HomeMy WebLinkAbout0085 ACORN DRIVE - Health 85 ACORN DRIVE
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'F 41 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL �..�
LOT ;
TITLE 5 y
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYST F
PART A
CERTIFICATION
t C
Property Address: RSy�o�
-- ---3p.ntal_�, vet t4- y O
Owner's Name: R L p Q 9�y 1P �OQ
s
Owner's Address;
Date of Inspection: & p�
Name of Inspector:(please print)
Company Name:
Mailing Address:
Telephone Number:SG -
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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
I Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
i
Fails-
Inspector s Signature: Date: 0
1
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 now 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
i
****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.
Title 5 Inspection Form l 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM`-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEEKWOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Qbs AWua 1D&,
lK1,caty►\1 t
Owner: a
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
0 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.
Z 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 eadiltration 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:
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:
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:
2
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 015 16C.
Owner:
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.
I. System 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:
_ 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. System 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:
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 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
"This system passes if the well water 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 must be attached to this form.
3. Other:
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Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
pv
Owner
Date of Inspection: `I a
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for afl inspections:
Yes No
k 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''/2 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.(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 most be attached to this form.]
X� (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 above)
yes no
the system is within 400 feet of a surface drinking water supply
I
_ 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
If you have answered"yes"to any question in Section E the system 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 11
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I '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: i615 wlock) iW .,
Owner:
Date of Inspection:
I -
Check if the following have been done.You must indicate`Yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
— Has the system received normal flows in the previous two week period?
i
_ 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)
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 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 no
— Existing information.For example,a plan at the Board of Health. '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)]
i
. I •
E
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Page 6 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
`:PARS'C
SYSTEM INFORMATION
Property Address: 'bc.
Qsi-C1Q�c
Owner:V$� 0
Date of Inspection: 44 S O
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design)-31mb Number of bedrooms(actual)
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#Abe?d2r000ms):
Q
Number of current residents:
Does residence have a garbage grinder(yes or no):_
Is laundry on a separate sewage system(yes or no):kiQ (if yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)): 00
Sump pump(yes or no): a
Last date of occupancy: Z 0
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): god
Basis of design flow(seats/persons/sgf,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
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. h6
Was system pumped as part of the inspection(yes or no): PO
If yes,volume pumped:_gallons--How was quantity pumpeddetermined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,dscUibudw hn-,v soil absorption system
_Single cesspool
_Overflow cesspool
—ivy
_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)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):_ELO
6
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Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 kcxxl
Owner:—Rvxtap•cl
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: 12-11
Materials of construction:—cast iron _)�,40 PVC—other(explain):
Distance from private water supply well or suction liner Towv w
Comments(on condition of joints,venting,evidence of leakage,etc.):
c,.�rc i.�T l.F•Q,c �P.ct.�Z`,�� U�� (msA. .
SEPTIC TANK: (locate on site plan)
Depth below grade:
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)
Dimensions: 1000 G w L
Sludge depth: 6 "
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: (w
Distance from top of scum to top of outlet tee or baffle: °t
Distance from bottom of scum to bottom of outlet a or baffle: i 34i
How were dimensions determined: KLPL5� 1
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
U ntr T
GREASE TRAP:Itoocate on site plan)
Depth below grade:—
Material of construction: concrete metal fiberglass `
(explain): — g _polyethylene—other
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
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Page 8 of l l
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OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A-5 iQiJQ*j \'NQ_
c�V_C"t 1,1c�
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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 evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: W (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of l l
c�
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 65 Ag3k*, `cj
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):1,J6_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: (_(SK 6
—leaching chambers,number:-3Lj 10;.k.10tt�5
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.):
vn' YVA��—p Sn'L Ila
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 layer:
Depth of scum layer:
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.):
PRIVYA (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.):
9
Page 10 of l 1
M
OFFICIAL INSPECTION FORM :-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'PART C
SYSTEM INFORMATION(continued)
Property Address: 2S —
Owner:_14wA
Date of Inspection:
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.
� 85
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Page 11 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1;S pop—%f— V 'NsL'
Owner:
Date of Inspection: R9 o
SITE EXAM
Slope r..1
Surface water x.;,
Check cellar Tt j
Shallow wells P.
Estimated depth to ground water t30' feet
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)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
raS Sufy4v - 4 A 65 Z,
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11
TOWN OF BARNSTABLE
;r},OCATION E35- ,gr021-1 PI?111F SEWAGE #
VILLAGE [e��-�� (� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. G p(z-n o 'Id-8-S(f((T
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ? &,162.5 (size)
. ,NO. OF BEDROOMS o�L PRIVATE WELL OR PUBLIC WATER q
BUILDER OR OWNER
DATE PERMIT ISSUED: 1/17hok
TE aDA •
VARIANCE GRANTED: Yes No
CO ell
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,.bj
�a 2ct�
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'1 a rin �%
Tom o% )Z.0 eIrov
3 �y
1
T6 5
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE Barnstable APPROVED
Conservation pepanme�t:•-�''
Allp iration for Dispaout Works..Toustrlin
i
Application is hereby made for a Permit to Construct ( ) or Repair (k_ an qIndivid
Sewage Disposal Date
System at: e
Location:-Address or Lot No.
......................_...�..�%�� ..-•-••-......---•-••.........-••-•-----•-... -:.....-•-•-----•---••-----•--••-••••...... .....----.....•••••-......•---••••••....••....
Owner Address
a G02DaN �l%/yt -u S
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling Z No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
tz, 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. 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.........................
9 ••--••••--••----------------•••-•-•-•••••-••••••--••••••••--•-•.....-•--•----•-•---•-••--...•--...........---•------••-••--•-•-•-•---••---•••-----••......•--
0 Description of Soil............................................................................... -------------------•---------------••----•--•---------.............................
W
U ..............................................••••----•-•-••-••-•-•-•-••-•--••-•-•-•...........•----.....---•••••••-•-•••-•-•-••-•••-----•---•----•••-•-••---•---•---•••••..................•-••--•••...
W ............................... --•---•-•-------•-------------------------------•---••............•------------•• _ ...... _
U Nature of Repairs or Alterations—Answer when applicable._.__.f!%�1�___.Sl rc. ..............�}�.�.1--...��2.�i
-•------------------------------------•--••••-•--•--•--•-•-•-•-----••-••••--•••••-••........--•-••...-•••--•--•----••-------•----•-••---------j-•-•---•...•--•-•-•---•---•••-•-••-•.......-•--••...
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 Compliance as been issu by &hhe �oad of health.
Signed e� dl F °` 21 a
Application Approved By ... d .Y.%. /'Is--- - ------------------------------------------ ,� ----/--e�---- Z
Date
Application Disapproved for the following reasons- ------ -- ---------- ----------- -------------------------------- --------------------------------- --------------------------
--------------------- -- --- ------------------------------------------------------------------------------------------------------------------------ ----- ....................................
Date
Permit No. - 6- -....-- Issued ... `'�.. .. ..
Date
THE COMMONWEALTH OF MASSACHUSETTS ..-4'
it
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrnrtiun y rrnn#
//-11 gz
Application is hereby made for a Permit to Construct ( ) or Repair (�) an Individual Sewage Disposal
System at* ,
8S /7COi2v ofe c - Qs—le �l
................_.--....... --........................_....-•----...------------........---•-• --...---•------•-------------------•----------- -------•----•--•-------------------------------
���,vL�cation-Address or Lot No.
....................... - ....._.......((.JJ.... ---••-•------•-•--. -----------.................._.
o2�v� Ow er Address
a Y �vr» v -------•••------------------- ---•--•-•-----------___-_-_............__.........._-_-_____--•-••--•---- --------•-•-----•--
Installer Address
U Type of Building � Size Lot............................Sq. feet
Dwelling Bof Bedrooms----uildi� Size
Attic ( ) Garbage Grinder ( )
Other—Type e
a . YP of Buildin g -------•-------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther 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 ( )
a Percolation Test Results Performed by....................................
.........................
Depth to,groiind water........................
LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth-to ground water....................
--
Ra,
----------------------------------------------
x O Description of Soil........................................................................................................................................................................
x = �-....................
U Nature of Repairs or Alterations—Answer when applicable.----- -- s ``t _____________ } _-3- !!fi/t��iJ/O2J
--------------------•----------•----------•---------•-----•-------------•-----------._......-•---------•----•-------•-----------------------------------------........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environment 1 Code—The undersi n d further agrees not to place the
system in operation until a Certificate of Complia as beex15�3 b th' •o d of health. pa
Signed -------- ------------------/--......................................................................... .....-..............-..........
.........
'� // Date'
Application Approved By ......:..:....��-.�^.�.�-i�ra/..---...------�-- -------�.'. ------...-- ----------...--....-------- �� � 7 '2
----------------------------------------
Date
Application Disapproved for the following reasons: .................... :....-...
------------------------------ -------------------- ------------------ --- --- ---- ---- -------------------------------------------- ------------ ------ ------------------------------- ..................---------------------
PermitNo. ...... ......... ...................................... �` Issued ........... - --/.
------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#ifiratr of CIaxntyliance
T S IS�TO CE Y, That the Individual Sewage�Dispos System cof�str/�cted ) or Repaired ( �)
by �'i! �------ ------ ----------------------------------- G?.- ��!_ �(---------�........................................................ Q I Staller /
at -------------C�-S----�Gc?•�Z-------- / /-l5 U / / --------- -.....
has been installed in accordance with the provisions of TITL 5 of The State Environmental Code as describe in
the application for Disposal Works Construction Permit No. -- �1�.-- dated ,J "-. �--.- -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- /- r, Inspector --� - "----------------------------------------------_--------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No............. FEEL- ... �
Disp o s 1 rks Tonst.rnrt#ion amit
Permission is hereby granted / . `---' L
-------------------••-------------- ---------.........
to Construct ( ) or Repair ( ) n Ifldiv' ual Sewage Disposal System
atNo....... � r1 � l._U .... ---.._..•-•••••------------ ---------------•------••------------•--•----•-------•-------•-----•-••-••--_....
st'
as shown on the application for Disposal Works Construction Permit-/11S��IT;o__________________(-�. ``ated_1-,
----...-•-•---, �"'/ --- --------------------
1 -- ----�of altfi
DATE-----/<......_'�'? _..__ lam_"-.. /
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
_.• "St 5
L{-DCQTION ' P SEWW:�E PERMIT UO.
`i
Ih1ST_L1,LLERS 1JL1,NlE � ADDRESS
BUILDER 5 Q &MF— ADDRESS
O&Z
DATE PERNAIT ISSUED �2 — —
D ATE COMPLI W-ACE ISSUED ; d"?
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No........ ......... FEs.../5....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH rp
M� JX'00 .... Ilse .. ....... OF,.-.. .. . . . ... .. . . .
Appliration -fur Ubpviial Evrks Tuttitrurtiatt Vrruift
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Dis sal
System at:
------------------------ 1°------------------------------------------------------------------.......-----
Location_Address or Lot No.
Owner 6 / dress
Installer Address
Type Building Size Lot f' �..C?_V_Ci____Sq. feet
Dwelling—No. of Bedrooms.,......... ..... .. _....Expansion Attic ( ) Garbage Grinder (4,0
a4 Other—Type of Building ....... No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ------------------------------
Design Flow�__Q_____________________ ________gallons per person per day. Total daily fIOW_'_4---4.�_----------------------------gallons.
W -
04
Septic Tank—Liquid capacity.1-V a_Pgallons Length................ Width-__.-..__._.. Diameter---------------- Depth.-..----__-.._..
Disposal Trench—No_ ____________....... Width------------------ Length.................... Total leaching area------------- ......sq. ft.
Seepage Pit No._/.............. Diameter./.O _ __. Depth below i et_:._____. _.__ _ Total leaching area..._._.._._-__._-_sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ® �G _ .3 _2 a - 7 a7
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------
W Test Pit No. 1----------------minutes per inch Depth of Test Pit____________________ Depth to ground water.........__.---.-_------
f=, Test Pit No. 2................minutes per`inch Depth of Test Pit-------------------- Depth to ground water------------------------
W ..........)••------- -•--------•-•----------
Description of Soil. ...0.------/�-------�� t ----_-Z--- ��"� -�°�' -4 ------- --------------
U ---------------------Z_-r sf= --•------------•-•-------••-•---------------•-------•----------------•--- -----------------
•--•------ --------------
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issue by th board o ;he?ah.
Signe 3- .22 -7 -7
-- ---------------------- ...........................
Date
Application Approved By------ / a 7
Date
Application Disapproved for the following reasons: -----•---•----------•-------•-----•--•-•-------------------------•-------------------
--•-•.............•----................................. ------------------------•----------•----•----------------•---------------••-------------------------------------.---------•---------------•---
0--7 Date
Permit No. Issued'. . -- ..........................
Date
l-------,..........................---- ------------------- ---------
r
de
J41........ Fus..... .......�.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H ,TH
r r
.100
ApplirtttiOn -for BiipOOttI Works TotuitrnrtiOn Vamit
Application is hereby_`made for a Permit to Construct ( ) or Repatr.(`_ ) an Individual Sewage Disposal
•System at:
Location.Address or Lot No
Owner ddress
Installer Address d Type Building Size Lot--../
. ,___________________Sq. feet
U 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�.A.0- __-..-__.-____.__.__.___gallons.
WSeptic,Tank—Liquid capacity/t� _ al.lons Length________________ Width___......_.._.- Dilmeter_._--_..__-.____ Deptll__.____.._...
xDisposal Trench—No.................. . Width-----------------S);Ntal Length............._------ Total leaching area--------------------sq. ft.
Seepage Pit No.../-------------- Diameter_ A?_&_.O__ Depth below ijW�et___ ._._ ....... Total leaching area.__...-_________sq. it.
Z Other Distribution box ( ) Dosing tank ( ) --�~`40A "' "22 ` 77
Percolation Test Results Performed by---------_------- ---------------------------------------------•-•-•----- Date----------------------------------------
Test Pit No. 1________________minutes per inch Depth of "Pest Pit_-__.______-____•._- Depth to ground water.-_._-__..__.__.._._. -
, Test Pit No. 2................minutes per inch Depth of Test Pit-_______-_.____-.-_- Depth to ground water------------------------
--------------------- . - r
Description of Soil--------- ---------�----•- . - -�-X'--='----`- �•-. 'r� V q�. W------------
V ---------------- --Z...._. /eZ . �'ti Q+-S=.i..
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 Article XI of the Statte`'Sa"riitary.Code=The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e n ssue by th--board,o hey h.
J- AZ -7 '-1
tgnew .... .:..................•-• ----------------•-----•---------
Date
Application Approved BY-------- ----- •-------- ---- �-------�--7-9-----
Date
Application Disapproved for the following reasons:. •-•---•-•-••----•-•-------------••---•---------------...--•--•---.........................
.
Date
PermitNo. ------------------- Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........Lt_hl./h............OF..........6..... ........... ..............................
Trrtif irttte Of (DOmplittnrr
Tbs IS T ERT IFY, That the Individual Sewage Disposal System constructed ( � or Repaired ( )
by its mil" -------------------------------------------------
•-------------
nista .,
7` l
• --'----•-•'------•------`---•`•---••....................................
has been installed in accordance with the provisions of _gc' XI of The State Sanitary„`Code as de Bribed in the
application for Disposal Works Construction Permit Jo._ ---Q dated:-.. '''a _2` 7
THE. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM."WILL FUNCTION SATISFACTORY..-`-
DATE....Z-!7 ••------------ Inspector..... .. .
THE COMMONWEALTH OF MASSACHUSETTS'
BOARD O HEALT
7j( !� ........:.OF......... .. .. ... .......................... -2 —77
No. .. --------- �•,' FEE........................
irOtto
l
J�iv �
Permission i reby granted-•--"---- _ ... rk ----- Ot--�rn..r.,:..-iO---t-t-----:---r---r---m-----i-t------------_........
......... ............
to Constrt orReit an wa 3ip9sal System
at No_ . ./y ---------------
Street 7
as shown on the application for Disposal Works Construction r it ----- ......- Dated.
-----------------
--- - -- ----- .......................................
Board of th
DATE.............................................'
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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SC/AGE / ��3o' L47--- mq ac q /8 1977
sf/owA/ o n/ -9 1O4el9n/ Fv2 T SEP//
S/1- V/.9 e-r cA -7Np 2ECa2DED iN
any. CLAN DK• 187 PG. 93
WARD '�` CE�QTif=y /9T Th/E ouNORTion/
!e.
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No 21 J. o n/ THE G2a unI O 9 $ SHu wrV
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THE Town/ of a q/L�I S TABC,E.
r�ARua i 8 977
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