HomeMy WebLinkAbout0389 BUMPS RIVER ROAD - Health 389 Bumps River Roar!
t Osterville i
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DATE: 8/16/0
PROPERTY ADDRESS:_38_9 _Bum_ps_ River_Road_
Osterville ,Mass_____--_
02655
On the above date, I inspected the septic system at the abo a WED
This system consists of the following:,
1 . 1-10,00 gallon. septic tank , $EP 3 2002
2 . 1-Distribution box .
3 . 2-1000 gallon precast leaching pits . (6 'X 9 '') TOWN OFBARNSTABLE
HEALTH DEPT.
Based on my inspection, I certify the following conditions: 4
(09 ,9
4 , This is a title five septic system . ( 78 Code )
5 . The septic system is in proper working order at the
present time .
6 . Pumped the septic tank at time of . inspection . Heavy
scum & solids layers were p_resent'
SIGNATUR -'--
Name:_ J .-P.-Macomber-jr.
r ,
Company:Jose-h _P, - Son,* Inc RECEIVED
Add r e s s :__Box _��------------
AUG 2 g Z002
_Cen-t-ervi11e,_ba _Q2632-0066 TOWN OFBARNSTABLE
HEALTH DEPT.
Phone: 5.08-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON,` INC:
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
f
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A r
CERTIFICATION
Property Address: 389 Bumps River Road
Osterville .Mass ,
Owner's Name:Bd Chandler
Owner's Address: Sama
Date of Inspection:
Name of Inspector: (please print�JOseph P .Macomber Jr . -
CompanyNameJ.P.Macomber & Son Inc .
Mailing Address: Box 66
Centerville,Mass . 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT `
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). 'The system:
Passes �l
• Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 4
Date: .
The system inspector shal mit a copy of this inspection report to the Approving Authority(Board of Healfi 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 he
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
****This report only describes conditions at the time of inspection and under the conditions of use at tha
time. This inspection does not address how the system will perform in the future under the same or different— -
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
i
Page 2 of 1 1
OFFICIAL INSPECTION FORM=NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ;
CERTIFICATION (continued)
Property Address: 389 Bumps River Road
stervi e , ass .
Owner: Ed Chandler
Date of Inspection:8 16 02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ,
A. System Passes:
Vd ,�have not found any information hich indicates that any of the failure,criteria described in 3101 CMR �.
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
The septicr.system is in proper werking order
-at the present time .
B. System Conditionally Passes: ,
1.16 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.
VO,The septic tank is metal and over 20 years old* or the septic tank(whether metal ornot) 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: F
ND explain:
,4/0 Observation of sewage backup or break out or high static water level in the distribution box due to broken orr
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;
-mod The system required`,pumping`rrore than 4 times a year due to broken or obstructed pipe(s). The system will '
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Proper Address:389 Burn-ps River Road
Osterville ,Mass .
Owner Fd Chandler
Date of Iaspectioo: $ 1 fi/02
C. Further Evaluation is Required by'tbe Board of Health;
d[� Conditions exist which require funher evaluation by the Board of Health in order to determine if the system
!s failing to protect public health; safety or the-environrnent.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(b) that the
system is not functioning-in a manner wbich will protect public bealth, safety and the environment':
40 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:
Ale) The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or rributary to a surface water supply.
QUO The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple.
.iJZ) 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 IIDA feet b 50 feet or more from a
private \pater suppl. well Method used to determine distance lJJ
}
This s.\stem passes if the well water analysis, performed at a DEP cenified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facilir) and
the presence of ammonia nirrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are rriggered. A copy of the analysis must be anached to this form.
3. Other.
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
I
Property Address:389 Bumps River Road
stervi e ,Mass .
Owner: Ed Chandler
Date of Inspection: 8 16 02
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no"to each of the following for all inspections:
Yes No
.
' ackup 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
d Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
esspool
�iquid depth in sesM ml is less than 6"below invert or available volume is less than ''/-day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped i.
t ny 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
PP Y rY
water supply.
_ _✓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 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.]
.UD (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails..The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: ;
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no /
the system is within 400 feet of a surface drinking water supply-
the system is within 206 feet of a tributary to a surface drinking water supply
tthe system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well ,
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered `
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
CHECKLIST
ProperryAddress:389 Bumps River Road
stervi e , ass .
Owner: Ed Chandler ,
Date of Inspection: 8/16/02
Check if the following have been done.You must indicate"yes"or"no" as to each of the following:
Yes No
Y 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 ? :_ r
— 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)
zWas the facility or dwelling inspected for signs of sewage back up ?
e� Was the site inspected for signs ofbreak out ?
�— Were all system component s,re eluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and ihe_interior of the tank inspected for the:
'condition
of thhee 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:system5?
The size and location of:the Soil Absorption.System(SAS) on the site has been determined based on:
Yes no
_4/Existing information. For example, a plan at the Board of Health. § t
' Determined in the field
ifan oft he failure criteria
— feria related t P( o art C is at is,ue— Y. s approximation of distance
_ RP
is unacceptable) (310 CMR 15.302(3)(b)J
5
Page 6 of 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
a
Property Address:389 Bumps River Road
Osterville .Mass .
Owner: Ed Chandler '
Date of Inspection: _8/16/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): �5 y.
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): �� �i7�lb•��
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system yes or no):;E)Z [if yes separate inspection required]
Laundry system inspected(yes or no): `
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd))-2000-64, 000 gal lons=175 . 35 GPD
Sump pump(yes or no):4)0 2001.-7.6 000—gall, ons=208. 22 GPD
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): 4�
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):,(//I
Water meter readings, if available:
Last date of occupancy/use: r
OTH, R(describe): /UR
GENERAL,INFORMATION
Pumping Records
Source of information:Maint . Pumping : 10/5/00
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped:/VD gallons-- How.was quantity pumped determined?/_/AW/
Reason for pumping`.Heavy�-scum & solids lavers were present,.
TYPf OF SYSTEM
,'Septic tank,distribution box, soil absorption system
4Z2) Single cesspool
,f)O Overflow cesspool
Privy
WShared 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 syst�owner)
Tight tank ;J Attach a copy of the DEP approval
Other(describe): .e),
Approximate q of I c rlt one ts, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
i
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:389 Bumps River Road
Osterville ,Mass .
Owner: Ed Chandler
Date of Inspection: 8/16/0 2
}
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:#6 cast 'von /' 40 PVC AM other(explain): Alf
Distance from private water supply well or suction line: ie't
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight No PyidpnCP of leakage ThP AystPm
is vented through the house vents .
SEPTIC TANK: (locate on site plan) 14WawiG�
Depth below grade: /aG
Material of construction: concrete A4 metal V.0 fiberglass 4JOpolyethylene "
,Ulother(explain) ,19A
If tank is metal list age:" is age confirmed by a Certificate of Compliance (yes or no):,VG3(attach a copy of
certificate)
v
Dimensions: �,rJ� y//d y"yo 6"17."44
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle: `.
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:
How were dimensions determined:
Comments(on pumping recommendations, in and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage, etc.):
Pump the septic tank annu l ar ._ M n1Pt R ontlPt t-Peq
are in nl are ThP tank i c etr1irt:livally sound are- shows no
evidence of leakage . Pumped tank at_.time--of—inspection Aeavy .scum
& solids 1 y rs. were esent./Garbage disposal is present . Z
GREASE TRAN t(locate on site plan
Depth below grade: 4/� r,
Material of construction;r/_concreteq/Ameta�? 4'fiiberglassrllolyethylene2G9other
(explain):
Dimensions:
Scum thickness: A1A
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: 4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not pr.Psestt
7
Page 8 of
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
#SYSTEM INFORMATION(continued)
Property Address:389 Bumps River Road
sterville .Mass . "
Owner: Ed Chandler
Date or Iospectioo: 8/16/02s
TIGHT or HOLDING TANYd4" (tarik must be pumped at time of inspection)(locate on site plan)
Depth below glade:
Material of construct concrete metal M fiberglass if/J? polyethylene,LG¢ other(explain):
AM
Dimensions APA
Capaciry: gallons
Desien Floe: IVA gallons/day'
Alarm present (yes or no):
Alarm level: A>A Alarrn in workin ;order or no es Date of last pumping:
A
Comments (condition of alarm and float switches, etc.):
Tight or holding tan s are . not present .
DISTRIBUTION BOX: present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any eviderce of
leakage into or out of box, etc.):
Distribution box has two laterals . No evidence of solids
carry over .No evidence of leakage into or out of the -Fox . .
PUMP CHAMBeRtb.(y,(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 chamber is not present . .
41
J ✓
8
Page 9 of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 389 Bumps River Road
stervil e ,Mass .
Owner:Ed Chandler
Date of Inspection: 8 16 02
SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan, excavation:not'required)
2-1000 gallon precast leaching pits . ( 6 'X9 ' )
If SAS not located explain why:
Located : See page 10
Ty✓F� /
eaching pits, number:
V40 leaching chambers, number: O
NO leaching galleries, number:
Na leaching trenches, number, length: O
VO leaching fields, number, dimensions:
;overflow cesspool, number: �--
innovative/alternative system Type/name of technology:�� Cid'°t,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
:tc.):
Loamy sand to medium fine sand . No signs of hydraulic
failure or ponding . Soi s are dry . Vegetation is norms aste
water #1 pit 36" below the invert . #2 pit 68 below the invert .
CESSPOOL$/(&!e,(cesspool must be pumped as part of inspect ion)(locate on site plan)
Nurnkr and configuration,
Depth — top of liquid to inlet invert:
Depth of solids layer.
Depth of scum laver
Dimensions of cesspool: AX
Materials of construction:
Indication of groundwater inflow(yes or no): _LQ
Comments.(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): ,
C_es_sp6ols are not present .
PRIVY2&�e(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.):
Privy is not present .
9
Page 10 of I 1
OFFICLA—L INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FOB
PART C
SYSTEM INFORMATION(conclnvcd)
Pfopern A60fC,, 389 Bumps River Road
stervi ,
Oxocr:Ed Chan er
DI1c of Inipc<Iioo:TT/-02
SKrTCH OF SEWACE DISPOSAL SYSTEM
Pio•ioc c iknch o(tha icwi<< oilpolcl IXII(m Inclvding.11ct to ai Icaal'nvo permancnl rc(crcncc IanSmux�.o
oc^cNnvki Loci( ill ..<Ili in;n 100 (cci. Logic what pvblic waicr jvpply cnlcrf Inc bviloin .
6
PZ
to
I
Page I l of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'(continued)
Property Address: 389 Bumps Ri-v'er Road r.
Osterville ,.Mass .
Owner:Ed Chandler
Date of Inspection: 8 16/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated ground to depth 'p gr water feet ,
Please indicate (check)all methods used to determine the,high ground water elevation:
N 0 Obtained from system design plans on record - If checked,date of design plan reviewed: N A
TE-S-Observed site (abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: NA
Y E,S Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: http : //town. :barnstable .ms . us .
You must describe how you established the higgh ground.water elevation:
USED : Gahrety & Miller MOdel . 12/16M Ground water elevations: 'above
sea level . '
USED: USGS : Observation well data . June 1992 .
USED : USGS:: Techn ' al ul e n92'-000-2 Plate #2 Annual ranges
61
ground aterrou elevations•. January 1992
Leaching -
i
Pit -
9V eet
�Jl�y4
Groundwater: Feet Below Bottom of Pit High
g Groundwater Adjustment 1.8 ft per;Fnmpter Method
Therefore, the vertical separation distance between the bottom�/ /
Of the leaching pit and the adjusted groundwater table is �7
feet.
11
r
`:••I'R.RI•`/�If l'T.'1"T�M1Tlf.-IT.'lM1T.TrJTTf.1S+T.T.T.:'.�Tf'1TT:TT!S>•TT TTT1T31'1YTIL.T.rl'R • .. .TTTTTT�T�'�..�." _...F
TOWN OFBarnstable BOARD OF HEALTH J
SOBSURFACF SFWAGF DISPOSAL SYSTEM INSPECTION FORM PART D .- CERTIFICATION
.•.•-••••1••••••M1��.ItT.'•.�T.T.11•R.'TTI 1"ZT�TTITST"1"Tf'T!.'1,"51'T^61M1'IT1Qf�T1'TC�'S4fii'ST•RiZrC'TCTf 7TII IfTiTITTrTiO�
-TYPE OR PRINT CLEARLY
PROPERTY INSPECTED
STREET ADDRESS 389 BUMPS RIVER ROAD OSteryillP , MnRg
ASSESSORS MAP', BLOCK AND PARCEL
OWNER' s NAME Ed Chandlet
PART U - CERTIFICATION r
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME Box 66 Centerville ,Masg'.02632
COMPANY ADDRESSJ. P.Macomber & Son Inc.
Street Town or City State I I P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the "sewage disposal 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
recommendations regarding upgrade , maintenance , and .repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems :
Check one ;
System PASSED
The inspection ;Yhich I have conducted has not found any information
which indicates that the 'system fails to adequately protect public
health or the environment as defined in 310 CMR 15, 303 . Any faililre
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this forgo-,
System FAILEDT
The inspection which I have con acted has found that the - system fails to
Protect the public- health and the environment" in accordance with Title
5 , 3.10 'CMR 15 . 303 , ., and as specifically noted on PART C - FAILURE
CRITERIA of, this. inspection form,
Inspector Signature f Date 4 r-1-11✓ate
copy of this certification must be provided to the OWNER, the IIUYER
One
where applicable ) and the BOARD OF HEALI'JI.
* If the inspection FAILED, the owner or"'o` erator shall u P pgrade ' the eyetem
within one ,ear of the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CHR 16 . 305 .
partd . doc
TO OFBA�RNST�►ABLE �
LOCATION ,F9 ���'4� SEWAGE # F—,-V O,R
VILLAGE ASSESSOR'S MAP & LOT- 3�
SEPTIC TANK CAPACITY
--LEACHING FACILITY: (type) � (size) Ar
NO. OF BEDROOMS
a-B :ER OR OWNER
PERMIT DATE: _0MPLIANCE 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 L.eachin Facility (If any wetlands exist
within 300 feet of c f Feet
Furnished
� ��,�.�s `�,v�.v c2�� , 6sf�� ►1�.
r.
a
J9
� Qr
I
TOWN OF BARNSTABLE
r� l
LOCATION >OO Q � UM95 ky< e"r9 SEWAGE # qT-Ise
VILLAGE Oe7-� (J►1 ASSESSOR'S MAP & LOTZZ
INSTALLER'S NAME & PHONE NO. �y�tC� C��l d5 n1-U rgC61I
SEPTIC TANK CAPACITY (�d C� �� b�l S
:o y
LEACHING FACILITY:(type)L"e^L�" y -I (size) I� 6L
NO. OF BEDROOMS_ -3 PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER V\ 0101" C�(
DATE PERMIT ISSUED: —I 'Zyl q 5-
DATE COMPLIANCE ISSUED: �
VARIANCE GRANTED: Yes No
r3
,s
v'
Rig+, i
I
MSEMRSMAPN
ma "
No .............._ FEE..............................
THE COONWE-ALTH OF M-ASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Alip iration for Diripniul Mnr1w Tomitrurtiurt runtit
Application is hereby made for a Permit to Construct ( ) or Repair X) an Individual Sewage Disposal
System at: ��
Q
%g q��`" s•Y'- r`�-•--`---°--------------•----------- -------------------------------•-----------•-------• --•-----------
Location-Address or Lot No.
ner C
Address
�,.��'k�� , ;Installer �"IG Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..-_--__-3____________________________..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons--------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures -------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow-------------------------------------,------gallons.
WSeptic Tank—Liquid capacityl,00---gallons Length---------------- Width________________ Diameter_..-----._..-_ Depth-----_-_---_-.--
x Disposal Trench—No. .....N.�.�. ........... Width_T._..._------___-_ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.- d 00 44_P�+ me ........... Depth below inlet.._..0........... Total leaching area__________________sq. ft.
c ....
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-----------_-- ---------------------------------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.----._-__._-_-__---...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.-.-_------..-_____- Depth to ground water........................
----
J_ C �------------------
--------------------------------------------------------------------------------------------------------------
0 Description of Soil..!ZlAr .
x
V .........................•-----••-----.....----------••---------•--•----------------------•--•---------•----------------------------••--------- -•---•----------------------•-------................
W
x .................... ----------------------------------------------------------------------------------------
U Nature e Iirs c�Alterations—Answer when applicable ^tiS 9 .lC'. .OX.__.aw:C�... ..........
...... -�-- � o ---------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp a e a n issu by the board of health.
gSi ned .._..... . --- u :....
Application.Approved B -------------- ---- ------------- �� F3�
Dace
Application.Disapproved for the following rearon.r: ..- - -- ---------------------------------------------------------------------------
-------------- ----- ------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- ---------------------------------------
Permit No. .... `�. ��- ------- Issued ..............�''-'--- ���� '
Dace
NO..... . r _ 4 _
THE COMMONWEALTH OF MASSACHUSETTS •
-BOARD OF HEALTH
TOWN OF. BARNSTABLE
_ AVVr iratiitn for Di-tipa ial Work.5 Toustrur iatt ratni#
Application is hereby made for a Permit to Construct ( ) or Repair i�) an Individual Sewage Disposal
System at:
........-----•.....----.._.__ ------•------•----, .......---- -----------......................................
10)SAtn 01^H ��, Location-Address _ or Lot No.
.................................................
-----------------------------------------------
S
Ius tat ler Address
Type of Building 3 Size Lot.................'.........Sq. feet
aDwelling—No. of Bedrooms_____________________________________._...Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building --------------_-------.------ No. of persons-_---..._-___--_____:_._._. Showers ( ) — Cafeteria ( )
p'I Other fixtures -=---
d ------------ --------------._.......---..._...---------•------••------------------------..
W Design Flow____________________________--------------__gallons per person per day. Total daily flow---.,_..____......._________--.-.__- -----gallons.
WSeptic Tank'—Liquid capacityl,00—_-gallons 'L'ength_____-..__.__-- Width---------------- Diameter-.._.____---_--- Depth................
x Disposal Trench—No _____________________Width.f____..._____._._. Total Length.___---_-_a----_-_ Total leaching area....................sq. ft.
Seepage Pit No..� 0004 DDiameter..._.//��._._.:__.__ Depth below inlet_____
a---• ICJ p (0.-.-.-...__ Total leaching area..................sq. ft. I
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------ ------------------------------------------------------------- Date........................................
Te5t Pit No. 1----------------minutes per inch Depth of Test Pit_--_-..---.____--_ Depth to ground 'Water.....................
fZo Test Pit No. 2................minutes per inch Depth of Test Pit-_------.--_-___-_- Depth to ground 'water........................
xDescription of Soil...! '� ----------------------------------------------------------------------------------------------------------------------------------
U ------------------•--------------•-----•-•---------------•------------------------------------•----.
----------•-••----•-----...----
W
U Nature ep irs q�p Alterations——Answer when applicable..TtiN i.�.9-..._�..�?0]C._._9!�_L�f...�
� .__-____-_��(
,�-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp 'an e ha e n issu by the board of health.
Z6
Signed /t; ZX ------
------ --- ----............:............. .- ..-
�e
Application.Approved By .... . .............. -------------------------
' Dare
Application Disapproved for the following reasons: ..------------------------- - ... -
......._...... .. . ............. .. .................. .. ....... ..... .. ...
Permit No. .1.4rZ ........ Issued .............. .-'. ? -.. �
Dare
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
TOWN OF BARNSTABLE
CITertifirate of Complianee
THISYS TO ERTIFY That the Indiv'd 1 �e_wra Dis al System constructed ( ) or Repaired ( )
b ..................nO. X 0A �' G f �� ._...... - ........ - -
Y 5... ...... :._E...
at ............. -W w±P `, d4 -
-------------- -----------------------------------------------------------------------------------------------------. -
has been installed in accordance with the provisions of TITLE of The S,tLtat�Environmental Code as described in
the application for Disposal Works Construction Permit No. J�.W. '` ../V....... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL FUNCTION SATISFACTORY. .
DATE - --- Z.� ............�.................
.........:................................__. Inspector ---- -- -------------- - - � f
THE COMMONWEALTH OF MASSACHUSETTS
I
BOARD OF HEALTH
TOWN OF BARNSTABLE
No........................ FEE........................
(.. .. L^� 1 _ jCoWV1
Permission is hereby granted-_ .. ..............................................
to Construct ( ) o Re air ()) an Individual ewage Disposal System
at No................ �5....�'4 4 d°l •------- ----------
PP P st / 1 �
as shown on the a lication for Dis osal ��orks Construction Pern�-- � Dated
2 ��✓ ,
••.......-•---- . ----- • -------• ....
Board of Health
DATE--- -------•---t-----•...............................................
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
No.... l/0------• Fua..../ ..............
THE COMMONWEALTH OF MASSACHUSETTS
n BOAR® OE HEALTH
V�� ........_... - ------.OF............Z.0 : r...........------- ..................
Apphration -for Dig giitt1 100rks Cnongtrurtion Vrrmil
Q� Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
O System at• _ 1
4� Pj
•------------------------- --- 1---- -- ------------------------------•--•----••---------------------•--••----••-•--••---
�. k,�cati Address 'or Lot No.
-----------------------------------• ...... � -...... ............................................
O er Addres ]��
Installer Address 9
Type of Building Size Lot.... . . Sq. feet
U
Dwellin (� ( )N ,o. of Bedrooms__._.___.._ �_______________________-__-Expansion Attic Garbage Grinder
p.., Other—Type of Building ._------------------------ No. of persons____-_-__. _--------•---. Showers ( ) —
Cafeteria ( )
a4 Other fixtures
W Design Flow...... :--------------------------------- gallons per person per day. Total daily flow--------------------------------------------gallons.
9 Septic T tnk�Ligtlid capacity_I-gallons Length---------------- Width-------.-------- Diameter---------------- Depth.__._-----..._..
xDisposal 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 "Pest Pit-------------------- Depth to ground water...-_--.._---.-.__.-_---
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.-_-_-.-_-------_-----
xDescription of Soil-------=,!�k `/--------------------------•---------•-•------------------.-------------
V .----------------------------------------•-•---••-••--•-•••-••-•-••----••-•--••--••------•------••-•-•••....----•-.......----------------------------------------------------..........................
W
-------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------.---
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agreesve ..
not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
v
t
Application Approved B A,--__X-r
PP PP Y �.2--7 -- 7X.. . .ate
Application Disapproved for the following reasons:......... .-----••-------------•-------•----------------------..----------------------•------••----••--
---...--•----•--•-•-•---••-------------------•--.•-----------.........----------•---•---------------•----.......--•-•-----------------------------------------•-••------------------------•-----•--•••-•-
Date
PermitNo......................................................... Issued...................... ------..........................
Date
No.._ --l.�i---•--• t Fs$ .............. ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE HEALTH
_OF............ �4!L�-Z�.., :.......................................
Application is hereby made for a FPermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: DD
-- ----••------•----------•-••-•-.._._..--•------------••---
riir Locaa -Address q 'o. Lot No.
'\ O er Addre
� !`t�!---------- __. �.�';��'1'/..._. fly` IU'f fiJ,�_ K �-•`. ...
. . -."�
Installer Address
Type of Build' Size Lot_._J-�_-----------------Sq. feet
Dwellin No. of Bedrooms_._._.....3---.__._---•________________Expansion Attic � Garbage Grinder ( )
Other—Type of Building ___------------------------- No: of persons............................ Showers ( — Cafeteria
dOther fixtures.------------------------------ --- �.
W Design Flow____ . .....................................gallons per person per day. Total daily flow.:..____.___._______..._..._..._._..........gallons.
a.
R; Septic Tan Liqui j�ttvjl�-gallons Length,---------------- Width---------------- Kimeter-----------..... Depth----------------
Disposal Trench I ___......`......__. Width-------------------- Total Length----- Total leaching area--------------------sq. ft.
l� Seepa�, _____________________ Diameter..................... Depth below inlet.................... Total leacliiltg<tre:t...__._.____._____sq. It.
z Other Distribution box ( ) Dosing tank ( )
'—' Percolation Test Results "rfornaed b !
--
W Y--••-----------------•-•••••-••---------------•---••-----•....------•••--- Date---------------------------- -•---- ...
P
.l Test Pit No. L4,f= ;;___namutes per inch Depth of Test Pit.................... Depth to ground water----------------------
44 Test Pit No. 2-__--:_•-._____minutes per inch Depth of Test Pit________________•__- Depth to ground water...----------_------
....
W ,. _ .
O t
Description of Soil-------.�9:�.�!:��---------------------------�_::':::.:-a:=-------------------------------------------------------.------------------------...---
U --------------•------------------------••------•••--•----------•----•-•---•---•---------=----••-...--••----------•-••------•-------•----•------•--•-•---•--•--------------••---•----.....-•----------.
W
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
-------------------------------------------------- ------•••......••--•--••-...--•-----------•---••----•-----.....-•-----------•••-----------------•- -----------------------------------------
Agreement: ,
The undersigned agrees`to install the aforedescribed Individual Sewage Disposal System in accordance with
.the provisions of.A`rticle XI 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 board of health.
Si �qL � .. ��
��I" Al ate
Application Approved By..•. �_ (� _ -------------------
Applicationw T00
. w --�--- -- '- ate - --- ....Di r v r th ll wi Sapp o ed f o e f o o ng reasons:........... .....V------------------------------------- ..... ..........................................
-""-"-•-"-••--•---..._...--•...............•------•------------........---•---•---••-•--•-----•----•----•---•---•---- ---•--------....--•--•-•---•-----•-----------•----•----.......-•--- ............
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"TUrtifiratr of 01,lampliattrr
IS IS-TO CERTIFY hat the Individdt Sewa e Disposal System constructed ( ) or Repaired ( )
. by--•-- = _ -
.....� �tl ....................................................
, � ,. '`
ate---- - ----tl±�./�•---��'-'�+1 ---------------------------------------
has been installed in accordance with the provisions of Article XI of T e State Sanitary Code as descri d in the
application for Disposal Works Construction Permit No--------- .: .._ ----_----- dated._z.... . _.;2�_ ...,1
J7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT E THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------------------ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH,E ,
Jj '...�' -----......
4- OF....
FEE- •...............
kii'( nn rtion Vrrmyt
Permissio is hereby granted�"_..
.- . ..E"- - r------- ll,u.
to Cons Wucy�,Repair ) an dividuAq Sewage p sal Syste
Street
as shown on the application for Disposal Works Construction Wit No Dated_.__/; .�`�'�' ' ......
oa
DATE -
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '
" S
i8 s lb 7-
8. 0
004,40
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0
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N �0o O` 8R8 .'
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CE. RT;I ,.FI -& D.. P :L OT PL• A N
L 0 C AT,1 0.N: OSTE.RV I LLE M"Ss —
S CA, L.E: � 30' D ATE;
R E F,E R,E N C'E �E1NS 1-.OT " � t SNov�tN_ ,
REGoP.OEO .'
OF OSEVS 'Aw PLAN BooK\"ass PRGt (c(o
D.A T S
HEREB.Y " C'ERT'IF.Y THAT THE BUILDING REG. U.ANO 5URVEY00
SHOWN O.N , THlS PL,AN : 1S LOC. ATE'D O.N �
T H E G R:O U N D- A S S- H O W N . H E-R E 0 N ; A N D
S>OES CONFORM TO THE
THAT 1 T','
ZONJNG... BY - LAWS. .0F THE .. T0WN OF
8PlRNST RBLfi w H E N C. O N S: T R U C T E D.
BA`RNSTAB:LE SURVEY C-ONSU .LTAVNTS9- INC .'
W EST 'Y A R�M O U T H,.M A S S