HomeMy WebLinkAbout0568 SANTUIT ROAD - Health 568 SANTUIT ROAD, COTUIT
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S P.A TOWN OF BARNSTABLE4/
LOCATION �WEWAGE # 5:�
VILLALE ASSESSOR'S MAP&LOT Clo-)--U V 3.
INSTALLER'S NAME&PHONE•NO. �/
'SEPTIC TANK CAPACITY 1-5-04n
LEACHING FACILITY: (type) `7 111*17�, � size)
NO.OF BEDROOMS
BUILDER OR OWNER .m�'11�
PERMTTDATE: '� L( _ _COMPLIANCE DATE: cI
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
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 leaching facility) Feet
Furnished by
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AS
ta3. OfY
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_ TOWN-OF ARNSTABLE
LOCATION e SEWAGE #
VILLAGE �� ��5� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. -
SEPTIC TANK CAPACITY.
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
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 f leaching f cili -.Feet
Furnished by
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No. S c Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes/
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS v
k
01ppfication for �Diooml *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 1tomplete System ❑Individual Components
Location Address or Lot No. /(Jl Owner's Name,Address and Tel.No.
Assessor's Map/Parcel c U T u% r
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 45 D gallons per day. Calculated daily flow J Z C7 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. l�t�Cc (Kkt .(a�-
Description of Soil �
Nature of Repairs or Alterations(Answwer when applicable) T-ctA. V 4-( \,S d�=7— Ol.� ✓C�ZG ?_��A iT�k SZ
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 Enviro mental Code and not t ace the system in operation until a Certifi-
cate of Compliance has been' y this;Bo
Signe Date
Application Approved by e i Date
Application Disapproved for the following reasons
Permit No. 9�"3` 7 3 Date Issued
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M A�-C&l
DATA
No. far,,*„ Feey,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS v
2ppYtcation for. )Di.5paaf *pgtem Cougtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) omplete System ❑Individual Components
Location Address or Lot No. 56 TV/� Owner's Name,Address an el.No.
Assessor's Map/Parcel C U (-A , �[/"e k C_�_
Installer's Name,Address,and,-el.No:, ��. a+ w 'j l � Designer's Name,Address and Tel.No.
V� C0S� p1'aC _ 1 t
Type of Building: n ice .
Dwelling No.of Bedrooms:. > Lot Sizes sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons ` °% E Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date ii Number of sheets Revision Date
Title \
Size of Septic Tank \S cro ' Type of S.A.S. PC,.i
Description of Soil
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Nature of Repairs or Alterations(Answer when applicable) -
-N o v. 4Z)5 (A.� lid S'\G�-2. O L(`c
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 Envir nmental Code and not ace the system in operation until a Certifi-
cate of Compliance has been ' y this Bo eafth
Signed Date -q'
Application Approved by Date 'y
Application Disapproved for the following reasons
Permit No. 9:�~ S` 7 3 Date Issued y S
THE COMMONWEALTH OF MASSACHUSETTS J,
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded )
Abandoned( )by 1M i 17-C�A ft S c aN i c-
at S fA NTV't7 A 0 �(MTh`� l _ has been constructed in accor ance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be co strued as a guarantee that the system will function as designed.
Date Inspector
No. � 73 ———— Fee V
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
x1h5poea[ *p.5tem (Con.5truction Permit
Permission is hereby granted to Construct( )Repair(7 )Upgrade( )Abandon( )
System located at �i GVA(&6' S•. d
5)4 o-k L t T f& t;
Ccv L,�i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thi t.
Date: �- / r 9 Approved by -
I 1019197 ��'
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his Form Is To Be Used For the Repair.Of
ffoTICE: Failed
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Septic Systems Only
CERTIFIC
AND-APPLICATION
ATION OF s T FORA y.
DISPOSAL WORKS
PERMIT
ITHOUT'
ENGINEE
RED PLANS?
ceti that the epQiicetion for dispo�►
--�ltembY fy
� the
Ire dated
' oonsttuction pern+it signed by , , •
• .�� meets wit of the
property lasted
following coterie:
I aye ne wetHnds Ioeet�d
wNhM 100 het of d+e p�eposed keehMt WRY -
' i
0.r.ri'm wails wmm ISO het of the PC"" "Ole ,f
There M ne Inaeese'In flvo►
dlor d"10 in use prvPoeed
i There rfe ne Of {
0 1 pIih►will be loeeted
whhM 230 het of 01 wettends,the button+
l/' irtheropdsed
let�chins lrcilitX will�be beefed less then)fwfleen(IA) wl
feet above the maximum
w tebk eleKtiea• ! i
• � I
ihesse emplete the(b11e�w1ets
ineerin�pivlslen 0.1.3.map) =
A)'Ibp Elevet (eeee�dMt to the /. ,
'` eaordMg roHeelth Divbion weft n+ep)�,.. - �•
DATE:
fig WALLL+k IN TFM lb N OF BAtWgTABLB i,1UM81?R
N � tM Itd» h+�lb►vewra.ewetn.A plat a� -
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LOCATION
�y ' ®SEWAGE #
VILLAGE / ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. �
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) -1-7 '
(sue)
NO.OF BEDROOMS
BUILDER OR OWNER --------------
i PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 306 feet of leaching facility)
Furnished by Feet
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Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: Villlfag C;�W4
BUSINESS LOCATION: / /T
MAILINGADDRESS: AbOy_ Mail To:
TELEPHONE NUMBER: � Board of Health I,
i / � Town of Barnstable
CONTACT PERSON:
P.O. Box 534
EMERGENCY CONTACT TELEPHONE NU' BER: o?l�/ Hyannis, MA 02601
TYPE OFBUSINESS:L'"�{ iIC
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO_
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor& furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic zardous (please list):
Spot removers & cleaning fluids
_VY
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
Date:
TOXIC AND HAZA DOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: ✓✓ 1
BUSINESS LOCATION: 612/7 54 ilk& a C v
MAILINGADDRESS: Mail To:
TELEPHONE NUMBER: gIZ57
Board of Health
Town of Barnstable
CONTACT PERSON: r P.O. Box 534
EMERGENCY CONTACT TELEPHONE U BER: b` ' ���' `li��� Hyannis, MA 02601
TYPEOFBUSINESS:
Does your firm store any of the toxi r hazardous materials listed below, either for sale or for you own
use? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes Leather dyes
Asphalt & roofing tar = Fertilizers =
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor &furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
r 01 ►Q�9 ,
0ATE:.,6./22/8
PROPERTY ADDRESS: 5'68 gantuit 'Road '
Cotuit•,Mass.
02635
On the above date, 1 inspected the septic system at the above address.
This system consists of the following:
1 . 6 'x8 ' block desspool.
2 . 1 -1000.' gallon precast leaching pit
packed in stone.
based bn my InSD&C flon, I certify the following conditions:
3 . This is not a title five septic system. -
4 . This is a sewage system that is in proper ,
working order at the present.
5 . .The system is dry.,.'
6 . The house has been vacant for about two years.
SIGNATURE: '
Flame. J. P Macomber Jr... i
r- -------
Company:_` . P,Macomber- & Son• 'Inc h
,
Address --B•a-u-6b------.i__ - RECEIVto
_;Cente'ryilleLMass__0.2632 ' JUN 26 1998w' _
ftN OF BARNSTABLE
Phone:---Sa8 -7�^3338-------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-LeachfleIds
Pumped & Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
77.5-3338 775-6412
f
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIASI F.WELD TRUDY CO
Govcmor Sccrci
ARGEO PAUL CELLUCCI DAVID B.STRL
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissic
PART A
CERTIFICATION
Property Address:568 Santuit Road Cotuit,Mass. Address of Owner: 7 Durham Street
Date of Inspection:6/1 g/gg (If different) BOston,Mass.
Name of Inspecton jnRim h y Macomber Jr. 02155
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J.P.Macomber & Son Inc_
Mailing Address: BOX 66 C'PntPrvi 1 1 P, MRSS O2632
Telephone Number: 5()8-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accuratc
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 se age disposal systems. The system:
Passes -
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: (f 9 9 f g g
The System Inspecto all submit a copy of this inspection report to the Approving Authority 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 the system own•
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY:, Check A, B, C, or D:
AI SYSTEM PASSES: ,
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303
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, upc
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; c
4.
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan
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.
(sevlaod 04/25/97) P&ge 1 of 10
DEP on the World Nhde WO: http:/rwww.mapnel.state.ma.us/oep
Printed on Recyded Paper
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' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
h CERTIFICATION (continued)
Property Address: 568 Santuit Road Cotuit;Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/9 8
BJ SYSTEM CONDITIONALLY PASSES (continued)
.V%/& 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled'or replaced
tD The system required pumping more than (our times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS.UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
W Cesspool or privy is within 50 feet of a surface water
AM Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the prese ce of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance _(approximation not valid). i
3) OTHER
k Ix 9 &44dml. 14.01 Tj lib AK 4 0"56-
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(revised 04/25/97) Yap• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:568 Santuit Road Cotuit,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/9 8
D) SYSTEM FAILS:
You must indicate ei-v,er "Yes' or"No" as to each of the following:
_M I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system cpmponent 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.
k�Ity l t
Ligvid depth in,eeetpeel 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(s1.
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" as 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
N/1t the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/37) ?&go 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 568 Santuit Road Cotuit,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/9 8
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 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.
The system does not receive non-sanitary or industrial waste flow.
Z _ The site was inspected for
signs of breakout.
.) &
All system components, cling the Soil Absorption System, have been located on the site.
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:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. 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))
(revised 04/25/97) Pep• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
SYSTEM INFORMATION
Properly Address: 568 Santuit Road Cotuit,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/19/98
FLOW CONDITIONS
RESIDENTIAL: y-�
Design flow,
t J%Q R.p.d./bedroom for S.A.S.
^umber of bedrooms::
Number of current residents:
Carbage grinder (yes or no)._
Laundry connected to system (yes or no).�
Seasonal use (yes or no).VA7 �p
L•:aier meter readings• if available (last two (2) year usage (gpd): p Cif= V /�1`),,,
Svmp Pump (yes or no): 1Q 9 '(/y� r7119
;ast date of occupancy i
COhimERCIAUINDUSTRIAL-
Type of establishment:_ ,yfg
Design flow: gallons/day
Grease trap present: (yes or no)_
industrial Waste Molding Tank present: (yes or no)-90-
Non•sanitars Haste discharged to the Tale S system: (yes or no)-ARWater meter readings, if,availaVe.- All*
Last date of occupancy:
OTHER: ;Describer OVA
Last date of occupancy
GENERAL INFORMATION
PUMPING RECORDS and source of igforma(ton.
System,piumpecr as an of inspection: (yes or no)_
if yes. volume pumped: , gallons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow el.��
Privy �l
Shared system (yes or no) (if yes, anach previous inspection records, if any)
I/A Technology etc. Cop of up to date contractI
Other f�
PPRO�ALM:A,T,E AC,E�of all components, date ,ns}aped (if known) a d s urce f informs n:
Srwage odors detected when arriving at the site: (yes or no)/A h'
tr.vy..d 0�/JS/971 Y&y• 5 of 10
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress:568 Dantuit Road Cotuit,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/9 8
BUILDING SEWER:
(locate on site plan)
Depth below grade:/ t
Material consstru iioon: cast iron 4Q PVC_other (expla'
Distance If �rivate water supply wel or suctA line _ OF
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
Jointa appear tight No evidence of leakage The sUgtPrn iz
vented through the house vent
SEPTIC TANK:&MV-
(locate on site plan)
Depth below grade:
Material of construction:concrete,V,&metal�iberglasX,&Polyethylen other(explain)
If tank is metal, list age &d Is age confirmed by Certificate of Compliance4l6 (Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_4-14
Distance from bottom of`scum to bottom of outlet tee or baffle:,
How dimensions were determined: otw
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.)
e septic tank is not present
GREASE TRAP:, f—p
(locate-on site plan)
Depth below grade:
Material of construction AO concret&OmetaWkFiberglassAJ,*Polyethyleney.�other(explain)
Dimensions: 144
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 baffler
Date of last pumping: V17
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.)
The grease trap is not present
(rsvisod 04/25/97) Ps96 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 568 Santuit Road Cotuit,Mass .
Owner: Theresa Eagan
Date of Inspection:6/19/9 8
TIGHT OR HOLDING TANKa&f2QPTank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of constructionconcretei(j�rnetal�/�FiberglassN�Polyethylene,Q�other(explain)
� t
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order4 Yes;,Q4 No
Date of previous pumping: .42-4_
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tiq t or holdinq tanks are not present
DISTRIBUTION BOX:/bve—,,,
(locate on site plan)
Depth of liquid level above outlet inven:_ly/�-_
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.)
The distribution- box is not present.
PUMP CHAMBER: ff�
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order(Yes or No)_,V f
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
The pump chamber is not present.
(revisal 04/25/97) P.9. 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 568 Santuit Road Cotuit,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/9 8
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation 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,length:
leaching fields, number, dim sions:_
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Foamy sand tn medi tam f i np Rand-Nn c; nng r,f by rau1 J c failur®
or nondina.All veaetation is normal
CESSPOOLdr'z
(locate on site plan)
, J
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 groundwater:
inflow (cesspool must be pumped as part of inspection)
Did not pump cesspool . The system is dry. House has been vacant
for about 18 months or so.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Same as above. No signs of hydraTlic failure or ponding.
All vegetation is normal.
PRIVY:
(locate on site plan)
Materials of construction:_ Dimensions:
Depth of solids: AA&
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privies are not oresent _
F
(rwised O4/7S/97) D490 B of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:568 Santuit Road Cot6it,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/98
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)
0
/9
/ i I
C
(r.vl..d 04/15/17) 1'499 9 of 10
SUBSURFACE SEWAGE DISP,. t. SYSTEM INSPECTION FORM
I C
SYSTEM INFOI. 'ION (continued)
Properly Address: 568 Santuit Road Cotuit,Mass.
Owner: Theresa Eagan
Date of Inspection: 6/1 9/98
Depth to Groundwater /S Feet
Please indicate all the methods used to determine High Groundwater EI('••a:ion:
/Obtained from Design Plans on record
Observation of Site (Abuning property, bservation hole, basemtrYsimp etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
ZCheck local excavators. installers
oca e c
Use USGS Data
Describe n your own words how you established the High Grounciwa*er Elevation. Must be completed)
Used water contours map.
Gahrety & Miller Model
12/16/94
Installed leaching in 9/2/75 . No water encountered at 14 '
lr•vl••G 01/25/97) P•f lO�t 10
i
>•r.rnrw -n.r►r.•�- e>rant•n>sw�>rtn+xm>rt�r»v.rt�.�++'+nn m-n.ti r►a-rrratmn .tr-rr•+rr-ir-+r--:..�-.r••�
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�. F.-•sn-T•:-:: —�. r.-.-rr+.+r.+n-n.•nnrnams+ra+r-.mom-r-titi�vnc�anrm--r*++ncwr rsmn•'mr'.rs�m+.rR•.:--.nrr•r--�.—..�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 568 Santuit Road Cotuit Mass.
ASSESSORS MAP, BLOCK AND PARCEL # CJ f Di
OWNER' s NAME Theresa Eagan
PART U - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Svri' INc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
�Systeui PASSED
The inspection which I have conducted has not found any information
which ind.icates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con trcted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection if rm .
Inspector Signature Date 6/22/98
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF RZAL1'1(.
If the inspection FAILED, the owner or shall u
* pgrAdo • tho system
within o'ne year of the date of the inspection, unless allowed or required
otherwise as provided in 3,10 CMR 16 . 305 .
partd .doc
`V
w
7U
7 - r�
ti
Sys �71
THE COMMONWEALTH OF MA.SSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
hInr 8. 199S �t
Acting Director of (lie. L) inn ul Water Pollution Control
y �
DATE._ 8;/;10/95
PROPERTY ADDRESS:_.,568 -Santuit• Road- RECEIVED
C.otuit AUG
2 4 J995
D Mass .02635 HEALTFI DES
TOM OF B
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 ; 1=6 'x8 ' b.l'ock cesspool . Acts as septic tank.
2. _1-1000 'gallon precast leaching pit * Act as overflow.
Based on my Ink*Ctlon, I certify the following conditions:.
1 . -This is not' a title f- .ve_ sep.:tic:system.
:2 . .This is. a-• sewage system that'. is:-in IY't.oper....K-orking .
or'd'er•- a.t the present time .
3... Cesspool was - pumped no signs. of .ground .wa-ter orpo,;R:dXng.,
i 4. I�f ant e� terior changes arty, made the . system= jai;l' have to be
u,pgradede ,to a title five - septic system. '
5IGNATURr,:
Name:_J_P_M_ac'omber jr....
Company:_J. P_Macomber & Son-
Address: '
Centervill;e Mass: 0.2.632 '
Phone:---50.8. 77_5_333a------_ , 1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped h Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
77.5-3338 775-6412
_ 7
Sub E DISPOSAL SYSTEM 1NS:tCTION
Actress Of Proper.t 568 Santuit Road Cotuit ,Mass. 02635
Owner ' s name Geraldine Borlotti
Date of Inspection 8/10/95
PART A
C}i UCKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and 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 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.
.The site was inspected for signs of breakout.
1�tID t0
All system components, the SAS , have been located on the
site.
AF The ^�' � � ^kymanholes were uncovered, opened, and the interior of
c..
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 SAS on the site has been determined baser
on existing information or approximated by non-intrusive methods.
--4/— The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance '•of SSDS.'
z
r
SUBSURFACE SEWAGE DISPOSAL BYSTEM .INSPECTION FORM
PART 8
SYSTEM INFORMATION
FLOW CONDITIONS:
If residential
I •
number of bedrooms
number of current residents
..i?. garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes. or no
If nonresidential , calculated flow:
Water meter readings, if available: 1993=40,.00' g0. ' allons='109Y.59 GPD
1994,=27 , 000- gall..o`ns.=73'. 98 =GPD.
wP k nds Last date of occupancy
GENERAL INFORMATION
Pumping records and sourceo i�g t 'on:
Maint pumping . 6/30[- 826 89 8/25/92
Oyprflow pit installed 9/2 75
i NO System pumped as part of inspection, yes or no
if yes, volume';: pumped �-�
Reason for pumping:.
NONE
Type of system
No Septic tank/distribution box/soil -absorption system
YFR Single cesspool
YES VyVITIOMVWWWOIbIXX Precast leaching pit..
.din Privy
,Nn Shared system (yes or no) (if yes, attach previous inspection
records, if any)
NO Other (explain)
Approximate age of all components. Date. installed, if known. Source of
informa.tion:_...
Leaching pit 20 years old . Cesspool 55 years old.
NO
.Sewage odors detected when arriving at the site, 'yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: NONE
(locate on site plan)
depth below grade: NnNF
material of construction: ,N44gconcrete metal FRP -other(explain)
NONE
dimensions.: Nnmy.
0 sludge depth
distance from top of sludge to bottom of outlet tee or baffle
0 scum thickness
0 distance from top of scum to top of outlet tee or baffle
0 distance from bottom of scum to bottom of .outlet tee or baffle
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, recommendations for repairs, etc. )
NONE
DISTRIBUTION BOX: NO
(locate on site plan)
N0NF depth of liquid level above outlet invert ..
Comments:
(note if level and distribution is equal, evidence `of solids carryover,
evidence of leakage into or out of box, recommendation .for repairs, etc.)
NnNR
i
t
i
PUMP CHAMBER: NONE
i
(locate on site plan) i
pumps in working order, . yes or no
1
Comments:
(note condition of pump chamber; condition of-pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
NONE
i
- - i
•
i
C/D
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART B
SYSTEM INFORMATION coatiaued
SOIL ABSORPTION SYSTEM (SAS) ; Y_ES I '�
(locate on site plan, if possible; excavation not! re iced but 'ma be ,
approximated by non-intrusive• methods) ' Y
If not determined to be present, explain:
Type
leaching pits and number i 1-61x7' precast leach pit.
leaching chambers and number . 0
leaching galleries and number 0
leaching trenches, number, length 0
leaching fields, number, dimensions 0 _ ,,�.
overflow cesspool , number ,,_,,, 99 esl„
Comments:
(note condition of soil; signs of hydraulic failure, level of ponding.,
conditnonsifnveoftation, ecommTndato°n fo r maintenance or repa.irs�etc.
Nn rppairs at the present time
CESSPOOLS (locate on, site plan) :
number and configuration ck cesspool .
depth-top of liquid to inlet invert ArtgA9 A SQDtic tank
depth of solids layer .
depth of scum layer ' ,
dimensions of cesspool
materials of construction �nnrrcip hlnrk
indication of groundwater No indication of ground water.
inflow (cesspool must be pumped as
Tart of inspection.) ; CQ�0n„ni n„ P mDd hree 'weeks ag
r
Comments: Pit dry at that time.
(note condition of soil, signs of hydraulic failure, level *of ponding,
condition of vegeta.t 'o re a sofopo�ingenance or repairs etc.)
Sand ;No signs o. .hny ra�� � � g�
No repairs neededat. e
PRIVY: .NONE
(locate on site plan)
materials of construction _ NnNF
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, - level of. ondi n condition of vegetation, recommendations for maintenance
,
or repairs,P"
i
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L_SPOSAL SYSTEM
include ties to at least two permanent references landmarks or benchmark
s
locate all wells within 100 ' Town Water
• �i
r .�
i
DEPTH TO GROUNDWATER
201+ 1depth to groundwater ,
method •of determination or approximation:
Tn9tg11Pd 1000 eallon nit in 1975. No water at 1 '
Inc . -
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM l
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . . Describe basis of
determination in all instances. If "not determined", explain why not) :
A10 Backup of sewage into facility?
_1M Discharge or pondin.g of effluent to the surface. of the ground or
surface waters?
LOX Static liquid level: in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1
flow? . /2 day
_. Required pumping 4 times or-more in the last year?
number of times pumped OAI -
Septic tank• is metal? cracked? structurally unsound?: substantial_
. ' infiltration? substantial exfiltration? tank .failure imminent?
Is any portion of the SAS, cesspool or privy
below the high groundwater elevation?
within 50 feet of a . surface water?
_f10 within 100 feet of `a surface water supply or tributary to a surface
water supply?
, Q within a zone I of .a public well?
within 50 feet of a' bordering vegetated wetland or salt marsh-
(cesspools and .privies only, not the SAS)?
Alb within 50 feet of a private water supply well?_>
less than 100 feet but greater ter 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 anal;
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
--r�r.—rrr•s-.r...r�r.xre-.+-rvrs:.s:sr=-eaa ..^ rtmenrer.�re•-�'
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D.- CERTIFICATION
�n^:»ter•:^:r..-tten sr. r.:— r .'a--rr.rr...rr...censserr.•..r._rr.�rrrrt7 ... ._. ..^. �. sr.... ..^. ...- rrr.•�,.�.�.
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 568 Santuit Road Ctuit ,MaC;G _
ASSESSORS MAP, BLOCK AND PARCEL # 2-4 /
OWNER's NAME Geraldine Rarintti
PART D - CERTIFICATION t
NAME OF INSPECTOR Joseph P. Macomber Jr _-.
COMPANY NAME J.P.Macomber & Son INC.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 075- - 3338 FAX ( 790 I 508 - 1587
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal .system at
this address and that the information reported is true, accurate , . and
complete as of the .time of inspection . The inspection was performed and any.
recommendations regarding upgrade , maintenance, and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems:
Check one:
XXXXX System PASSED
The inspection which' I have conducted has not found any information
which indicates that; the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have- conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on , PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date 8/11'/95
One copy of this certification must be provided to the OWNER, the BUYER
(where applicable) and the .BOARD OF HEALTH.
* If the inspection FAILED, the owner or'll,operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
J.4.
f
Ccrnrrenwearn c; Massccn:aers
Execurrve Otfice cr Envlrcnmenrc, nftcs
Department of
Environmental Protection
Water Pollution Ccntrol Temniccl Assocnce ana Training Sections
WlNlam F.Weld
Gonna.
Trudy Co:e
SwwrY.EOfd i
Thomas&Powen
aar+y Comm..pn..
06/12/95
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and San
PO Box 66 !
Centerville, MA 02634-
Dear Joseph P. Macomber, Jr. ,
I am pleased to inform you thac, you have attended training, met
the experience qualifications, „and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR. 15.340. The passing grade for
the exam was 39/52 or 75%.
This is an official notification that you are a Certified Department R
of Environmental Protection System Inspector pursuant' to 310 CMR 15.340. '
You will receive a System Inspector certificate at a later .date.
If you have any futher questions, please write to at. the followin
9
address:
Kimball Simpson
D.E.P. Training Center
50 Route 20 '
Millbury, MA 01527
Thank you vet much for ! j
Y Y you: time. and consideration in this matter
•41
i i
i
Sincerely, j
Kimball T..• Simpson;
DEP Training Center Director I
(2405)
Route 20 hilllbury, MA 01 . 7 e FAX $08-755.9253 a Telow--i• 506-756-72"'
• i
Water
Cofis'ervation
SAYE Tips
ME!
CHECK FOR LEAKS: : ,
Water Loss in Gallons Due to Leaks
Leak
This Loss Per Day Loss Per Month
Size
' 120 3,600
360 10,800
• 693 ' 20,790 4
• 1,200 36,000. ;
1,920 57;600
• 3,096- 92.880
.0 4, 96 .128.980
. 0 6,640 .199,200
6,9.84 '. 200,520
8,424 ' 252,720
�. .f 9,888 '
296,640
® 11,324. 339,720
12,720 381,600`
14,952 448,560
No......................... Fss....a ...................
THE�COOMAOONWDEALTH �FH EAcHUSET TH Ts
�6-1Io�2 A
Appliration -fur Uiipwial Work.9 Towitr7an
n Vantit
Application is hereby`made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
System at:
�/ cation_Address or Lot No.
s//
Owner Address
a ,...._ .._.. °= . �--------------- -------------------------------------
Installer Address
UTyplofBtuiiilding Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth-.___-___----
x Disposal Trench—No-____________________ Width._•_-_-.--__._--__-- Total Length.................... Total leaching area--------------------sq. ft.
b
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- ---------------•---•--------•------ ----------------•----•--•---- Date................-----------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...._-.-_____. --..._...
(14 Test Pit No. 2................minutes per inch Depth of. Test Pit.................... Depth to ground water------------.--.-._-___.
P4 - -----------•----- ----------------------------••--•------------••--•---•---------------------•-----------••------.....----•---•-._...----------•---•-----
ODescription of Soil---------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
U -----------•-----•---•--------------------------•--•--------•------•-------------•-------------------•-------•-•--•-------•----•---•-•--•----•--•-------•------------------------•----•----.:_---------
W ---------------------- ----------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable.-.-... .............rt�i.- /6 � f
- ------- ----- -
------------------------------------------------------------- ------••-•----•-•-•••-------••---------------•••-•-------------------/---------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. Y. �0
Date
A licatian A roomed B - - � ��� ----------
PR PP y
Date
APPlicaticn Disapproved for the following reasons: ....:........•--•--------------..........-------•-------..........--------.....--•••--------•-•
--•-•------------------------------•--••-----•---...------------.......---•--•----------•--------------------------...................--------•--•••---•---------------..............--•---.......-----
Date
PermitNo......................................................... Issued------(�............................................`!�
Date
No............... ----••-• Firma jet:.....................
THE BOARD F H EA T H
COMMONWEALTH OF MASSACHUSETTS
TS`
1----OF........
Appftrtttturt -fur R,>ipuiitt1 Workfi TunfitrurttuYt Vr ru�-t tt
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
s6
�L ocation•Address or Lot No.
.............. ..%. c............. ................................. ..
� Owner Address
a •••---- , ••:.....161.� 1�................. ----------••-••-----•----••-••-•---•._......._...
-----
Installer Address
UType of Building Size Lot............................Sq. feet
-I Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures -------_----------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity----___-_--gallons Length________________ Width................ Diameter---------------- Depth----------------
x Disposal Trench—No. ..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area-------.----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--- _____________________________•• Date---------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest 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------------_--- --•--••-----------•-••--------•------•--•--•----••-----•--•-•--•---•--••----- ------------------------- ----------------------------------------------
x
W
x o-,-,_ ---�� �
U Nature of Repairs or Alterations—Answer when applicable.-'._�__.�_._..._ _-�._-.__1_-_._�----------------...................�.._....
----------------------------•-- ----.-.---------------------------------------___----------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
-•�by the board of health.
�f
Date e
Application Approved B Ct�t .__._ _.- 1 '�l G L ------•--•--•---•••-••-•••--- ---9--�- 7
PP PP Y -
Date
Application Disapproved for the following reasons:-----•.................•------------------••--•-•--•---•----•-••--------------•---•-------.....____....___------
•---••-•--•-----------•---•-----•...................•----------------------•-•--•------________---•---------------_..__.___..---------•--._.----------------•-----------------------•---...-----___..___
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
.......!......�1/�................OF.......
... � .. ..............................................
�rrtifirate of 051,11mptitturr
_
7l�HIS RTO Cff�?IIFY, That tpeII1, .pal Sewage Disposal System constructed
b ( ) or Repaired ( )
y��'= y _//l l'��-C�' _l ,_.._.. In$ ;;� •------ - _ -------------------------------•---•-•----
has been installed in accordance with the provisions of A rticle XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No� Z--- :.................. dated--...�__..�.-__�_._ r.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS E® AS A GUARANTEE THAT THE
SYSTEM WILLJUNCTION SATISFACTORY.
DATE.............. = ----�-- -7.....----------................... Inspector_-- ----------------••-•----------•-•---•-••--•-----•-••-••••----•-••--•-••.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH f
. ?/1- .......O F......... � �`� ' '�= _--
No.------- �� FEE�___••--____.__-
�i� ut� , aurk Qluuitrurtiutt rmit
. �
Permission is hereby granted,.,--*../-_.:..._._� j�-�__�_-----_i,�-_- ��..._:_
to Constr ( )for Re air (�/an Individual'Sewage Disp dal steifl
/ �.- �_
at No._`1 /...r! �L.c...-••---•-•--•-= G`fr - - ... -- �L' =
Street
as shown on the application for Disposal Works Construction Peet No--- __. Dated-------------- -
/ .......................
_ •----•_----•---•----- Board of Health
DATE. ..•.. .. ..................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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DATE: REVISED
F _ _ �� ORAWIN[i NUMBER
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