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HomeMy WebLinkAbout0145 SANTUIT ROAD - Health 145 SANTUIT ROAD, COTUIT A=021 094 ✓ ir F- t L f f TOWN OF BARNSTABLE` L :)CATION 1 � SP17U�V1 1 SEWAGE # r l?ILLAGE C�)�c>l ( ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. bqftd SEPTIC TANK CAPACTPY � � LEACHING FACILITY: (type) IT (size) NO.OF BEDROOMS BUILDER OR OWNERt� EERMfPDATE COMPLIANCE DATE: Separation Distance Between the: Groundwater Table and Bottom of Leaching Facility Feet Facili Maximum Adjusted Ground 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 feet of leac nng facility) . _ Feet Furnished by_� n c L-T 1 b3 0 lb1 611 61 43'G" 5 COMMONWEALTH OF M�kSSACHt-SETTS EXECUTIVE OFFICE OF E?��;IRO�'�1E\TAL AFFAIRS 41 DEPARTMENT OF F. IRON �IE\TAL PROTECTION 13t= ONE WINTER STREET. BOSTOS. NI O:1C�S 61'•:S:•�:(�C� a o : lip wTLLlAV.F.V►-ELDCG?— . e �DA�I ARGEO PAIR CELLVCCl _. 5 Lt Govemar SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F lry�y9�s� 199 0• ,iss�orr_. PART A CERTIFICATION i� y 5 . Property Address; ( QOTU�—' Address of Owner: Date of Inspection: ;5kI115b / :(if different) Name of Inspector. /17 1hQ'o 1) E��Cn - c6ry IT) MAir. 1 am a DEP approved system inspector pector pursuant to Section 13.340 of Title S (310 CMR 13.000)•, Company Name': Mailing Address: 'Pr) /;inA Y 3?' H ftSNOP1Z- h' 7'0 Telephone Number: rf�CZ;Z CERTIFICATION STATEMENT - f serif) that I have pe•sonall. rrspec-ed the sewage d!s;:Osal syster a: this address and that the iniarrration reaoned below is true. accurate and cornole:e as o:the time of inspec;,o-. The'inspect:an was Pe-;armed base- on my training and experience in the proper funcicn. and maintenance a;on-site sewage dasposa� systems. The cvs:erm Passes • _ • _ Concu,onai:. Passes _ Neec: Furthe- Evatuano,. Ev the Loaf Ap�ra�ing Aathont) - Fa.•= -. Inspector's Signature/�it Date: Toe Svi:e-- Insz?_o- shay submit a cop%. of this inspeGion reocn. to the Aporoving Authoriry within thin• (30i dais ei cornplesing this inspe�ion. It the syster•i is a shared vvstern o- has a devgn flow. of 10.000 god or greater, the inspector and the sys-,e•r. cwner shall submit the repo- tc the aporopriate regional a^ice of the Department of Envirenmenta* Frotec:ior.. The crig-.na! should be sent to the mierr, c ne- and copes :--i;to the buver• ii applicable. and the aporoving duthorin . INSPECTION SUMMARY: Check A, E, C, or D Al SYSTEM PASSES: I have not found any information which indicates that the system violates.any of the failure criteria as defined in 310 CMR 13.303. Any failure criteria not evaluated are indicate✓ below. . COMMENTS: 61 SYSTEM COtiDiTIONALLY PASSES: One or•more system components as described in the 'Conditional Pass' section need to be replaced or repairer'. The sN stern, ueon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NO,• Describe basis of determination in all instances. If 'not determined', explain why not. _ The septic tank is metal, unless the owner or ope^ator 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: Of the septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfiltration, er unk 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. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ r CERTIFICATION (continued) Property AddrAss: - Owner: Date of Inspection: ;r - 61 SYSTEM CONDI7 ONALLY.PASSE5 iconanjitj. y. Sage backup.�or breakout or high static water leve! observed in the distribution box is due to broken or obstructed pipes) or due`to a b fokenb sealed or uneven distribution box. The system will pass inspection if(with approval of the Board of�Health). pescribe observations: f0broken pipes) are replaced Obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets)..The system will pass dnsoection if twith approval of the Board of Health): broken pipe:si are replaced Obstruction is removed C1 FURTHER EVALUATION 15 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 biting to prate_:the public health, safe-*-and the environment. - t) SYSTEM WILL PA55 UNLE55 BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFr'TY AND THE ENVIRONMENT: _ Cesspool or prl%� is within So fe--:of a surface water _ Cesspoo! ar pri%-, is w ithin 50 fee: o:a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL LINLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING. IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The sys;em has a septic tank and soil absorption system (SAS, and the SAS is within 100 fee:to a surface water supply or tributan• to a surface water supoly. _ The system has a septic tank and soil absorption system and the SAS is within a Zone ( of a public water supa(y we!l. _ The syste-n has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply weil. _ The syste•n has a septic and soil absorption system and the SAS is less thar. 100 fee: but SO fee! or more from a private water supply well, uniess a we!I water analysis for coiiform bacteria and volatile organic compounds indicate-, tftat the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) _ OTHER b . (re�isot 0A.':5/7') page 3 of 10 o r 1 SL.'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: - You must indicate either 'Yes" or 'No' as to each of the following: I have determined that the system violates one or more of the following failure criteria a< defined in 310 CMR 15.303. The oasis 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. Sta;ic !iauid level in the distnb.,tion bo), above outlet.-invert due to an overloaded or clogged $AS or cesspool Lieuid depth in cesspool is less than 67 below invert or available volume is less than 1/2 day ilov. Required pumping more char. 4 times in the last year NOT due to clogged or obstructeo pipe s Number o'times pumped t An:portion of the Soil Absorption System, cesspool or privy is below the high groundwate• eie4ation. Am por:on of a cesspool or privy is-1thir. 100 feet of a surface water supply or tributan to a surface water supply Any por,on of a ce'sscoo' or privy is within a Zone I of a public well. Am pc-:jo- e;a cesspool or prnti• is within 50 feet of a private water supply well Any por.or. of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceo;able Ovate- quart\ analysis. If the well has been analyzed to be acceptable. attach cope of well water analysis for cohicirm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either -N'es-.or "No- as to each of the following. The ioliow:rg criteria aop;,, to large systems in addition to the criteria above: The system serves a facile with a design flow of 10,000 gpd or greater (Large System; and the.system is a significant threat to public health and safeti 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 31-4 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (rev&/od •04/2S/97) pay• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properts Address: IL(5 5P'4`SV1_ � Owner: , Date of Inspection: h� Check if the following have been done: You must indicate either "Yes`or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as pan of this tnspectton As built plans have been cotatned and examined. Note if they are not available with NIA. _ The iac:lits or dsselltng was inspected for signs of sewage back-up. The systern does not receive non-sanitary or industrial waste flow. The site seas inspected for signs of breakout. k _ All sysiem. components. excluding the Soil .Aosorption System, have been located on the site. The septic tank rnanhoies %ere uncovered. opened. and the interior of the septic tank was inspected for condition of baifies or tees. materta? o'construction. dimensions, deptn of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption Svstern on the site has been determined based on _ The iac•l,ts os.ne• ,ano Occupants. d dtneren: tram owneri were provided with information on the proper maintenance of Sub-Suriace Disposal Svsterr.. Existing inio'mation. Ex Plan at B.O.H. _ Determined to the field !if am of the failure criteria related to Pan C is at issue, approximation of distance is unacce:)tabie 115.30231:bi! j #_- A AA/!A/C" Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properts Address: Owner: I'JZ*1 Date of Ihspection._$1ilr�j U FLOW CONDITIONS RESIDENTIAL- Design iloA a o.dlbedroom for S-A c Number of bedrooms Number o'current residents- Garbage g•: der (yes or no,: f•� Laundry cor—ected to system (yes or no! Seasonal use Ives or no!:_L)1 Water meter readings. if available (last two i2 vear usaee (gpdt: Sump Pump Ives or note Lac: date o"occupant, N� COMMERC i AL'INDL'STRI AL• Type of establishment Design fio%% ea!ionsida� Crease trap present ryes or no_ Ind-avria! \taste Holding Tani: oresen; -ves or no_ ':on-sanitan, Haste discnargec to the Title 5 sys;em ;yes or no X%ater meter readings if availabie Las:pa;e o; o ,"anc. OTHER: Describe Last pate of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of informatior. ::VmQeA •its —T System pump�p as par, of tnspeaIon. ryes or no.�T� • If •yes, volume pumped ¢allons Reason for pumprnF k TYPE OF SYSTEM NSeptic tankrdistrtbution boxlsoil absorption system Single cesspool Overflow cesspool Pm)- Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: J- 3 Sewage odors detected when arriving at-the site. (yes or not (revised 04/25/9i) Page 5 of 10 SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION (continued) IL Property Address: 'y S �U��• Owner: Cq; -101 Date of Inspection: /III s 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 Ir-e Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK: J (locate on site pl n Zi/ Depth below grade�_ materialos construction* _meta _Fiberglass _Polyethylene _othertexplam If tank is metal. Iis: age Is age con'.irmec o% Cen;iica;e of Comp);ance _(Ses.-%o Dimensions 0uogPA Sludge depth 1, 9 _ if Distance from top o: s uaee to boron o'ou:'.e: tee o• ba�)e Scum thickness _ Distance from top of scum to top o;outle: tee or ba�.e _ q Distance from bottom of scum - n to boo- IOU ne; t e e• bar.•e �_. How dimensions were determined Comments trecommendanon for pumping. co�ditio� o let and outlet tees or baffles. depth of liquid level to rqa ton to outle in ert, str ural ie�ty, evidence of a gage. etc i s Vv�� Z�te Ilj.{ 1 GREASE TRAP: (locate on site plan! Depth below grade Material of construction. _concrete _metal Fiberglass _Polyethylene —other(explain) 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 i,,let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ;ntegrity, evidence of leakage, etc.: SL'SSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Address: �-n I OM ner: ` Date of Inspection: . II I h/ TIGHT OR HOLDING TANK: 1 `-'Tank must be pumped prior to. or at time, of inspectloni (locate on site plan, Depth below grade. Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity- gallons Design flov, galionsda. Alarm level Alarm in %%orking orde, _ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition o- ala•m and float switches: etc.) DISTRIBUTION BOX:119. doca:e on site p a•: Dezh o` liouid level aoo,a oune: rme,7 Comments lno:e le e! anY dis")bui!on )s eo ev- a-ice i sol-ds carryover, ev) rice of leakage Into o t of bo),•eu.► PUMP CHAMBERIb (loi:ate 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.) a (revised 04/25/91) ` Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORkA PART C SYSTEM INFORMATION (continued) Property Addr-ss: ' Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):�� )locate on srte•plan, n possible, exca%a:ion not required. but may be approximated by non-intrusive methods: If not determined to be present, explain: Type: leaching pits. number. leaching chambers, number:_ leaching galleries, number. leaching trenches. number,iength: leaching fields, number, d.-nensiocs overflow cesspool, numbe! Alternative system Name of Tecnno)og\ Comments ino condition of soil, s! ns of hydraulic failure, levei of pon mg. condition t vegetate of 1� eir , CESSPOOLS: C� (locate on site plar. Number and configura:,on Depth-top of liquid to inlet Inver, Depth of solids Jaye- Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwate- inflow• (cesspool must De pumper as par, 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 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-at PART C SYSTEM INFORMATION (continued Propert. Address: Owner: Date of In,pection: .� 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) H alog2Lq5 (:.y166d'04'75157) F.y• f of 10 l l" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Adores- Owner-. Woe Date of Inspectwn: Depth to Ground ater lFeet Please indicate all the methods used to determine High Croundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) Determine it from local conditions Cnec: wth local Board o• nea::^ Ciiec:. FE.NAA mam Check pumping records Check Ioca' e.ca%alo,s irs:alle•5 L se L SC: Da:a r. Describe 11 %our o— %.orcz ro••% %o- es:ao!+shec the `iifli Cround%sxer Elevation. (Must be completed r / lits, yolo�licin:-D Suau<; `'1' `�05 c �N I ff S� lrevcsed 04.'25 5- Page 20 of 10 TOWN OF BARNSTABLE LfCATION�[ SEWAGE # VILLAGE ASSESSOR'S MAP & LOT - P G5 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY r.S"00 LEACHING FACILITY:(type) titi l (size) NO. OF BEDROOMS 3 - PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER D--,c- Q5 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �„� ��'�% & VARIANCE GRANTED: Yes No l (IF Rouse- qj i 6 Sb /� L 0 CATIONS E W A G E PERMIT NO. ,3 41 �' , VILLAGE 7LU I N S T A LLER'S NAME i ADDRESS ® UILDE R OR OWNER DATE PERMIIT ISSUED DATE COMPLIANCE ISSUED �J7 /ta �� 1 t 2r-r�r� ,, �. L` �� ., v`` �` `�� ' � � _ No.. .._....... Fzzs- �`-__C�_.-.-_ THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH TOWN OF BARNSTABLE ,-6 ppliration for Disposal Works Tontrurtion .erinit C,2 A�licati n is hereby made for a Permit to Construct ( ) or Repair (ran Individual Sewage Disposal -- I ocatio -Addre r Lit No. O ner Address a -•••••-••--`............................ .__ --.......-- --�-....!..-...-' ... Installer Address Type of Building Size Lot____________________ ____ sq. feet V Dwelling—No. of Bedrooms____________ ................................Expansion Attic ( ) Garbage Grinder ( ) `k Other-T e of Building No. of persons____________________________ Showers — Cafeteria Q, Other fixtures - -------------------------------------------------- ----•---------------- d W Design Flow--------------------------------------------gallons per person per day. Total daily flow,__-_________--_____________________________gallons. WSeptic Tank—Liquid'capacity____________gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No__________________... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------------------------------- •................................. Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...................................... •--__............ ___.... __.... _--- •------------------- -------------- •---- •------ ------------ ------------------- 0 Description of Soil......................................................................•................................................................................................. x AiwV Nat re of Repairs or Alterati s—Answer�r w n a licable�:..�.. . 1vTi !/-_.-___•_�% ___ 1Q Agreement: The undersigned agrees to install the aforedescribed dividual/bao#Z al System in accordance with the provisions of TITLE 5 of the State Environment C e—Therther agrees not to place the system in operation until.a Certificate of Co Tian een issued health. Signed ,j` 1....... Date Application Approved BY L .---Y-----Y -..�L—��` - �`. f ---------------------- ------------------ ------------------------ ------- Date Application Disapproved for the following reasons- ------------------------- ------- -------------------------------------- ------ .......................................... ........................................ /. Date Permit No. Issued ....-9`....` 1------------ 1{-- ------------------------- Date No....f�.................. ` 1>b THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CO2 plirntion fur Dispusttl Works Tonstrnr#inn Plernfit Appltca�n is hereby made for a Permit to Construct ( ) or Repair .( y �n Individual Sewage Disposal tem S���....... l" --------------------- .. -. .... 'Location Tdre�s - r LotVo. - �- ! ..J� •...................... ... T....`�^.C_ l�if/ 1/i ...A�Vb er Address may. � Installer L/.. ....... 4—eeVAddress d Type of Building Size Lot...................../Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures ----------•---------------------------------------------•---••••••••••••••••••-••••-•------••--••-••-•••......•••--•......--•-••......-•----••_.----- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._____-____._- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 •••-••••••-................................................................................................................................................. 0 Description of Soil...........................................•-•-•-----------------------•------.---------------------...------------.....----------.._....----••......-•-••.......... x W Nature of Repairs or Alteratio s—Answer when ........��v�..__ ��d ��✓ ........... ---------------•-•----•-......•-------•------•--..._...........---1--•---.------------ Agreement: The undersigned agrees to install the aforedescribed�Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmento/C,od/e—The under. gnefl further agrees not to place the system in operation until a Certificate of Compliance -as'been issued by th bo r��f health. ��, Signed ..... ... .............oe ' ............. �� r Dar Application Approved By .. ----------------------------------------------- --- '-' -----------r�'� Dare Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------- . /` Dare Permit No. ... ?!`. r -+ - .......... Issued .---.. ... � j, " ...... Dare 4 i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Telrtifirate of C amplianre THIS IS 0 CRTIF� hat the Individual Sewage/DisposA System constructed ( ) or Repaired ( t/ ) by /��..s....... 5 � i. ... - .. . Installer at .........- � .... - it , L- nl................... 14/l? -.................................................................... -----...---- has been installed in accordance with the provisions of TITLE 5 of The State nvironmental Code as described in the application for Disposal Works Construction Permit No. .,�// ze- �...�....f�...- dated . c-• i. -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION (SATISFACTORY. DATE.................. .............�........-- -/�---............................. Inspector ..... ... ....------.............� . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � � TOWN OF BARNSTABLE .No. ............... FEE.� .= ........ Otupguul Works 011nstrudinn rrutit Permissionis hereby granted... ...................................................................................................................................... to Construct ( ) or Repair ( n Individua Sewage nisposal System p � •Y / �... ._:-aft r^ Street�� � 4 as shown on the application for Disposal Works Construction Permit I o ��'.... Dated..f..'`r1. ................. Board of Health / DATE..::......: .. ---•' �l' .. (/ .................••••.......... FORM 36508 HOBBS✓!WARREN.INC.,PUBLISHERS ATo...............l.r �- •.. Flms......� % THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH ...........................................OF......................................... .............. ApplirFation for Disposal Morks Tonstrug ion Hermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at . I T-1-j- ...... .. . , r` ....... .. ....... .......... _ r -- -•--•-•--.....__.......--.....--- .•-- Lo tion-Add ess or Lot No. ....�. �'u:.r_`c ........V RL Y•------.C-A.U.T Lcaner Adaress ..................... .. ....................... Installer Address A Type of Building � � q �c��(/ Size Lots - _- q.S f. Dwelling—No. of Bedrooms.......... ------------------------Ex ans on Attic ( ) Garbage Grinder p, Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Other fixtures ....................... . W Design Flow...rr..............................gallQns per person per day. Total daily flow----.:5` .L I..........................gallons. WSeptic Tank—Liquid*capacity.t.75�all o'_Iength................ Width................ Diameter--.----......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No......`............. Diameter...... 1`_7. Depth below inlet..... ._. Total leaching area..9t!�t.t....sq. ft. Z Other Distribution box ( Dosin tank ) WQUf / --.... Date.--•- . ••- Percolation Test Results Performed by--_ .- �! © _. ........ Test Pit No. 11� .�4rminutes per inch Depth of Test Pit....kln....... Depth to ground water........................ fs, z Test Pit No. 2................minutes per i ^4 Depth of Test Pit.................... Depth to ground water......---...........---- o -, - ------------- Description.Df Soil---� ............ .�'.! - _ •-•------.._1-✓,---------- x 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 iITI.E 5 of the State Sanitary Code— The undersigned further a rees not to place the system in operation until a Certificate of Compliance has bee is ued by the boar of health. Date� Jll Application Approved BY / .. td ............ ... ... -Cd••-- Date Application Disapproved for the following reasons------------------------------- ......................................................... •----.............. ------••••......•-----••-----••-•---------------••••---•---•--•--•-•--•---------......-•---•-----•-•---....................-•---- -----------------•--•--------------------•---------------•-•--------•-- Date PermitNo......................................................... Issued....................................................... Date i Fimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F.......................................--------------•-•----------•--..._................. Applirtttion for Uiipoiittl Works Tonitrnrtion rruti Applicatiiax on i-s hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ................___._.._...---...... .... ........................................... .........-•----------. _ -- --------•-------------•---------• - Loc io Addr ss or t No. ...`� �� !�.. . .+ r�:t,"%.. ,_........ �cP� ............... r . �rj...---.. .. .......� .�..: !a caner Address W ...../�... ............. .t.....�..........:-..................--•--^........ ...---............................••- .....•-•----............................ Installer Address Pal __ d Type of Building � Size Lot Sq. fee a Dwelling—No. of Bedrooms........... ........................ Attic ( ) Garbage Grinder ( p., Other—Type of Building ............................ No. of persons........................... Showers ( ) — Cafeteria ( ) , Other-fixtures . -----------------------------------------------•---------------.......----------- W Design Flow....S. ............................gall er person per day. Total daily flow----Z. Q._..._.•..................gallons. WSeptic Tank—Liquid*capacity_.._.__` _ ons 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.t.. Total leaching area...7®.J....sq. ft. z Other Distribution box ( Dosing tank ) P r .`" - l / ~' Percolation Test Results Performed by _____ ................... .. ...... ............. .. Date....7t_ Test Pit No. 11-`—*�`..�inutes per inch . Depth of Test pit----_.....'":...... Depth to ground water........................ Test Pit No. 2................minutes per i7r ,Depth of Test Pit_____--_----____--: Depth to round water......................... �V Q ............ -----............ A Description of Soil...in-c 1-.............. .... . ....................1 f` ---------- W ------------------- =----••-----••-•-----........-----•---------•-------•----------...----.....--•-----•-•-••---------•..--•--------•--•-----••------•--•---•---•--------....-••----------------•-•• UNature 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 TIT12 5 of the State Sanitary Code— The undersigned further a ees not to place the system in operation until a Certificate of Compliance has bee is ued by tre boa o.�f.heal-th. -•-------••--ign ... . .........••-•..............--•- .-----.................... -•, Application Approved BY _._:.....--�_. .. ... 't. , .. Date Application Disapproved for the following reasons------------------•---------•--------•-------------------------•-•-----------.._..--------------•---•---•----•--. ..............................•------...•-•-----...--•----------------•-------••-•.._........•----------•--••-•--•••--•-•---•-----•--•-•---•-•--•--••--••------••-•----•--------•-----•••-•----•-------- Date Permit No............................ .................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O :HEALT, ...., �? t,....oF........... .:. .. ......................... C�rx�#ifirtt�e of �ont�littnr�e feen IS TO RTIFY, That the Individual Sewage Disposal System constructed ( ��®r RepairedA. ( ) by.. .�.... Ins ....... ........ /�fll� at m r hasinstalled in accordance with the provisions of 5 of The State Sanitary C?ale as describ d in the application for Disposal Works Construction Permit No. ...... .--- _2............. dated------61'.'_ _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM wiLL FUNCTION SATISFACTORY. i DATE........................ .........................../l .. ZI.--•-•----•-----•-•-----------. Inspector- THE �f 1 ..---•................•---. COMMONWEALTH OF MASSACHUSETTS BOARD 051HEALTH .......OF...:........ ���.:.......................................... �.1 G/ No......................... FEE.....•---- .......... MIT,. 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