HomeMy WebLinkAbout0165 ACORN DRIVE - Health 165 Acorn Drive
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COMMONWEALTH OF MASSACHUSETTS MAY O-6 c'003
EXECUTIVE OFFICE OF ENVIRONMENTAL AF AIRS
:�'^�F BARNSTABLE
A , d DEPARTMENT OF ENVIRONMENTAL PROT I 'i/`f `ALTH DEPT.
ti I�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION E s
4 e .
Property Address: 165 Acorn Drive°
Barnstable(Osterville),MA
Owner's Name: Mary Schmonsees
Owner's Address: c/o Cynthia Steidmann MAP I T T
1310 Hamlin Dr.,Clearwater,FL 33764-3660 PARCEL _$ -
Date of Inspection:April 9,2003 LGT fl
,Name of Inspector: Gary J and/or Jane E Rabesa xt
Company Name: Rabesa Subsurface,Inc dba Warren Cesspool Service
Mailing Address: 72 Sandwich Rd ,
Falmouth,MA 02536-5602
Telephone Number: 508-540-7143 „
CERTIFICATION STATEMENT r
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:
X, Passes
''; Conditionally Passes `
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature Date;April 24,2003
t _
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: Title V system in good condition.' n
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This
ins ection does not address how the system will perform in the future under the same or different
P Y
conditions of use. . '
it
Title 5 Inspection Form 6/15/2000 page l'
e '
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA
Owner: Mary Schmonsees
Date of Inspection: April 9,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: YES
X 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: NO
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:
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:
Warren Cesspool Service 508-540-7143
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) `
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA
Owner: Mary Schmonsees
Date of Inspection: April 9,2003
C. Further Evaluation is Required by the Board of Health: NO
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 accordance with 310 CMR 15.303(l)(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 a septic 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:
Warren Cesspool Service 508-540-7143
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA
Owner: Mary Schmonsees
Date of Inspection: AAvril 9,2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone I of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ 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 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: N/A To be considered a large system the system must serve a facility with a design flow
of 10,000 and to 15,000 gad.
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
the system is within 200 feet of a tributary to a surface drinking water supply
x
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.
Warren Cesspool Service 508-540-7143
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA ,
Owner: Mary Schmonsees
Date of Inspection: April 9,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x — Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
x Has the system received normal flows in the previous two week period?
x Have large volumes of water been introduced to the system recently or as part of this inspection?
x — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x — Was the facility or dwelling inspected for signs of sewage back up?
x _ Was the site inspected for signs of break out?
x Were all system components, including the SAS,located on site?
x_ 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?
x 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
x — Existing information. For example,a plan at the Board of Health..
x 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)].
Warren Cesspool Service 508-540-7143
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Page 6 of 11 .
F
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA
Owner: Mary Schmonsees
Date of Inspection: April 9,2003 r
FLOW CONDITIONS
RESIDENTIAL °
Number of bedrooms(design):3 Number of bedrooms(actual):3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 gpd
Number of current residents: none(two until 02/28/03)
Does residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no[if yes separate inspection required]
Laundry system inspected(yes or no): n/a
Seasonal use:(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)):2001Raveraged 104 gpd,2002 averaged 129 gpd
Sump pump(yes or no): no
Last date of occupancy: 02/28/03
COMMERCIAL/INDUSTRIAL: N/A
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 present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no) _ R-
Water meter readings,if available: 1
Last date of occupancy/use: -
OTHER(describe):
GENERAL INFORMATION' '
Pumping Records
Source of information: (Cynthia Steidmann)has not been pumped.
Was system pumped as part of the inspection(yes or no): no -
If yes,volume pumped: gallons.-- How_ was quantity pumped determined? j
Reason for pumping:
TYPE OF SYSTEM ;
x Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy ,r
no Shared system(yes or no)(if yes,attach previous inspection records,if any) `Y
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner) F
Tight tank - Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:1095 permit#95-377.
Were sewage odors detected when arriving at the site(yes or no): no
Warren Cesspool Service 508-540-7143 ;
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4
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville).MA
Owner: Mary Schmonsees
Date of Inspection: Aaril 9,2003
BUILDING SEWER: (locate on site plan) '
Depth below grade: 14"
Materials of construction: x cast iron _ 40 PVC other(explain):
Distance from private water supply well or suction line:town water line 40'+/-.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: YES(locate on site plan)
Depth below grade: 10"
Material of construction: x 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: standard 1000 gallon tank
Sludge depth: 12"
Distance from top of sludge to bottom of outlet tee or baffle:20"
Scum thickness:2"
Distance from top of scum to top of outlet tee or baffle: 27"
Distance from bottom of scum to bottom of outlet tee or baffle: 12 ;
How were dimensions determined:onsite/installer's"as-built"
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):Tank appears to be in good structural condition with no
failure criteria. The tank should pumped and put on a regular schedule for maintenance. The DEP
recommends pumping every three years,depending on use.
GREASE TRAP: NO(locate on site plan) ,
a,
Depth below grade:
Material of construction: concrete metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Warren Cesspool Service 508-540-7143
T.+1.c 1„0„o r;.,, F,....,,4/1 4 i)nnn 7
Page 8 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA
Owner: Mary Schmonsees
Date of Inspection: April 9,2003
TIGHT or HOLDING TANK: NO(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: YES(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: none
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.): There are no failure signs. The cover is 19" below grade.,
PUMP CHAMBER: NO(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.):
Warren Cesspool Service 508-540-7143
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville).MA
Owner: Mary Schmonsees
Date of Inspection: April 9,2003
SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
x leaching fields,number,dimensions:one: 21' by 9'
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.): Per installer's"as-built"there are six infiltrators forming a leaching bed. Viewed by remote camera,
the infiltrators were dry with no previous failure signs. The area of infiltrators and stone is about 21' by 91.
CESSPOOLS: NO(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): no
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: NO(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.):
Warren Cesspool Service 508-540-7143
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville).MA
Owner: Mary Schmonsees
Date of Inspection:April 9.2003
SKETCH OF SEWAGE DISPOSAL SYSTEM NOT TO SCALE
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.
W AT62- --
P+Pt
' EA2
arty.
Icawk�n�- ,
t4r,
,meet 17ef�e,
i
i .
i
t
Installer's"as-built"
Warren Cesspool Service 508-540-7143
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 165 Acorn Drive
Barnstable(Osterville),MA
Owner: Mary Schmonsees
Date of Inspection: April 9,2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water is greater than 6 feet
Please indicate(check)all methods used to determine the high ground water elevation:
x 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)
x Checked with local Board of Health-explain:compliance issued 3-15-95
Checked with local excavators,installers-(attach documentation)Engineer's certification
x Accessed USGS database-explain: tomography maps,USGS survey maps
You must describe how you established the high ground water elevation:
Grade to bottom of leaching is 52". From observation of site,Acorn Drive is lower at#145 than
bottom of leaching at#165. From topographic maps,the lot is at least 20'+/-MSL.,Groundwater contour is
10'+/-MSL. Groundwater rise for the area is no more than four feet.
elevation 20'+MSL grade over leaching
elevation>I7.5'MSL top of leaching
elevation>I5.5'MSL bottom of leaching
elevation 14' MSL highest probable groundwater rise Zone C MIW29
elevation 10' MSL groundwater contour(map#144)(West Pond el.9'MSL)
Warren Cesspool Service 508-540-7143
TOWN OF BARNSTABLE
LOCATION 6"aoo� Rej SEWAGE # 7
VILLAGEE ASSESSOR'S MAP & LOT�r
INSTALLER'S NAME & PHONE NO.60 ll 4ZZ S-6�f4
SEPTIC TANK CAPACITY 00
LEACHING FACILITY:(type) id �?/�' (size)
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:_T za&/- 3,
DATE COMPLIANCE ISSUED: s'
VARIANCE GRANTED: Yes No
i��'r�l�✓t ��2icr�
✓
%b
3 / 0
No.. - .. Fss.......
2)
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphration for Biti-pntittl Works Tomitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (P-'5"'an Individual Sewage Disposal
System at: �/{�/t /�^ n C_
..............1__ .._.1/..l.O"�•IK�� OJ/e
Location-Address or Lot No.
...:.......... ..v_2�--�Le.. n.M. . ................................... ..................................._............................................._................
a G02L1 Owner Address
----------------------- !-v►� us
Inst Iler Address
Type of Building Size Lot............................Sq. feet
►, Dwelling—No. of Bedrooms.___..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv.._.__._...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-.----------_-_---_-
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-__--------_-.._--_--.
------------------------------------------------------------------------------------------•---------.........................................................
0 Description of Soil........................................................................................................................................................................
x
U •--------------•----------------._.._...--•-------•---------------------------------------------------------------------------------------------•------------------------•--•----•......--------------•-
x --- --------------------------------------------------------------..............------------------------------. /
U Nature of Repairs or Alterations Answer when a�ic e...._.. ...................................................
�l> } $1 SF ��'?�c'�G�1ox l`..... �d! --- �y-,s�a/'e--------------------------••----.....----'
t_.._....._..
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 Complian e has/been issued by t bard of health.
Signed -- - ---- -- -- --- ------------------------------ ------------------------ ------._....._....... ..........:
Application Approved B
PP PP Y = .......... ...... ... ....................... ------ .... .....�
e
Application Disapproved for the following reaso ----------------------------------------------------------------------------------------- -
---------------------------------------------- -- — .......... -------------------------------------------------------------------- -- -------
� � Date
Permit No. ... ......... Issued ............
Date
No. ...... / FEE .....
- s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Divi-pnml Works Tnn,itrnr#inn Frrmit
Application is hereby made for .a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:,t _
-•-----•--••.•-------•••-••..... --••••...................••------.......-----•-•••-------_._... -----••--•-•---------------•--•••••--•---•-•••--------•-•------•-- ----------------••----••----•
-Location-Address or Lot No.
\t .
.......... -......:PA.AD...---•-•........................... .............................................................................................••...
Owner Address
....
rZ.....
Installer Address
Type of Building Size Lot............................Sq. feet
..t Dwelling—No. of Bedrooms._.. ----------------------------_--Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QI 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.---_._--___--__-------
40 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ...._•-•---•---------------------•-------•------------------•-•••-•---------•------•---••-•---------.........................................................
0 Description of Soil.........................................................................'..............................................................................................
UW ------------------------------------------------------------------------------------------------••-----• ------- -- '-----------------.:...••-------------------------------•••......-•--.---••-
Nature of Repairs or Alterations—Answer when ap lica-ble.--.-_.�/,�. L���.Ss fr^�j
5r-.' %7.a�r � .� �y�J'r/... /ce �__m /� .,53P
fi
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 has been issued by the b and of health.
/J ------d------------------ - --
Application Approved By 4P11(�/� ...........�. ....`.-..i. .. Z ?. ..... >!..- -�
l � �
f to
Application Disapproved for the following reason - ------------------------------------------------------------------------------------- ------------------------------- -----------
--------------------------------------------- J�—.. j ------------------ ----------------------------------------------. .... _..-................
�� Qre
Permit No. Issued ........................
/� -- -- /Dare �
7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifi ate of Tantylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by _7,3
Ir„ttdie-
��J
at --...... .02.r�-- .�...2 i '`---------....- ---C�' r-;
has been installed in accordance with the provisions of TITLE^5 of The St to Environmental Code as described in
the application for Disposal Works Construction Permit No. V. -�...J-........_. dated ................__..-_._..._........._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEID�S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE----- .. .. ------------------ Inspect r .... - - --------- --------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLEp
No.- --.... FEE....5 �...........
Dispop,al Works Tnntrudinn "rrntit
Permission is hereby granted--------' o Ka"c�--_.w.^10,u-?..........................................................................................
to Construct, ) or Repair ( an Indivviifd`ual Sewage bisposal System at No. )(G..........................................� �.E f�. r V C........tStreet
as shown on the ap lication for Disposal Works Construction Perini No..____..` ated_�� �_/ //. .__ .._.
� I i
DATE
�31q6 f�H alth
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FORM 36508 HOBBS♦!WARREN,INC..PUBLISHERS