HomeMy WebLinkAbout0284 BUMPS RIVER ROAD - Health 284`BeMPS RIVERyROAD, OSTERVILLE
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TOWN �BAIRNSTABLE
LOCATION n� �Y IE�V�'1 �tv�l �cS� SEWAGE #
VILLAGE SSESSOR''S�.tMAP& LOT
INSTALLER'S NAME&PHONE NO. t 1 iZra,e-[ V-�� vt� 9 S S— 7&6k>
SEPTIC TANK CAPACITY
LEACHING FACILITY: t T (size) 6 'Co,
\ NO�OF BEDROOMS
BUILDER OR OWNER � 64fd z4 rrMS�RoK4 J
PERMIT 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 /v A A
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac/hi-ngp facility) / J Feet
Furnished by !
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DATE 10/17/05
PROPERTY ADDRESS 284 Bumps River Rd
Osterville
MA 02655
On the above date, the septic system at the address above was
Inspected.
This system consists of the following: -S 33-.7
1.1 1-1000 . ga eion zept.ic tank.,
2., 1-Dizt2.igut.ion Box.,
3., 1-1000 gaiion ieach.ing '12.it.-
Based on inspection,I certify the following conditions:,
4., 7h.i,3 .iz a 7.itie Five Septic .6yztem., (78 Code)
5., The zept ie zy,3tem j.6 ..in 12 opea wozk.ing oade2 at the
/2aeZent time.'
SIGNATURE PVIZ:�_
Name: Robert A. Paolini
Company: Joseph P. Macomber & Son Inc
Address: P. 0. Box 66
Centerville, Mass 02632
Phone: 508-775.3338 or 508-775-6412
mom
JOSEPH P. MACOMBER & SON,. INC.
Tanks-Cesspools-Leachffelds
Pumped &.Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 026.32-0066
775-3338 775.6412
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�.\ COMMONWEALTH OF MASSACHUSETTS
z. EXECUTIVE OFFICROF ENVIRONMENTAL AFFAIRS
> DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM .NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: . 284 Bumps River Rd
Ostervilla MA 055
Owner's Name: Vint-or LnRni cennni are.
Owner's Address: Same
Date of Inspection: 1011 7/n 5
Name of Inspector:(please print ' Ro r. A P o.l:'
Company Name:
Mailing Address:
erg e2v7 e, ��s.s. OZ632
-� Telephone Number: 5 0 8-7 7 5=3 3 3 8
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 M000). The system:
XXX Passes
-Conditionally Passes
Deeds Further Evaluation by the Local Approving Authority
Fa'
Inspector's Signature: r Date:
� .
The system inspector shall submit a copy of this inspection report-to the.Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,060
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 tolhe system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and,Comments
""This*report only describes conditions at the time of inspection and under the conditions of use at that
li time.This inspection does not address how the system will perform in the future under the same or different i
conditions of use.
Title 5 Tnsnection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION;FORM-NOT FOR VOLUNTARY ASSESSWNTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION(continued)
Property Address: 284 Bump&j River
Osterville MA 02655
Owner: Victor LaBoissonniere
Date of Inspection: 10 17 TO 5
Inspection Summary: Check A;B,C,D or.E/ALWAYS-complete;all of Section.D
A. System Passes: qES
NO 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:
Septic bys.tem .ib .in pzol2e2 wolik.ing ozde/i at the /72ehen.t LiMe.,
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.
NO 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:
NO 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:
NO' 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:
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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: 284 Bumps River Rd
Osterville MA 02655
Owner:. Victor Boissonniere
Date of Inspection: 1 0/1 7/0 5
C. Further Evaluation is Required by the Board of Health:
NO Conditions.exist which require further evaluation by the_Boardof 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:
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no Cesspool or privy is within 50 feet of a surface water
no 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:
no The system has aseptic 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.
rn o The system has a.septic tank and SAS and the:SAS is within a Zone 1 of a public water supply.
n o .The system has a septic tank and.SA&and the SAS is within 50 feet of a private water supply well.
no 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 v i�sua
"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:
M .
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued]
Property Address: 284 Bumps R_iyar Rd
Osterville MA "02655
Owner: Victor LaBoissonn'i Pri=
Date of Inspection: 1 0/1 7 f 0 5
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'/s,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.
— 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&Zont 1.of a.public well.
X Any portion of a cesspool or privy is within.50 feet of a private water supply well.
_ �.
_ _T_ 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 pollutiom.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 fora.)
NO (Yes/No)The system fails.I have determined that.one or mord?pf 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 1.0,00.0 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
X the system is within 400 feet of a surface drinking water supply
X 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 @nterim 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.
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Page 5 of 11
OFFICIAL INSPECTION FORM—NOT-FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART P
CHECKLIST
Property Address: 284 Bumps River Rd
Ostearville MA 02655
Owner: Victor Boissonniere .
Date of Inspection: 10117105,
Check if the following have been done You must indicate"yes"or"no"alto 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 th} inspection?
X _ Were as built plans of the system obtained and examined?of they were not available mote 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,excluding 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 b_affles 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 Soll-Absorption-System(SAS)on the site has been determined based on:
Yes no
X Existing information.For example,a plan at.�a Board of.l talth.
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))
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL:.SYSTEM.,INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 284 Bumps, River Rd
Osterville MA 02655
Owner: Victor LaBgi -,cnnni arrz
Date of Inspection: 1 0/1 7/0 5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(des ign):..3 Number of bedrooms(actual): 3.
DESIGN.flow based on 310 ChIR 15.203(for example: 110 gpd x 4 of bedrooms): 3 3 0
Number of current residents: 2
Does residence have a garbage grinder(yes or no):n o
Is laundry on a separate sewage system(yes or no):n o [if yes separate inspection required]
Laundry system inspected(yes or no): n o
Seasonal use-(yes or no): a 2003=43, 000gateonz G%D=117., 80
Water meter readings,if available(last 2 years usage(gpd))2 0 0 4=5 0, 0 0 0 ga i i o n z q1 D=13 6.- 9 8
Sump pump(yes or no):n o
Last date of occupancy: R a e z e n t
COMMERClAVI.r,0DUSTRIAL N/A
Type of estalll hmont:
Design flow_(based on 310 CMR.15.203): gpd
Basis of desieflow(seats/persons/sgft,etc.):,
Grease trap present(yes or no):T
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system-(yestor no):
Water meter readings,if available:
Last date of occupancy/use: .
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 5123103 pump 7 main.t I., Nacomgeiz
Was system pumped as part of the inspection(yes or no):a o
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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:
unknown
Were sewage odors detected when arriving at.the site(yes or no): n oo
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Page 7ofll
OFFICIAL INSPECTION FORM—NOT FOR-VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address: 284 Bumps River Rd
Osterville MA 02655
Owner: .Victor LaBoissonniere
Date of Inspection: 10 17 0 5
BUILDING SEWER(locate on site plan)
Depth below grade: 2 4"
Materials of construction: cast iron X 40 PVC_other(explain):_
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
10-int.6 aRQea2 tight No Penkaye Vented 1hAough hnliAo )),Pat.,
SEPTIC TANK:�XS(locate on site plan) /0 0 0 ya i P o n h
Depth below grade.18"
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: 8' 6"X5 8'X 4' 10
Sludge depth: g a c e
Distance from top of sludge to bottom of outlet tee or baffle: tg a c e
Scum thickness: .t g a c e
Distance from top of scum to top of outlet tee or baffle: t g a c e
Distance from bottom of scum to bottom of outlet tee or baffle: 117n c e
How were dimensions determined: m e a s ug ed
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
P uml? .tank evelzy 2 ueazz,s , Intiet & out.Pn.f tvo,c 61,70 ;a nCarn ,
Tank .i s ztguctuga-e4il .s:ound. L iau.id .Peve P.6 age noltm_a..2.,
GREASE TRAP:n X(locate on site plan)
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.):
Cjgea.3e tgap not /2ge6ent
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Page 8 of 11
OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: 284 Bumps River Rd
0cter37j I I e MA 02.655
Owner: Victor LaBoissonniere
Date of Inspection:10/17 0 5
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(explairl
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.):
Tight o z ho eding. tankzs ate no:t /2.,ze6en.:t
DISTRIBUTION BOXY e-3 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
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.):
Box .ins . eve e., ftaa 2 ea;t e za.e .., No z ignz o;e zo e is ca/zizy .ove/z
oa .leakage .in o2 out o,E gox.�
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.):
Pump eham&ea .ins not 12aezenmt
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Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 284 Bumps River Rd
• Osterville MA 02655
Owner:._Victor LaBoi�onniere
Date of Inspection: 1 0/17/0c;
SOIL ABSORPTION SYSTEM(SAS): .(locate on site plan,excavation not required)
If SAS not located explain why:
Located Ise
Type
X leaching pits,number:
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.):
Loamy to med..iam .ine .sand., No 3i n
6o c �. ate day vegetat.ioh iz noitma
CESSPOOLS: n0 (cesspool must be pumped as part.of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: ti
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes br no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
ce,6,3/2ooi,6 aae not /22eZent
PRE: n o (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.):
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Page 10 of 11
OFFFgAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SA:CE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 284 Bumps Ri yPr. Rd
Ostervi 655
Owner: victor LaBoissonniere
Date of Inspection: 1 0/1 7/0 5
SKETCH OF SEWAGE.DISPOSAL SYSTEM
Prov�d"sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100.feet.Locate where public water supply enters the building.
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Page 1Lof 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART.0
SYSTEM INFORMATION(continued)
Property Address: 284 Bu Rd
Ostervi ie MA 02655
Owner: victor Lgpoissonniere
Date of Inspection: 10 17 0 5
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water.LID. feet
Please indicate(check)all methods used to determine the high ground water elevation:
-NO Obtained from system design plans on record-If checked,date of design plan reviewed:
u e.3 Observed site(abutting property/observation hole within 150,feet of SAS)
Checked with local-Board of Health-explain: ry
no Checked:with local excavators,installers-(attach documentation) u�
htt :t own.'gaan stag fie. ma.
database=ex lam. /�
Accessed USGS p
You must describe how you established the high ground water elevation:
Used Cape Cod Commision !Jate2 7a&.Pe Codtoua.6 And %ugtic Nate2 SuI2124
oeii head zotect.ion aaeas ma Se t 1995
�ate2 zezou/tce,6 0,04ice cape cod comm.iZione'
Top of Grouna
Leaching
Pit I I'eet
�q •
Groundwater: Feet Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per Frimpter M4thod
Therefore,the vertical.separation distance between the bottom V
of the leaching pit and the adjusted groundwater table is Z
feet.
:.•}BIRTH T�nrrr•+•'v�Trnramrn+n►rrnrraerfcirarr.'R*Ssrrler�*t.TT7eTentfsTTIP'w7mu7n -T*re7•'+r-.gTrte'!::Tr.r••}
TOWN OF BARNSTABLE BOARD.OF .HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D •- CERTIFICATION
••TP1-T•YS:T�T177^.ITT'1J.7T.n1•RTJtT•iR.EF7PYfT!R7•ITr-SM T"{tTfRT7lrRil7� A'ChQ�fRel '!R7nowmin iTl^T7'-'7T•^1 •••!•�
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 284 Bumpz Riven Road '
ASSESSORS MAP, BLOCK AND PARCEL # 120-134
OWNER' s NAME V.ic.toa LaPo-izzoanze2e
PART D - CERTIFICATION
NAME OF INSPECTOR Pokea•t !aoiih-i '
COMPANY NAME ;oseph 'P.I Nacomla)? Son Inc
COMPANY ADDRESS Box 66 Centeavt-iie Nass 02632
Street Town or City. Stag LIP.
COMPANY TELEPHONE ( 508 17:75 -. 3338 FAX ( 508 .)790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally. .inspected the sewage disposa'l system at
this address and that the information reported, is true, accurate, and
omplete as of the. time of •inspection . The inspection was performed and any
recoinmendations regarding upgrad.e, . maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
XXX Systeoi PASSED `
The inspection which I have conducted has not found any information
which indicates that. the system fails to adequately protect public
health or the enviro:.t.iment as defined in 310 CMR. 15 . 303. Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
f
The inspection which I have con acted has found that the system fails to
protect the j-,ublic health and the environment in accordance with Title
.51 310 CMR 15 , 30.31 and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date
Xwne
copy of this certification must -be provided to the OWNER, the. BUYER
here applicable ) and th+a BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade ' the system.
within obe year of the date of the inspection, unless allowed or required
otherwise as provided in 3,10 Ch11t l6 - 305 .
' • � •• Imo`• - • �, #
=� COMMON-WFALTH OF MASSACHL:SETTS
$ i I:\. :CL"Cri'E OFFICE OF EN-VIRONNIENTAL :OFF.-IRS
DEPARTMENT OF ENVIRONMENTAL PILUMMON
,\. O.NE "INTER STREET. BOSTON NSA 4121014 i617r 292.51VII)
W1LLUM T. WELD TRUDY COXE
G,,.wnat �reretary
,•s;TGEO PALL CELLUECf DA%ID 111. STRUHS
L:t Govomw Cerr►autswner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�p [
Property Address: , -Uvs'h�9 ut„��JfQ� �I z .Address of Owner.
Dade of Inspection: 9�Q tQ� l� Js different! YO Lk
%Jame of l"WC10r: ►e�.e��� ��G��f u fit Lib in,
�
I am a DIP pproved system i ector pursuant to Section 15.340 of Title S (310 CMR 15.0001
Ccmpamy Nana: h v' n rn l�weGM
Mitilinit Address: O o2f.
Telephone Nurnbert
CIAjINCATION .
f certi y than I have personally inspected the sewa{e disoosii System al this address and that the imiormatton reported below is Irut, XCuratt
and complete as of the time of inspection. Tne inspection wag performed bawd on my training and exoenence its rho proper iunction and
rrtarntenance at on-site sewage dwal systems. The systefn
Passes
Ne01004 funnst ivaW.nnn AV rn• Larai Aeprnvrn! Aatnutd�
Fails
Inspector's SiXtosiure: Cate: AO
thtr System inspector shall submit a copy of this inspection report to the Approving Authority within thirty i301 days of completing this
ins,majOn. If the%$'stem is a shared system or has a desrpn flow of 10,000 gpd or greater, the inspector and the system owner shalt submit
the report to the appropriate regional Office of the Department of Environmental Protection. The original should be sent to the systetn owner
and copies semi to the Layer, i(applicable, and the approving suthonty.
INSPECTION SUMMARY: Check A. 0, C. Of ®:
Al SYSTEM PASSES:
ll� f ham not found any information which indicates that the system violates any of the failure griteria as.dtfined in 310 CIVIR 1S.303.
Any failure criteria met evaluated are indicated below.
COMMENTS:
b� SYSTEM CONDITIONALLY►ASSES%
r One or more system components as described im the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacemerst or rtoarr, as approved by the board of Health, will piss.
Indicate yet, no. or not determined'M N, or N01. Oescribe basis of determimmion in all irtstances• If"not determined''. explain why not.
The septic tank is metal, sinless the owner Or operator has provided the system inspector with a copy of a Ce"dicate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the rnsataton: or
the septic tank,wtsotheo or not resew!, is cracked, structuralty unsound, shows subatanttat tntrltrauon or exfiltratron, or rank
failure is Imminent, the system will piss inspection if the existing septic tank is replaced with a contrsrmtng septic tarn
as "proved by the board at Health.
r(t�rsaed N/lls/ail t►atp 1 •t to
rhaM a%wve*o plane
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM msPECTiON FORM
PART A
CERTIFICATION iconrinuedi
Prnperty Addrt:*s•:
Otb ner: A tM Ott*
Date of I rnp ectiun!
11!iYSTEM CONDITIONALLY PASSES (conlin% to
Sewage backup of.breakout or migh twric tvaier level ubs r%cd in lieu distribution box is oue to brnkrn or ribOruc:rci
pipeisl or due to a broken, settled or uneven distribute x, The system will vase inspection p 1—IN 3tipr0v4i to tn"
Board of Health), Describe ogscwauons'
broken nipetu a. aced `
obstruction emoved
distnb n box is loyellod or replaced
_ The witem req d punllrna more than four times a%ear due to bruk-en or olntruned pipctsi The %Nvem will ilea
inspection �f I approval of the Board of Health):
brokeen pipe+sl are replaced
�
obsirunion is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reoeuite further evaluation by the Board of Health in o t to determine ii the system is fading to txMOect the
public health, saiety and the enveronmeni.
1) SYSTEM WILL PASS UNLESS BOARD Of HEALTH DETERMIN HAT THE SYSTEM IS NOT FUNCTIONING IN A MANK$R
wWtPt1 av11► Ppe%j T TMi PI!Rl IC ► 1 At YN ANfl urn— sv'l 'Or f°,'t!✓ `•� P►''
w„ Cesspool or privy is within SQ teet of a sun water —
Cesspool or privy Is within 50 feet of a rdering v"eetated wetland of a 1411 marsh.
_} SYSTEM WILL FAIL UNLESS THE BOARD HEALTH (AND PUBLIC WATER SUPPLIER,If APPROPRIATE)DETERMINES THAT
THE SYSTEM iS FUNCTIONING IN A NER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVfRONMENTt
The symem has a soalpti nk and soil absorption system (SAS) and the SAS is within 100 het to a surface water supply or
tributary to a su ater supply.
The system has a is tank and soil absorption sysem and the SAS is within a Zone I of a public water supply well.
The system has septic tank and soil absorption system and the SAS is within SO feel of a p►rvm water supply yell.
The system s a septic tank and soil absorption system wad the SAS is less then 100 het but SO Beet of more from a
private w r supply well, unless a well water analysis for coliform bacteria and volatile orWic compounds Ind-icties tha
the is Iree from pollution from that facility and the presence of ammonia nitrogen and nitrate nutogen is ecual to of
IOU S ppm. Method used to date one distance,,.�,..,_„tepprostitesettitan not validl.
i
?) OTHIER
ke••saa•e eo/'aisst e•e. a •t sa
SUDWR/ACE SEt,,ACE OISPOSAL SYSI(m InSPECTION FORM
PART A
CERTIFICATION(continued)
P►+�erW Addrt•�►: �, S J tM®S R, VIA
O+t'ntr. r rA S j'lt M,
pate of Inspection: p )�Q l t]ct .
DI SYSTEM FAILS:
ou must indicate either "Yes" or "%%o" as to each of the iollowing:
I ha►e deterrttrned that the system violates one or more of the iollowinc failure criteria as defined in 3 10 CMR 15.301. The haws
'or this dlewrttsnation is trlenUf ed lavlow. the Board of Neal:h should be rwilaved to otterinme %.iva will I*necessan• °(i Correct
the failure.
�P5 Vn
seckup of sewage into facility or system component due to an oeded or clogged SAS or cesspool.
Jischarse or ponding of effluent to me surface at the . and or surface waters due to an overloaded or ctngged :,AS fit
Cesspool.
' I
Static liquid level in the distribution box ve outlet invert due to an overloaded or ctogged SAS or cesc000l
i
Liquid deptn in cesspool is less t n 6".below invert or available voiume is less than V2 day ilow.
Reouired pumping more n i times in the last year !�M due to closed or obstructed p+oe•st.
14umber of times purrs
any portion of I Spit Absorption System. cesspool or privy is below the high groundwater elevation.
-Anv ponio of a cesspool or Privy is within I OC feet of a surface water supply or tributary to a surface water suoph-.
4m onion cf a cesspool or privy ,s N ithin a Zone : of a puo.:c :yell. .
Any portion of a cesspool or privy is within 50 feet of a private water supplv,well.
Any portion of a cesspool or privy is loss than 100 feet but greater than 50 fiat from a prvate water supply •11 with no
acceptable water Quality analysis. If the well has peen analyzed to be acceptable, attach copy of well water „nail-sis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate netroten.
d
111ARGE SYSTEM FAIl3s
Yoij must indicate either"Yes' or'silo" as to tech of the followity:
The following criteria apply to large systems in addition to criteria above:
The systsns tt yes a facility with a design flow of 1 tpd or treater dirge System) and the system is a significant thre4ta to
public health and safety and the environment use one or more of the following conditions exist:
Yes. No
the systarn is within 4 feet of a surface drinking water supply
the sys(rom is 200 feet o(a tribuilotty to a surbw drinking water supply
the system ' lom4d in a nitrogen sensitive area (Interim Wellhead )protection Area • IWPAI w a mapped Zone It of a
public supply wall
The oweter or operas f any such system shalt bring the system and facility into full compliance with the groundwater treatment program
requirements of 31 MR 5.00 and 6.00. Please consult the local regional office of the Otpanmtnt for further inionnation.
91ettvtaN 44/if/1171 so" S es to
5kJ9SukfACf SE%%'AGE OIS►pSAt St'STE.%t INSPECTION FORM
PART •
CHECKLIST
x
Prtgsrtr Addr ss: % vrG -
Owner.
Oate of I ,ion:
ChKd. rf the following have been done: You must indicate either 'Yos•` or NO' as 10 each of the iollOwrn*.
Y!!� No
Pumping information was provided by the owner, occupant. or Board Of Heailh.
y None of the system compontrnis have been pumped for at least two weeks and the system has been receivrnj normal
— flow rates dursng that period large volumes or water have not been introduced into the system recei,tty or
as W of this inspection.
As Will plans have been obtained andettamtned, Not* a ihev are not available with hlA.
— he facility or dwelling was inspected for signs of sewage back-up.
The system does not tecene non-sanitary or tndustnat waste ttow
— The site was inspected for signs of breakout.
All system components,-excluding the Soil Absorpunn Svstem, have been located on the site.
tV*P� r 6 tNrt w Irn9ptt lOt t
v�y o.rd f� � , t4.... , .. ,
_ Tli c Saft+&^k M, t�wO.t 'Vft*4,4 ie *t's 4i 0'0. • Co�'ZPAews as
fiats)):!W to". ttWL-1t41 ut CYnalruct,wi. dimonaiunl, uepth iii :,c46A, drtWh of sludga, do;xh 81 scurf~.
The size and location of the Soil Absorption System on the site has been determtned based on, w I1
— 'he iactlity owns►tend occupants, ii different tram owner were provided wish irtforrnauon an the groper maintenance of
— Subo Surtiaa Disposal System.'
Existing information. Ea. Plan at N.O.M.
Determined in the field(if any of the failure criteria related to Part C is at issue,approritnation of distance is
unacceptable) 't 5.302(3)Ibl1
t
y n
stnwlrN aeii+aittl Page 4 .e 10
�t.'IISt•Ri>aCt Si�ti'+cE ®15PQSAl SYS1E�1 i%SPFCftO% FORM
PART C
SSN SQTEM IIgFORMATION
Pn�er1Y Addfess: pd Cf V yy1 r► fztR 7G�Jl .
Oarnrr: �rM3$/ C�
Bale of Inspeeliot4:
i
FLOW CONDITIONS
RE5 IDENTIAL•
Dew Ilow: �/a vor 6.A S.
Vurnbfr of bldroomc-63
Humw Oi cy"M reftdenlf
Garbage Ifind1w tyef or not!
LaundlY connected 10 SYSISM t}ef Or n0t:.Lg
So., -ai W"("S Of fi t-&-* 49 8 5-8f labia 7 38 P
water feeler read,n�f, i i , lilst two t11)'far usage Hlpds: �
Suirp Punnp nes Or n01:
L&A dale of occupant)':
Twe of eftablishrrietr
Des,tn itow:�llOrtsuday
Gfeast trap present:Iyes or Mal—
i lteustriai Waste Holding To*present: (yes:syll;:
Npaasanilan• waste discharged to the Title S. ycs or nol—
winer mlMer readings, if available:
rw**k. t^JC G J
O"MER:(Defcribel
Last date Oi OCcuOancY:
GEMERAL INFORMATION
PLlM04NG RECORDS�agd sou of inforfna ion:
N e �_e 54=
Syitern purrged as pan of inspeq►On: tyes Or nOI—
If ties,volume punted: asllons
RUMM for pum".
TYPE O�MTUA
Septic tankNistriWion bWsoil absorption system
Sinille tessp"
Overflow cesspool
Privy
��.Shared sys0ern W Or nol (d yes,attach previous inf{section records, if any)r
e_s I/A 760r4ogy W- Copy Of up to dM COMM?
Ocher
Mr►ROI wAATE AGE of all components. date instilled (if known)and source of Information:
sawa,e Odors deteeW when arrlvin`at the site: lyes or ner 7Lo
I
t Irwar�l et/SDittsl eat* a *! to
SUBSURFACE $tWAGt 01SPOSAI SYSTEM I%SPECTION fORht
PART C
r1 SYSTEM INFORMATION !Continued'
Property A rss: ii ,' 'l 01MA,Ps Rwo 1G6f
Owner: rlomero
Date of InVoction:
at
RVIUMNG SEWER:
'locate on sett pianl y
r
Depth below srxk-.—
matonal of Construction: 40 Pt'C v'hM'explainl
a)itWtte (rt)fn private w supAly well or suction line
I�littlete► �„r�
C.txnrrtenls: IC tOf1 Of 10lntt, venting,ewticnCe Of aCAkia><t!, etC.l
:APTIC TANK:1/
:locam on Ht0 plan!
le �_
Depth below grader
satafal of Ctmu(uc OW: A:onc►ete _me'al _Fibertiass _Polvethvione_whertexplam)
if tank. is natal, list ase— Its"'M Con,in.Kd W Cen:i,care of CornplianCe lyedNa
0irnl1,14100n6:
iluoet depth:
icum thickness:
')igainf a from top of scum to top of outlet tee or baffle:
Distamn irom ta0Rom of scum to baton►of outlet t or baifle:_Jg^
how dimensions were determs"Odr
omTertesr �I
recomrnent$ation for pumping, condition of iqgi and outlet tees or baffles, death of liquid level in relation to outlet 1nvem structural
ntesrity, 4A idOng
of leatluse, etc.
e
• d3Rfl1lE TRA/r�_ ,
;locate on ell!plan)
Depth below Va&.- _
%aeritl of Cones udion: _Conttrete _nmsl_Fiber s ►olyethyfene�,,etherletrp�tinl
Dintettliona:
Sawn dtid AW:_
DiNviilIe fiat!cep of loom to top of at or bldMle:_.,,.,
Dimana hom boom d scum to of outlet we or beft:_,.,,
Date of laq low"irts:
-ornirierns:
lrMcorrtrrtettdatbn (or p pins, condition.of into and outlet too or baffle',depth of liquid level in reiation to outlet inven, structugi
inleyaty,evidence of akase, etc.'
1 te�rsNt 00/:t0/!!) 1sN 1 of t0
SL 11SURFACE $J%V.%Cf DISPOSAL SYSIEAt INS►EC710.% FORM
0"ART C
.6 SY 5TE.\t 1%FURMAT10%tcrnitinweld)
Prcgvrt% Address: � 8`ti ZJ m`s
OM r+er. Arm 6't'ro i%-t;,t
0,1 to of Impectior►: p,l ( pit y p 8
TIC;Mf OR HOLDING TA`K:_•Tank must be nuTnco ONO, to, Of at I cri Imsoecrtont
,c<:ate Oil site oianl
Dipmh beICW trifle:
vat.r0 of construction: concrete .,,,,110181 _Fiht:►eta i'ctivclR%lane 61
tlfleM+onfi
CataacnY:_.._ i,l sort
aeutn floK:_„_„�iaRonf/daY
kla,rm fevti:�,4 Martin" to txt�ins order� Nat,
Date a previous pumtpinl:
Comments: •
condition of+filet tee, con ion of alarm and gloat swucnes, etc.)
014TRIBUTION 80L
.I0:41C an slat`plats (.
Death of 14utd le%el Above outlet invea: 6L a �✓��
Co+taments:
Owe I(1 l aml distribution is equal, evidence,of said$ carrvoti r, evidence�ll�� of leakage iot or out of box, at :.
Q. ✓ T
PUMP GMAMRE�to.
(lowim on site pwo
vow to working order: 1Y"or Nos
Almms in working order(Yes or No)_,,,._
Comments:
:neat condition of pump chamber, Can it. sumps and appurtenances, etc.)
.10
r IrwsaM Is/�s/t71 1qt 7 •! 11
4 •
1,LBSURFACE DiSPOS.aI SisIt.4,1 u%setcT,oN rant
PART C
SYS71m NFORNATION 16-Atinutul
CA
oat*ai Irts elion, n
SOIL ASSO4/110N'S)'S`fM tSkSl:-4
)orate on site olan. If oosslblr. Wavatton not UUt may lit antuoximmed by nonontrusive;rnethw. -
u not detArrnrned to.be praent,explain:
ham.. . .
leaching pits.number,
leaching chanftbtts. r►utttlier'r,,., ;
leaching gallenes. number.
leaching trenci ts, nurnber,lengtha_„
:e&chin# fields, number, dimensions:
overflow cesspool. number:—
aUa;matiw sylterr+:
name o?technology:
;Werra eor tiesn of soil.+tgns of hvdrauite iaiture, level of vein n�, carttly��o r N•cge:ot+on. eu:t
1.
CESSPOOLS-
)orate on stte plinD
. vurber and cOnfiguratton:
04wh4op of Diquid to irtim Invent:,
dsth of sdods layer
Oelmh of wurve layer:
Osman wd of caspool.
Marwrats of construction:
Indication of grour+dwatw:
Inflow 1C"Spool,mum YI I as pan of Inspection) r�
Corrwmnents:
Mane condition of is carts of hydraulic failure,.level o+ponding, eondition of vewtion,'etc.)
MVV.
locate en site plans
MMauls of construction:
. Oepth`of se+ieds:a„e„�,, Oirntinsiont:
•rnar condltlon,oi toll, signs of h� ulic�ia-lurt Its%et ni ,ndl pc nt Condo,*"of vegetation,.etc.)
ti
page 1 et la
SIBSIRFACE SE%%AGE DISPOSAL S1Slot INsPI ION FORA
PART C
SYSBEM INFORMATION icantinu*di
Prape►ty Add'
r 8�{ so vi&�S t V e A
Owner: ��ft`O�
Oaee
SKETCH Of SEWAGE DISPOSAL SYSTEM:
.ncluds ties tO it Iltst tW®IWfr"an`m`i rcterences lam"Wks W ti*^Cnntar.s
dJ1C li) ��l'llc h itMri IOt)' �lt�',It! � T?e t►uu:'C .vAtN Suptiiv cc�►t°s loin hAuia l..
zr-q1 si
�tsrwi�� uey4iN►
fMa Y o! 3 0
}. l
T�
Se111S{,1R8ACE SEWAGE DISPOSAL SYSTLI%9 WSPSCTdOM 'rQ&%t
PART C
5YST8.1 WORMATION ItMdA1240
�.. Addrar= ae is 2 u e CV_'C_0T.
i=see of , -� ,
y
Cteptb,t,e Gn wwwaW 1°feet
pum Waco ell the W edtods used to&Wrretine High Grourldweter lrlcvetan
pboaimd front D"ifn Pierre On record
obscweelan of Site(AbUOMS PMPItY- obe.rvetwn hole,DeserneM swop nc.)
D+eorrniee it flan ioeel pottditions •
chak .rids"m lard of Meath
.r.
Crock f EMA AAepe
f _w Creek ptt iq records
Chock low eaoevmn• inwllers '
Wo US=Dees
I)seaibs in your own words how-you nablished the Hi h Of -11M!� S'!os 4�116 M
� 1 ��t
v �� � � lo�%�t , Lrt'�
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S ,NAME i ADDRESS
UILDEIII OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE . ISSUED
__ _
r
�:...
� A
1 .
� 1
�� e
�� � ,_���
�- - �� ��
� �
a.
f
,` �,�'�'
�� ���
t � '
�� i
...................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.....Town................OF........Barnstable..._
.............................................
Appliration for Disposal Works Toustrnrtion Wrmit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
.............Lot..#.. _ - - �� =..:....°. 5} ,r �_'? .............._..
.... ...._...............Location.
Address....... ._`. L?..✓4 ....7.65._Falm4u .. oa(14...Hyayl?��,5. ................
Owner Address
WSteve Lebel ............................................ dre._...--------•-=••••..........----------.....
Installer Address
d Type of Building Size Lot............................Sq. feet
UDwelling—No. of Bedrooms.........3.................................Expansion Attic ( ) Garbage Grinder ( )
0`4 Other—Type of Building rangh.............. No. of persons............................ Showers (2 ) — Cafeteria ( )
a' Other fixtures ................................. .
W Design Flow.....................55..................gallons per person per day. Total daily flow............._.........3-30.............gallons.
G: Septic Tank—Liquid capacity1000.gallons Length.8.`...��.__. Widt14.'1.0...... Diameter________________ Depth..5'.8.1..._.
Disposal Trench—No. .................... Width.................... Total Length............_....... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter........ ....... Depth below inlet.......6......... Total leaching area.....26.6....sq. ft.
Z Other Distribution box ( ) Dosing tank (
Eldre e En ineerin 11-2 81
Percolation Test Rests Performed by.......................g-____._._..9..--•_............ ........_.. Date....____....._5-....................
as Test Pit No. 1...2.�.�_..minutes per inch Depth of Test Pit-.12_......._..- Depth to ground water.11Qne-•_eTlCOuriter-
(i, Test Pit No. 2-_N1A.....minutes per inch Depth of Test Pit:_N/A......... Depth to ground water----N/A........... e d
•--•---------------------•-----.....•--•-----•-•-•-----•-•-•--••---•-----•--•-------••••--............•-----•••--......-••••-----•.....-•••--......•--•._---•
Description of Soil --..2 ------loam----- topsoil-----------------•--------------------------------•---------------•---------.------
x 2 10 ' medium Yellow sand
-----------------------------------
•------...........•••••-------------------------------------
W ---••-----•----_.
10•' - --_-1.2.' med..._white__-sand traces-•of-__grave•��nq_.wa�e�_•_at 12 '
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'TT:1,:. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ued the board of health.
SignedZ.- --•---••---• - ---•• /
c�� Date
Application Approved By. = . .. Y
Application Disapproved for the following reasons:...................................... ...-----------••---•---------................._.. Date---------..._
--------------------•--------•------•-------•-••••--•-•-........._...•--•----••------.........••••----•-•-•••-----------•-••-••-•-•-------•-•------------------•--•--•--•------------------••......-•---
Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
Fizz.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............TolM................OF........Barm.-.table.................................................
Appliration for Elhipasal Workfi Tonstrurtion V.unfit
Application is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal
System at:
.....................
.............. . ..... L.H
Location-Address or Lot No.
.0 5...F CL alMUth..7
Road,,_Hvanni a...................
Owner Address
S.t_Qvia---Lebal............................................................. ..................................................................................................
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U
Dwelling—No. of Bedrooms.......... ................................Expansion Attic Garbage Grinder ( )
P4 Other—Type of Build -------------No._------of----p-e-rsons............................ Showers (2 ) — Cafeteria ( )
P4Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow....................55..................gallons per person per day. Total daily flow.......................3.3.0.............gallons.
04 Septic Tank—Liquid capacity.IQO.O.gallons Length..8.'.6."_.. Widt14.10..... Diameter................ Depth....5.1.8.11...
Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. f t.
Seepage Pit No......I ..... Diameter........6......... Depth below inlet........6.......... Total leaching area.....26.6...:sq. ft.
z Other Distribution box Dosing tank
Percolation Test Results Performed by......Eldredge..Engine.ering......... Date._1 —..25=R1...............
Test Pit No. L<20---minutes per inch Depth of Test Pit...12.!.......... Depth to ground watennone...e.rloounte
14 es-
4� Test Pit No. 2_.B/A.....minutes per inch Depth of Test Pit---N/A......... Depth to ground water....NSA......_____.
I.........................I.............................................................................................................................
0 Description of Soil................0-1........2-1..........10=.A...to-P-8-ail....................................................................................
WI I................................................21........1.0.1......m.e.d1um_.v.e11ow..-.sAn_d........................................................................
U
---------------_-1OL".........12........meal ...White..jsand .tr.azes...o-:f..Zra...Mel/ t
........................... Wa ex..At 12
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 A'I T 11,17, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bo r of health.
A/
Sign .......
Date
ApplicationApproved By................................................................................................. --------------
Date
Application Disapproved for the following reasons:.................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............T.olwn.................OF....;p4rnstable
.....................................I...................................
(9rdifiratr of Tontlifiattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired
by-----------------------------------Steve...L.ebel.................................................................................................................................
Installer
at.
..... p ... ...........................6.2.... . .........................................................
...........................v
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated_...-_____.___-____...__.._..__.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................ ................. Inspector................ 6...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'Rown Barnstable
No......................... FEE........................
lion rmit
Disposal Vorku TIMmArtu pr
Permission is hereby granted.......qtev.e...Lebe-1........................................................................................................
.......... .............
to Construct (X or air an Individual Sexage Disposal System
atNo......1011.? .3 ............------------------- ....... ..... ---- 9. I ... ...... ....................
Street
as shown on the application for Disposal Works Construction Permit o...................... Dated.._.......................................
----------------------------------------------------**----------*-------------------*-1A- -------- ------
Board of Health
DATE..................................W..
111 -------------- ----------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
'J
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oq
a4D opo , S
dal lip
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LEGEND ,A OF CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION 010
EXISTING CONTOUR --- 0 --- i JO*NWN y -0T e� 13V/'lns 7?- "' T 'r--'
FINISHED SPOT ELEVATION V1 Z-1-E
FINISHED CONTOUR 0--- , --"- --
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APPROVED, BOARD OF HEAL 4 Q�sr 13 RN S ?-;Al 8 L. �
DATE AGENT SCALE , /„=gOr DATE , w/7�8/
EL DRED G£ ENGINEERING
CLIENT 1 CERTIFY THAT THE PROPOSED
REGISTERE EGISTERE JOB NO.,9'0 0 S 1 BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE NING LAWS
ENGINEERS SURVEYOR DR. BY��"�• �' 0FBi�,�Nsr�*EQ.
M S
712 MAIN ST. CH.BY, `�'�'C' I 08 g HYANNIS,MASS. SHEET OF 2" DATE LAND SURVEYOR
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