HomeMy WebLinkAbout0008 TUCKER ROAD - Health 8jucker Road,.'
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COMMONWEALTH OF MASSACHUSETTS L
EXECUTIVE OFFICE OF ENVIRONMENTAL 't I:jfP F �*��RHcoiA�LE
DEPARTMENT OF ENVIRONMENTAL PROTEeT 11: 3
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: lV G kto✓ /C,G( l ! 110 4IJ / /�/ n L �� /
s+z ,(k of M
Owner's Name: -/ ,
Owner's Address: L /u T>A-v t pl /T✓ i M '"e-
3 st Itto f` 4W. Cen�evvilj-C
Date of Inspection: T — /_ 0—.5--
Name of Inspector: (please print) Joseph M. Martins
Company Name: Accu Sepcheck
Mailing Address: 17 Northside Dr., S. Dennis, MA 02660
Telephone Number: 508-385-5891
CERTIFICATION STATEMENT
1 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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
—x Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 0e,4 Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments: t
®lime• .
� /�C��1����� S�Ards �a� ✓r� o��� V
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
i
Page 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
18 Tucker Rd., Hyannis, MA
Owner: Trimble
Date of Inspection: 4/l/2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
1 03 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need replaced or
repaired.The system, upon completion of the replacement or repair,as approved by t oard of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the fo ing statements. If"not determined"please
explain.
The septic tank is metal and over 20 years of or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or ex ation or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complyin ptic tank as approved by the Board of Health.
*A metal septic tank will pass inspect' if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less th years old is available.
ND explain:
Observatio of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pip or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of and of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
D explain:
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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 Tucker Rd., Hyannis, MA
Trimble
Owner: 4/l/2005
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accor ce with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protec ' blic health,safety and the environment:
Cesspool or privy is within 50 feet of a surf water
Cesspool or privy is within 50 feet of a rdering'vegetated wetland or a salt marsh
2. System will faiZmanner
Health(and Public Water Supplier,if any)determines that the
system is functioniprotects the public health,safety and environment:
_ 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.
The system has a septic tank and SAS and the SAS is within a Zone a public water supply.
The system has a septic tank and SAS and the SAS is withi feet of a private water supply well.
The system has a septic tank and SAS and the SA ' less than 100 feet but 50 feet or more from a
private water supply well". Method used to dete a distance
"This system passes if the well water an sis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compou indicates that the well is free from pollution from that facility and
the presence of ammonia mtroge d nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. py of the analysis must be attached to this form.
3. Other:
Page 4 of
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 Tucker Rd.. Hyannis, MA
Trimble
Owner: 4/1/2005
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or`�no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the 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
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. IThis 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
Iare triggered. A copy of the analysis must be attached to this forma
No (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 of
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
yes no
the system is within 400 feet of a surf inking water supply
the system is within 200 of a tributary to a surface drinking water supply
the system is I ted in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped
Zone 11 o public water supply well
If you have wered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in ction D above the large system has failed.The owner or operator of any large system considered a
signifi t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 4.The system owner should contact the appropriate regional office of the Department.
Page 5 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
18 Tucker Rd., Hyannis, MA
Owner: Trimble
Date of Inspection: 4/1/2005
Check if the following have been done. You must indicate'yes''or"no"as to each of the following:
Yes No
_'/Pumping information was provided by the owner,occupant,or Board of Health
v Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period
/Have large volumes of water been introduced'to the system recently or as part of this inspection
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
-V—/— 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:excluding the SAS, located on site
_ Were the septic tank manholes uncovered opened,and the interior of the tank inspected for the condition
of the baffles or ees. material of construe n.dimensions,depth of liquid,depth of sludge and depth of scu�}
/ � ��/ t0✓14 'O� 7�j�tl K 1�It4iW�w ��✓/0✓^ /T Wits tJn�f�-'wAI
(/_ 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 AbsorptionS SAS on the site has been determined based on:
System(SAS)
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Existing information. For example,a plan at the Board of Health. 00Q !-�
�/ A10 p/a^ -Ga✓mil a��O f f.
_ i/ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
18 Tucker Rd.,Hyannis,
Owner: Trimble 7*1
Date of Inspection: FLOW CONDITIONS 4/1/2005 Qq/0-5 7*1,0
RESIDENTIAL 3
Number of bedrooms(design):3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): 0
Is laundn on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundn system inspected(yes or no): _VIA u 7�v 0
Seasonal use: (yes or no): N 7
Water meter readings.if available(last 2 years usage(gpd)):a 00;3 4 Oct d
Sump pump(yes or no _JN a 1 �'
Last date of occupancy: iIT'y.
COMMERCIAL/INDUSTRIAL `JJ
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank t(yes or no):
Non-sanitary waste di ged to the Title 5 system (yes or no):_
Water meter r gs, if available:
Last da occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records 0��� nl �l�Q Ts �
Source of information: ,S Y r C
Was system pumped as part of the inspection(yes or no): /V
If yes, volume pumped: gallons--How was quantity pumped determined? �ALI
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privv
_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
ob_tained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all compo to instal d(if known)and 5ource of inform ion: ,y
per
�. (/• .
Were sewage odors detected when arriving at the site(yes or no):—No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
18 Tucker Rd., Hyannis, MA
Owner: Trimble
Date of Inspection: 4/l/2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC_other(explain):
Distance from private wa supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:
11
Material of construction: concrete_metal_fiberglass_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) 11
��
Dimensions: V
Sludge depth: /► --Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 2 1t t(
Distance from top of scum to top of outlet tee or baffle:I C)
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: r v 0
Comments(on pumping recommend ions, inlet and outlet tee or affle conditi n,structura integrity, liquid levels
as related to outlet invert,evidence of leaka e,etc.):
o / e
v
A1411 fir ti l'e !I -P9/� .l
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass_polyeth le
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of et tee or baffle:
Distance from bottom of scum ttom of outlet tee or baffle:
Date of last pumping:
Comments(on pump' recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outl nvert,evidence of leakage, etc.):
r
Page 8 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
18 Tucker Rd., Hyannis, MA
Owner: Trimble
Date of Inspection: 4/1/2005
TIGHT or HOLDING TANK: (tank must be pumped time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete me fiberglass_polyethylene other(explain):
Dimensions:
Capacity: ga ns
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evioence of solids carryover,any evidence of
leakage into or out of box,etc.):
l -7 s Z Ov TcE-7s
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PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,cond' of pumps and appurtenances,etc.):
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 18 Tucker Rd.,Hyannis, MA
Date of Inspection: Trimble
4/1/2005
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type ,
�eaching pits,number:_
---,,,leaching
leaching chambers,number: G✓ 2- S?an2_ �f-rc/�✓f
leaching galleries,number:
leaching trenches,number,length: /
leaching fields,number,dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): ��_ �I�pUSPa►
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction,
Indication of groundw inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, of ponding,condition of vegetation,etc.):
PRIVY: (locate on si�plan
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
I
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
18 Tucker Rd., Hyannis, MA
Owner Trimble
Date of Inspection: 4/1/2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page 1 1 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 18 Tucker Rd., Hyannis, MA
Date of Inspection: Trimble
4/l/2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water t 20
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
V/Accessed USGS database-explain: 4 SCNC 6LvA19 AMA13
�- b��as tik,G-�Z%1otd ✓ �v�eve`� tn�t�Tfit t
You must describe how you established the high ground water elevation: FPS
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TOWN OF BARNSTABLE
LOCATION �yC�'P'� /`��'` SEWAGE #
il. VILLAGE / ' y q 4/� S ASSESSOR'S MAP & LOT 3yg� SZ
INSTALLER'S NAME&PHONE NO.—SCIV / v-ra P?Le— 77.r—So F7
SEPTIC TANK CAPACITY �OO/�' Cla�� [
LEACHING FACII.TTY: (type) =4; / ar (S (size) ` W L r-S7tVnX--
NO. OF BEDROOMS %_3 �P� -'ohs�1��e✓
BUILDER OR OWNER m `
PERMTTDATE: DATE: DJ
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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,�J Oe
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a
0
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TOWN OF BARNSTABLE
LQCATION_ SEWAGE # (1— ?i
a
VILLAGE ASSESSOR'S MAP 6Cz
INSTALLER'S NAME & PHONE NO. '�5�W
SEPTIC TANK CAPACITY tCX:)0 GAL- f O G6X
LEACHING FACILITY:(type)�(1 .�\ cr hg (size)
NO. OF BEDROOMS PRIVATE WELL O BLI WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:����
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No..-1--�='-._L. Fps.._. .... '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Allp iration for UinVniittl WorkB 6nntrnrtiun Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( �_ n Individual Sewage Disposal
System at:
r ,�
... �1•" .. `` ------------------------------------------- 7 ----- ---- ------•---------------------------•-------
Ilk L cation-Address or Lot No.
-U! ^^ A = -------------------- ---------------------.......-.......-....------------
%
a vr ! - Owner Ad•' �, -------------------------------------------------
. -------------------------------
Installer Address
UType of Building Size Lot............................Sq. feet
r 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_I 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 ( )
aPercolation Test Results Performed by---------------- --------------•---•---•-----------------••---•-------•--- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-______-____________-_.
(i Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................
•--••--•--•------------•-----------------------------•---•-•-•-••-•---.....•-•-•-•••----•-•---..._...........................................................
0 Description of Soil........................................................................................................................................................................
w
UNature of Repairs or Alterations—Answer when applicabl .-� _ __ ________________ �5 .! _ _ l_
ee Ag r ment:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia e has been issued of health. Id.
Al.ned .---- .............................. -----Id./.�.l...�.�.
Dare
A lication Approved B --------------- � ..�.- .—.. . ..
PP pP Y .........-. �-�~- Dace
Application Disapproved for the following
qq reasons- ------------ ---- ------------ -------------- -------------------------------------------------(----�----------.-.--
-----------------
----------------------------------------------------------------- -------------------------------------.....-------------------- -------..---....-................._........... ................�...-.........-......
Permit No. .------- Issued ----------------- -.e.. re..._.
�k^7
NoJy1-._l_y..7-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ,
, vvftratiun for BiuVn!3tt1 Wurk,5 Tnnutrudinn j1eruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ` an Individual Sewage Disposal
System at:
�.-----ac)........................................... ! =/b��`-•------ Lot No.
L cation-Address
Owner Addr ss
'Dr
Installer ✓ Address
UType of Building Size Lot............................Sq. feet
.-� Dwelling—No. of Bedrooms-----------2___________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons____-___-_-____-_____-_.... Showers ( ) — Cafeteria ( )
d Other fixtures
w Design Flow-...........................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv_A�O..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 ( )
aPercolation Test Results Performed by................... ----------• .......................................... Date........................................
14 Test Pit No. I----------------minutes per inch Depth of Test Pit__-___-_-•-__-____ Depth to ground water...__._____-____---__--.
Lr. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 .---•-•...........................................•---. --..........---••-•......--•---•-•-•-----•-•............................ _-................
-....
0 Description of Soil...........................................................................................................................................----......-.......................
x
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----------------------------
U Nature of Repairs or Alterations—Answer when applicabl ._.__._-_-q_'_(fe.......P_X`4.VC n_._)
k.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has been issued -board of health. (�
Signed ------ ----- ------------------------------------.------- ..... ..`#-.
Application Approved B ...
Da te
Application Disapproved for the following reatonf: ...... . ....... ............................ ................... ................ --
.......................................... ....�..........—....................._........... ... ........_.......------. -- . .. ........................................
Permit No. ..... -------- -/--�----------------------- Issued -----------------/. .. -..Q D�e...:..
6 Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BAR(�NSTABLE
Ertifirate of omplinurie
THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired ( V )
by ------ ------------------------------------------------------ ----------- --------------.---.......................---------------------------------------_----------
�-l Insrdler at . I St ....4 C,�JZ <------2"--------_-- �.��-- - �---
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.. ....7-`L-...7f ------------- dated ------_f.�_.r....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI L FUNCTION SATISFACTORY.
DATE----------- --------------- ........... �-------------------- Inspector ._ Vl�w---.------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G TOWN OF BARNSTABLE
No.... -.y'. j.� FEE........................
Rapasal Workii To otrur#ion "rrntit
Permission is hereby granted---------- I---------------•-----------------------------------------------------------
to Construct ( ) or Repair ( V"an Individual Sewage Disposal System
atNo...•-•-•---\-•Y----------k_.U(V\JCr-----U.......0- Cam^^_\ ...------------------------------------------------------------------•-.........--•--
Street qq
as shown on the application for Disposal Works Construction Permit No.(_y:.712__ Dated-----143,__�'.9-A. .._........
..................................•- �� -----------------------------------------
� Board of Health
DATE e�-f ----------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS