonotrur#ivat Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ` System at: Location-Addres8 33 Owner %/� �- Ad-dress ins is ° Address UType of Building Size Lot....................._......Sq. feet a-, DwellingNo. of Bedrooms_______. _____________________"__--__..Ex Expansion Attic— p ( ) Garbage Grinder ( ) Other—Type of Building _OL /�-X,—_X'-No. of persons---------- ............ Showers (2� — Cafeteria ( ) Other fixtures ......--•---...-••------.............. Design Flow............................................gallons per person per day. Total daily flow........................-...................gallons. Septic Tank—Liquid capacity/d! _gallons Length................ Width---------------- Diameter---.------------ Depth................ x Disposal Trench—No. ..............:..... Width_................... Total Length ----------- Total leaching area--------------­----- ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area----------_.......sq. ft. Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by..------------------------------------------------------------------------ Date---- .........................--........ Test Pit No. 1----------------minutes per inch Depth of Test Pit___:.....__ Depth to ground water_.___...______.:_...._.. fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water- _.._______"--_.-_._. •...................•---•----. 0 Description of Soil..................................................................................................................................... U •-•----••.....--•-•- -------------=--=------------------------------------------------------------------- "--------------- ----------------------------------- U Nature.of Repairs or Alterations—Answer when applicable.-------------.-----------------------------------------------------............................ .................................................................................................................................................................................................... Agreement: The undersigned agrees to install the afore escribed Individual Sewage Disposal System in accordance with the provisions of 1 5 of the State Sanitary ode= The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the board of health. pplication Approved . ..-••-.._._. -••••••--•----••-•-•• ------------ -- -------••----_---•- Date. Application Disapproved for the following reasons: Date Permit No. --- Issued................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F"A I C b^ Trrtgfirat� of TontAtattrr TWA IS T C.8R IFY, That the Individual Sewage Disposal System constructed Repaired ( ) by........ y ---------- __----- ------- :,�... .. ( . �l (Installer f has been instalee in accordance with the provisions of TI�Ty 5 of_T g/State Sanitary Codas s ibed in the application for Disposal Works Construction Permit No----15_— ____> `_____ _________ dated_- _- - THE ISSUANCE OF THIS CERTIFICATE SMALL NOT 6E CONST D AS A AN EE THAT THE. SYSTEM WILL F�N TI N SATISFACTORY. .DATE...............:. ` Inspector THE COMMONWEALTH OF.MASSACH TT BOARD OFLE..ALTH ........... t..l .........OF............. > ..:-� ....................No...:__.-...-� . _ FEE.... ................. Permission is hereby granted..__- t...._-------- ..._. to Construct or Rep.'r ( ) an Individual Sewage':Disposal ste�fiil �d � at No.-------------- _ .....- =� / :�: =� � � �t r�'� l{ i _____________ .:Y�:�,__. _. _-1_......_.._....._.._.____._..........._...._: Street as shown on the application for Disposal Works Constructi4� Permit No-_-____-..•__"•_...;,,Dat'ed-_________________________•-_-_.___._._:. .................................... ...............................!'_.._..._.......___....._.._.....__._....__..__._:__ �" oard of Health DATE.............. oZ-7.' FORM 12'$5 'A- M. SULKIN, INC., BOSTON - - q ro V V 1 1 IT -T-L asw `- ---► �-- 4 _ �lblfT EL+E"V.4T101�1 - �G�Ct��fj���%rj•� LF ITL- IT— - �- i--D,()T E-LEVA-710A) I RE1E/L .SLR'rA-llna1 ! TR Z/NS/c2 APDt7ton) PL,4n/f- t own:,S-/o-� aeveao F By sµAuoA) AAA-LQ, so�suSo .l -»8 667y aas wmffwmmsm ca . l F dU- 5•• .vow . �C3/Lco__6ucK . r 7jrPE C x - AU-JUST Ta A V o!D r r LOA-TAR.. W rJ E.. 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