HomeMy WebLinkAbout0086 WHITMAR ROAD - Health 86 Whitmar Road
Cotuit
A _ 05�114
D ATE :9/13/02
PROPERTY ADDRESS: 86 Whitman Road
-- Cotuit,Mass_-
02632
------------------------
RF-CE1 �®
On the above date, 1 inspected the septic system 'at the abov ad ress.
This system consists of the following:
SEP 2 5 2002
1 . 1 -1500 gallon septic tank.
2. 1 -Distribution box. TOWN OF BARNSTABLE
3. -2-1 000 gallon precast leaching pits. ( 6 'X1 0 ' ) HEALTH DEPT.
Based on my inspection, I certify the following conditions: _
4 . This is a title five septic system. (- 78 Code ) �
5. The septic system is in proper working order
at the present time.
6. #1 pit: The waste water is 66" below the invert pipe.
7. #2 pit: The waste water is 64" below the invert pipe.
SIGNATUR
Name:- J .- P . -Macomber-Jr .
Corripany :Joseeh P._ Macomber & Son, Inc .
Address :--8eX-E_k-------------
-_Cen-..erYtl_1Q-,_M.a-_n63.2-0066
Phone : 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks -Cesspools
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066 `
775.3338 775.6412
�-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 86 Whitmar Road
cptt i tt,Ma Ss
Owner's.Name: Daniel Kossman
Owner's Address: Same
r
Date of Inspection: 9 13 02
Name cf Inspector: (please print) Joseph P.Macomber 'Jr.
Company Name: J.P.Macomber & Son Inc.
Mailin Address: Box 66
_Centerville,Mass. 02632 a
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true. 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. I am a DEP
app.'oved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspec:tor's Signaturrbmit
� Date:
The system inspector shal 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.
Notes and Comments
7
This report only describes conditions at the time of inspection and under the conditions of use at that
time. Th.is inspection does not address how the system will perform in the future under the same or different`
'conditio.s of use. _ —
Title 5 Inspection Form 6/15/2000 page'I
Page 2 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 86 Whitmar Road
Cotuit,Mass.
Owner:Daniel Kossman
Date of Inspection: - 9/1 3/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D '
A. System Passes:
1 � _
_A,�Z7 1 have not found any information hich indicates that any of the failure criteria described in 3.10 CMR
15.303 or to 37VCIvltt'f3.3Zf4 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order
at the present time.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
d Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain-
,<0 The system required pumping more than 4 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
ND explain:
Page 3 of l I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 86 Whitmar Road
Cotuit,Mass.
Owner: Daniel Kossman
Date of Inspection: 9/1 30 2
C. Further Evaluation is Required by the Board of Health:
AV Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. S}stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
.6'0 Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. S-stem will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
,h'0 The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
4LI The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than I 0 feet b 50 feet or,more from a
private water supple well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bzcteria and volatile organic compounds indicates that 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, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this forma
3. O:her:
_ II
s
} 3
y
Paee 4 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prope-ty Address: 86 Whitmar .Road
Cotuit,Mass_
Owner: Daniel Kossman
Date of Inspection: 9 1 3 02 '
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yes No
B ckup 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 .
squid depth in 6o&5peel is less than 6" below invert or available volume is less than ''/ day flow
v/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
�Of times pumped d.
ny portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface-water supply or tributary to a surface
_Aater supply.
lny portion of a cesspool or privy is within a Zone I of a public well.
_ �/ y portion of a cesspool or privy is within 50 feet of a private water supply well.
�y 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 coliform bacteria and volatile organic compounds
indicates that 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, provided that no other failure criteria
are triggered. A copy of the analysis trust be attached to this form.)
(Yes/No)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 o�
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design .Flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes nc/
_ th; system is within 400 feet of a surface drinking water supply
system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes" to any question in Section E the systern is considered a significant threat,or answered
--yes" in Section D above the large system has failed. The owner or operator of any large system considered a .
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner.should contact the appropriate regional office of the Department,
4
Page 5 of I I
OFFICIAL. INSPECTION FORM DISPOSAL SOYSTEM INSPECTION FORMVLUNTY N?S
SUBSURFACE SEWAGE DISO
PART B
CHECKLIST
Properry Address:8 Whi mar Rn d
Owner: Daniel Kosstnan
Date of lospectioo:
Check if the following have been done You must indicate 'yes"or"no" as to each of the following:
Yes No
m]XPuping 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 rwo week period ?
ZHave large volumes of water been inrroduced to the system recently or as part of this inspection ?
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 break out ?
Were all system components,.ez luding the SAS, located on site?
z _ 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
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
Yes n
XExisung 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) (3I0 CMR 15.302(3)(b))
5
III- `
Page 6 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 86 Whitmar Road
Cotuit,Mass.
Owner:Daniei Kossman
Date of Inspection: 9 13 0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):_'�P'
DESIGN flow based on 310 C,M,R 115 203 (for example: 110 gpd x# of bedrooms):!22'—oyd
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no)-AT� [if yes•separate inspection required]
Laundry system inspected( es or no): d (f
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): 40
Last date of occupancy:ley
COMMERCIAL/INDUSTRIAL
Type of establishment: .tL9
Design flow(based on 310 CMR 15.203): ,_J4 gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_,�2t
Industrial waste holding tank present(yes or no): 414
Non-sanitary waste discharged to the Title 5 system (yes or no):,"
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION ,
Pumping Records ,
Source of information: /fk AM' iQ,�
Was system pumped as part of the inspection(yes or no):,dB
If yes, volume pumped: D gallons-- How was quantity pumped determined?
Reason for pumping:
YTYR OF SYSTEM
Septic tank, distribution box,soil absorption system
.�J) Single cesspool
,J�d_Overflow cesspool -
.Ul� 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)
,40 Tight tank 4 Attach a copy of the DEP approval
Other(describe): .60
Approximate ale of alj components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): .t�D
Page 7 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART C
SYSTEM INFORMATION (continued)
Property Address: 86 Whitmar Road
Cotuit,Mass.
Owner: Daniel Kossman
Date of Inspection: 2
4
BUILDING SEWER(locate on site plan)
Depth below grade: y/
Materials of construction:ALcast iron d 40 PVC other(explain):
Distance from private water supply well or suction line: s0`f
Comments(on condition of joints, venting, evidence of leakage, etc.):
,T ints appear tight.No evidence of leakage.The system is
vented through the house vents.
SEPTIC TANK: —L/cate on site plan)."' �i
Depth below grade:
Material of construction: ✓concrete.tt> metals. r fiberglasstiL%polyethylene
,�,other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate) r
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:
Distance from bottom of scum to bottom of outlet tee or baffle: 1
How were dimensions determined: Ag4swaz-
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
?ump the semi(- t-,ink PVPry7-3 years - Inlet $ n4itl et—tees
arP in nl aCt= ThP- tank is ct riir++ ti ���cT$913 � and sheios nE) j
evidence of leakage.
GREASE TRAP/4k(locate on site plan) x
Depth below grade:—t 9
Material of construction;,�conerete414 meta 140X fiberglass polyethylene c,�other
(explain):
Dimensions: J /�9
Scum thickness:
Distance from top P of scum to to of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: e
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present
7
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address86 Whitmar Road
Gotuit,Mass.
Owner:Daniel Kossman
Date of lospectioo, 9 1 3 02
TICHT or HOLDING TANK,I-S'� d(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: A
Material of consrructioonn:— concrete,-4�5—meial �1 fiberglass ,* of e(h lene
N p Y Y �iLother(explatn):
Dimensions ;Q
Capacity gallons
Design Floes .G gallons/day
Alarm present (yes or no): /}
Alarm level: A�$ Alarm in working order(yes or no):
Date of last pumping: 41*
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are no PLt--5ellL.
DISTRIBUTION BOX: 2(irpresent must be opened)(locate on site plan)
)
Depth of liquid level above outlet invert:
Comments (note if box is level and disrribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has two laterals .No evidence of solids carry.
aver-
PUMP C HAM BER4 je (locate on site plan)
Pumps in working order(yes or no): ,/
Alarms to working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present.
8 .
Page S, of I I r
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ress:86 Whitmar Road
Cotuit,Mass.
Owner:Daniel Kossman
Date of Inspection: 9/1 3/02 /
SOIL ABSORPTION SYSTEM (SAS): )r (locate on site plan, excavation not required)
2-1000 gallon precast .leac ing pits. ( 6 -X10 ' )
If SAS not located explain why:
Located: See page 10
Typeleaching pits, number: _L/'`"�0��J-C 6,xV r
s, j�leaching chambers, number: D
leaching galleries, number: O
0leaching trenches, number, length: 0
.00 leaching fields, number, dimensions:
ilJ5 overflow cesspool, number:ber: Cb
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.):
Loam,; sand to fine coarse sand No signs of hydraulic failure
or pond na_Veaetation is normal
CESSPOOLS? (cesspool must be pumped as pan of inspection)(locate on site plan)
N'uftiber and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver: A
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not Afresent
PRIVV,, (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.):
Privy is not present.
9
I
piv 100l11
OFFICLA! INSPECTION FORM - NOT FOR'VOLLINT A E h T
SUBSURFACE SEWAGE DISPOSE, SYSTEM 1NSPECTIONFOR.1,11 S
PART C
SYSTEM 1NFOR-MATION (comInvc0)
P1optrry A0off„ 86 Whitmar Road
Cotuit.Mass
O-DwQaniel Kossman
�,ic or In,pcci�oo: 1 3 02
SK.ITCH OF SEWACE DISPOSAL SYSTEM
A0� 0, , Itcich 0(,hI ,twl�c Oilp011) lyttCM InC,Vd(At IIc1 10 11 Icall rwo permcn<nl rcrcrcncc ILA(,ml/;)
Ot^tPJnvk, Locuc III W(III w,ih,n 100 rccl. l.o<c,c wh<rc public wcI<r Ivpply tnlcrt the bviloin;
s
cv�e LIIJF
1
pz
to
I
Page I I of 11 f
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:86 Whitmar Road
o ui ,Mass.
Owner Daniel Whitmar
Date of Inspection: 9 1 3 02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
UQ_ Obtained from system design plans on record - If checked, date of design plan reviewed: U2
YFR Observed site (abutting property/observation hole within 150 feet of SAS)
N8-- Checked with local Board of Health-exQPain: NA
Y-gs Checked with local excavators, installers- (attach documentation)
YT—S Accessed USGS database-explain: http: //town.I�arnstable.ma.us.
You must describe how you established the high ground tv-?ter eTev�ation:
Used: Gahrety & Miller Mod 1 � 2/1 6/cadGround -Wa��'4�P.�Pyati runs at sea level.
Used: USER- QhaarvatJ an we 1 rlata ,,Tnne 1 A92 '
Used: US
. 1992
Ul
Leachi o
Pit ��• 'ce
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
y
Of the leaching pit and the adjusted groundwater table is �!
feet. fi
ll
`-•nrnr-t«r rt+Ir. �—srrf—nr.•nmra-�r•;.rernrrr.:-.i+-erarr:rremmrrs�•as *a4rrrn rrn
TOWN OF Barnstable BOARD OF HEALTH J
SU(ISU.((FACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
...••^T•• •,•f—T,1 I�^.�T.T,T.T•R.'11ft 1••'tl�1fTlf fR1ST1'T!.•1 P-{IfTR�/T7TRr TTTT'R'Va'�R>�y�•RTt I
-TYPE OR PRINT CLEARLY'- m�nT° TTT�,r•rrrr•r•., A
PROPERTY INSPECTED
STREET ADDRESS 86 Whitmar Road Cotuit Mass. 02635 '
ASSESSORS MAP , BLOCK- AND PARCEL #
OWNER' s NAME Daniel Kossman
PART D - CERTIFICATION I
NAME OF INSPECTOR Jose •h 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 ) 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
0ecoinmenda
his address and that the information reported is true , accurate , and
omplete as of the time of .inspection , The inspection was
tion ardins re u performed and any
g g 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:
-/--/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 Lhe. 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* \
T
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 .
r
Inspector Signature '
Date
ne copy of this certification must be
O
where a}>pl icable ) and the BOARD o8 Irsni1 provided to the OWNER, the BUYER
* If the inspection FAILED, the owner or"o erator shall u pgrwithin one year of the date of the inspection , unless alloweddorthe requiredm
otherwise as provided in 3,10 ChIR 16 , 305 ,
Partd .doc
TOWN OF BARNSTABLE
_OCATJN _����l�l��l" �f� SEWAGE # � ��
LAGS ASSESSOR'S MAP & LOT
SEPTIC TANK CAPACITY
l
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DAT ==,,,- E--DAZE—. .
"Separation Distance Between.the:
'Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well Leaching Facility (If any wells exist
- on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Le ching Facility(If 'y wetlands exist
within 300 of c ' ihty) Feet
Furnishe y N
�tl P L-WE
46
LA8° _
-. Lj TO WN OF BARNSTABLE
iOCATION
; 13 nOC
SEWAGE #
zVILLAGE Co� ASSESSOR'S MAP & LOT 65 f
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITYU� ��vinS
LEACHING FACILITY:(type) (size) 1t 6o0 c,,,&[ if
NO. OF BEDROOMS 1 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER e-IS q?QA`i5 Gv> "7-j-oS59y.
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED;
VARIANCE GRANTED:- Yes 4, No .�/
&eA-a
fit: HS'
Z,
�o +
3Lib ILi
1�` .
THE COMMONWEALTH OF MASSACHUSETTS
�L50 BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Bi"ooal Works Tontrurtion Funfit
Application is h eby made for a Permit to Construct (,a() or Repair ( ) an Individual Sewage Disposal
Syst t:
.... ... - ................................ :____....___.___._._... ....... . ..._..... .._......_.........
..11aqafeh. ' io A
or LotNo
- —-------- - .. -•..... ......... .................. ..._..........Oner
W Address
a ••.. -••.............................................•-•---............_....•........
Installer Address y//�r/
UType of Building Size Lot..._.__`.!.................Sq. feet
�-, Dwelling—No. of Bedrooms............................................Expansion Attic (/J) Garbage Grinder ( )
a Other—T e of Building a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixture ------------------------------------
W Design Flow.....................1._D..............gallons per per day. Total daily flow.........:3......_....•..........•....•..gallons.
WSeptic Tank—Liquid capacity.`.000.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 Test Pit___._ ._........ Depth to ground water---A/dll
44 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
a - -- .-------------- - ---- - -
0 Description of Soil.... . ......... .... ..... . ...
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 TITLE 5 of the State Environmental ode—The undersigned ther agrees not to place the
system in operation until a Certificate of liance has b en i d by th oa of health.
Signed -- ........
-- ------------------------------ ------------------------------------
Dace
Application Approved By .................. . ..... ` --...9-' - 1� -
Date
Application Disapproved for the following reasons- ----------------------------------------- ------------------------- ------------ ------------- ---------------------------
---- ---------------------- ------------- - - ------------ ------------- ------- ----------- -- --------------- ---- ------------------- - ------------------------------------ --------------------- --------------
q Date
PermitNo. / .-.. L(.- G-------------------- Issued --------------------.. --------------.---------------------
Dare
q <:
No....L - �x � FE$......� ..........
� � THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Bhip ial Vark.5 Tom4rttrttaan ramit J
Application!is hereby made for a Permit to Construct (,�() or Repair ( ) an Individual Sewage Disposal
...............LIootlio.-Add r s — or Lot No. ........................
--��►......................... ......•-`_' .................... ......................................................
O ner Address
a ..... .... .. ---•------•.............................. ........ .L... --•---.................---•--.........................••••
Installer
Address L/// _1
vType of Building 3 Size Lot...... .................Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic (.vu) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.....----................... Showers ( ) — Cafeteria ( )
------------------------
Design Flow.Other fixtures . allons per e�e per day. Total daily flow..........330
Wg P P P Y Y •------- gallons.
WSeptic Tank—Liquid capacity.1400.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........................................
a
Test Pit No. 1......<......minutes per inch Depth of Test Pit.---- ....... Depth to ground water-...�t/t�.v-.-.
44 Test Pit No. 2................minutes per inch Depth of Test Pit..----.............. Depth to ground water........................
9 -------------- ------------------------•--------------
-.........
......-------------
•----
---•----- ----------------------------------------
D Description of Soil .'! r�-----------------------
x
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 TITLE 5 of the State Environmental ode—The undersigned�ther agrees not to place the
system in operation until a Certificate of Co liance has en issmed by the arXf health.
Signed ...----.
......... ........................-----...... .............. -----..
Da[e
Application Approved BY ............... .ri*l -c� .�.------------------------------ ----9'.-... _-�
Date
Application Disapproved for the following rea.rons- -- ---------------- ----------------------------------------_----...--............--. --------.......... --- --------
------------------------------------- -- -------------- -- -- - ------------------------------------------ .............:----....................----------`-----------.....------------- ----------------.........-------------
qqDace
Permit No. .---.-/.- --.. � -7 6 Issued ................................................... -
Dne
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
k!�ertiftrate of Clorajj iatcee
I. IS 0 E T F That the Individual Sewage Disposal System constructed ( K ) or Repaired ( )
bynst9 .. ------
at ........f ..................1 ....... ----------------------------------------------------------------------------------------- -----
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit NO. --;`�.-...�. 71--------------- dated ................................................
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
FEE...,11.1 .).........
M.5paau 1 Vorkli (9aan217u .5tr inn rruti#
Permission is hereby granted - Ij--••- ...............................
to Constr ct ( X) or Repair ( ) an Individual Sewage . ispasal System
at No..-• .f..._ `Z C �
------ .---•-•---••• -------------------•------------•---...............................................
Street ''``
as shown on the application for Disposal Works Construction Permit No. !��I?.... Dated_.....................................
_ ---------------------------------------------------------
Board of Health
DATE.............. ....
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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