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HomeMy WebLinkAbout0093 BAYVIEW CIRCLE - Health 93 Bayview Circle - Osterville A= 237-018 ° o n a 0 .o- a a m tommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco q a oG a Owner Owner's Name information is required for Osterville MA 02655 May 18, 2008 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Darren M. Meyer cursor-do not Name of Inspector use the return key. n/a Company Name P.O. Box 981 Company Address East Sandwich MA 02537 Cityrrown State Zip Code 508-362-2922 S 1 3920 Telephone Number License Number B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs,-Further Evaluation by the Local Approving Authority InspeGWrs Signature J Date The system inspector shall submit a copy Geti �is inspection report to the Approving Authority(Board of Health or DEP)within 30 days of compg 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. ****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. 93 BayAew Circle.Osterville-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information is required for Osteryille MA 02655 May 18, 2008 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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 Conditional)y y Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,no or not determined (Y, N, ND)in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ 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 93 BayAew Circle,Osterville-Title V-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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: 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 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: El 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. 93 Bayview Circle.Osterville-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 'commonwealth.of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information is Y required for Osterville MA 02655 May 18, 2008 every page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 et od used to determine distance: *This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent 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: 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 0 ® 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% 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. 93 BayAew Circle,Osterville-Title V-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system iswithin 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. 93 Bayview Circle,Osterville-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 bommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information is required for Osterville MA 02655 May 18, 2008 every page. Cityrrown State Zip Code Date of Inspection C. Checklist 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? ❑ ® 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 dwellinginspected 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 93 Bayview Circle,Osterville-Title V•08/06 Title 5 Official c al Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wu 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2006: 150 gpd 2007: 156 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 93 BayAew Circle,Osterville-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information is required for Osterville MA 02655 May 18, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system installed in 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No 93 Bayview Circle.Osterville-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18 inches feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): No issues, no signs of leakage Septic Tank(locate on site plan): Depth below grade: 12 inches feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: typical 1,500 gallon tank Sludge depth: 16" Distance from top of sludge to bottom of outlet tee or baffle 18 Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 101, Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? tapes/rods 93 Bayview Circle,OsteNlle-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 f c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information is required for Osteryille MA 02655 May 18, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 in good condition, concrete baffle is intact, liquid levels are even with outlet pipe, no signs of leakage. Recommend pumping every 2 years. Grease Trap(locate on site plan): Depth below grade: feet 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: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 93 Bayview Circle,Osterville-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco ` Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert no 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.): D-box was level,flow equal, no signs of solids carryover, no signs of leakage, everything functioning normally Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 93 Bayview Cirde,Osterville-Title V-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: One of two leach pits was not located, due to landscape obstruction, tree growth(branches, etc.) Type: ® leaching pits number: 2- 1,000 gal pits ❑ leaching chambers number: ❑ 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.): Leach pit that was located showed no signs of hydraulic failure, 4 inches of liquid at bottom, no ponding, vegetation normal. 93 BayAew Circle,OsterHlle-Title V•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forts Osterville MA 02655 May 18, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) " 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 ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): 93 Bayview Circle,Osterville-Title V-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name informiation required forts Osterville MA 02655 May 18, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. EAAK d o I Deco © ° - I ® J 4 T(Es A g 2q $ Z 47 93 Bayview Circle,Osterville-Title V-08/06 Title 5 Official Inspection Farm:Subsurface sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 93 Bayview Circle Property Address Joe Accrocco Owner Owner's Name information required forls Osterville MA 02655 May 18, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: Research of records shows no water to a depth of 12 feet below existing grade in area. Confirmed by hand auger. 93 Ba0ew Circle,Ostervllle-Title V-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town. of Barnsta. b .e Regulatory Services Bmws-resc.E, Thomas F. Geiler, Director �ArF019. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable HealthDivision received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this . report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. i QASEPTIMisclaimer Private Septic Inspections.DOC TOWN OF BARNSTABLE LOC4ATION SEWAGE# VILLAGEIL1�dILl.� ASSESSOR'S MAP&PARCEL �7 / I d S Pee` .-0 (OrM -ERS NAME&PHONE NO. k4p,,{v/ 50t 362-7-1 Zt. SEPTIC TANK CAPACITY o LEACHING FACILITY:(type) L c w Pt e S (size) — X NO.OF BEDROOMS OWNER TOS e Ek A.C(,RD(� P£ f DATE: COMPLIANCE DATE: 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 j, p hing facility) 3 o O Feet FURNISHED BY I {L. a � q—i 17 A 4 t 33 a 4 TOWN OF BARN TABLE - o 1 L LOCATION ` � SEWAGE # e ` VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME 6z PHONE NO. SEPTIC TANK CAPACITY 6 LEACHING FACILITY:(t / ' YPe (size) �C/Q� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATF_R/r -' BUILDER OR OWNER DATE PERMIT ISSUE DATE COMPLIANCE ISSUED: . . VARIANCE GRANTED: Yes No Rt 1 t ' ri f ASSESSORS MAP N0: 1 Lf 2y No.`.:?' -..._ - PARCEL NO: ��� Z Fps...... w , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di-ayoottl Work,i Tomitrnr#inn ran it Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ri J....^.104® . --------- ............................................................. • `� anon Address a or l of No � .� % -- -----------------c , ............... , O vn E .........................••-•--Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.___.._._ Expansion Attic ( ) Garbage Grinder 016 ' aOther—Type of Building ............................ No. of persons_-__-_____------------ Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------- W Design Flow..................... ......................gallons per person per day. Total dail flow._._......_........._...._____--------------gallons. Width(, ?._f rameter---------------- Depth---------------- R; Septic Tank—Liquid capacity_/�... ..gallons ,Length..___.___ �' W Disposal Trench—No. Widt g Total leaching area-..................sq. ft. x _._._.._._.. :-----___-- otal Len th------.1 Seepage Pit No.. ............. Diameter....'_...__...._ Depth below inlet___�v`____._----- Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Result's Performed b ______________________________________________________ Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit-_-_-------__-__-_._ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit_-.___-__-.--___.--- Depth to ground water........................ a - 0 Description of Soil._ V ..................••-•-----...... / ---•-•-•-------•-•---------*1-------------------------------------•--------------------•-------------------------••---•------•-------. W .............................................................................................................. ------ Nature�f,Re arrs or Al ns— nsw.er when hcable.. ______-_. wsyst L a`Agreement. -The undersigned agrees to install the aforedescribed Individual.Sewa e sposawith 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 Compli ce has ee .issue y the board oft health. 7 � ......... Date ........� ApplicationApproved By -- -- --------------1-------- ------------------------------.`-----.-- ------------- -.- ------------------------------------.._., .......`� . Date Application Disapproved for the following rea.ronr: ........................ ............... ..........-----------------------.........----------------...__.-------------- . ....... .................. .._......... ............................... ....... - ---- - ----------- Permit No. .:4.. F`,J�.'���.. � Issued ..---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE((..�� TETtifiratE of 11 omplian-ce T (S IS 0 CERTIFY, That the ndividujl Sewage Disposal System constructed ( ) or Repaired . X hs�:,u« c. . - ---------- -------------------------------------------------------------- in ta '`i-accordance with the provisions of TITLE of e State Environmental Code as described in has been s p T _ the application four Disposal Works Construction Permit No. ' '".....� . .._....... datedr ' THE ISSUANCE OF THIS CERTIFICATE SHALL NO(BE CONSTR EA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... _....-.... --------- - --...------------------ Inspector --------------------------- ------------------------`------------------------- ----------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS = J11 "Z --v)i`2— BOARD OF HEALTH TOWN OF BARNSTABLEg F'EE..... r 5 (Z.anstrurtion "amit Permission is hereby granted_ -...12. ... __..... .�. v��.,��.............. to Construct ( ) or Repair (� an,-Individua Sewage Disposal-System at No. 's �`:•',- ! t_� -✓./ - �� � t, ' '�'- . 1 , Jtreet as shown on the app ��cation for Disposal Works Construction Permit No._-____7..__-l1`__-./_ Dated--- ' ..:. ........ ---- Board of Health J DATE ............. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ZFEz....... 4. _ :....._ THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Diopoottl Work, Towitrurtion rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-:\ddress . or.Lot No.. ----- - ............ . ........... ....•-• ...... Oviv a .n�__�._./�-J---e•---•--------------------- --•--------------------...-----------------_Address-•---•-----•--••--•--------•--^-........_. Installer r / .� Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........ •---------------------- ---Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons.__..___.__._.____.__. Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------•-----------------....._.....-----------••-.....--•------------- ---•----.._..•---•-•------•••••-•..........------••--------•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.l4. �allons Length_. .......... Width64--A...Ibiameter................ 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 O Dosing tank ( ) _ a Percolation Test Resulti Performed by-------- ..........-...................................................... Date........................................ \ Test Pit No. 1= ............minutes per inch Depth of Test-Pit-------------------- Depth to ground water-._-_.--------_-._---.-. G Test Pit No. 2................minutes per inch Depth of Test Pit---.---------------- Depth to ground water........................ P4 - Description of Soil_� ..�», �%./ ......--• �.n:��a� ------------------•---------------------- U . ... :1 ------------------------------------............................................................. W ------------------------------------------------------------------------------------------------------------- ►ri u .__ �JJ^.�^l.t....�...711..... :e!'. V Nature�o.�,Re airs or Altar• trons.— nswer when applicable_ --.-:.-_-- R , --------------------- . Agreement: The undersigned agrees to install the aforedescribed Individual Sew a`e 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 een,issuediby the board oq health. Signed :... . i t/ �.. � •�Application Approved By .. Date �.... ...C=-. ..... ---c�Z-------------_------.. . / Date Application Disapproved for the following reasons: ..... - . ..........._........ .. ........................ . ........_..:....................................... .....................................:............. .. ............ ... . -- ... . ............................... -------- ----------- ................ .. ---- Permit No. f "�.� s° Issued ....................... Date