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HomeMy WebLinkAbout0051 DAVID STREET - Health 51 DAVID STREET, OSTERVILLE A= 141080 - - TOWN OF BARNSTABLE 9d S, r' SEWAGE VILILAGE �t/ b I ASSESSOR'S MAP & LOT D INSTALLER'S NAME&PHONE NO. I„P W //4"t► % c2 SEPTIC TANK CAPACITY lk` �� a Q a ' ij�;LEACHING FACILITY: type) /Irx/.a / (size) M , NO.OF BEDROOMS—0 �j ��BUILDER OR OWNER PERMITDATE:�— ' ®0 v COMPLIANCE DATE: o `� Separation Distance etween the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) _ _ Feet Furnished by t� A �C . ( x No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 3pprication for Mtoogal *pztem Cone;tructton Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. y� Owner's Name,Address and Tel.No. Assessor's Map/Parcel V 6- 1/,Y/_0 Q p-f� � � � Installer's Name,Address,and Tel.No. ��j Desig is Name,Address and Tel.No. r t3aj-fS- �1 Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank F_1Ct S.L /0_0-0 gPr 1. Type of S.A.S. Description of Soil f Nature of Re airs or Alterations(Answer when applicable) �� . ' s '- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss o ealtff. ae a Signed ®/�' Date Application Approved by Date-,:?,. --cj' •9 avg!� Application Disapproved for the ollow g reasons Permit No. ct401n, — t y.�_ Date Issued -- -------- — --- —————————————————— —————— TOWN OF BARNSTABLE LOCATION.�, lot,0 -_ lid S' SEWAGE 66o — / v VILLAGE // ASSESSOR'S MAP & LOT V INSTALLER'S NAME&PHONE NO. rM f, SEPTIC TANK CAPACITY lk`5 fin p Q a LEACHING FACILITY: (type size l�.�. ) (�Sfi►lc NO.OF BEDROOMS BUILDER OR OWNER ©00 o PERMTTDATE: -� � COMPLIANCE ATl~: i I. Separation Distance etween the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist I on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ jA a L . Fee—1 5 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppfication for Migaal *pgtem (fongtruction permit Application for a Permit to Construct( )Repair( -y)—Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot:No..SU Owner's Name,Address and Tel.No. ff6� 86( 111-44r5ar) Assessor'sMap/Parcel l��/'CJ F Installer's Name,Address,and Tel.No'. ,�p Desig er's Name,Address and Tel.No. A 6W --#I$ t 61- 5_':�Y Q�fiia„ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank F)CtS1 /0 a D 5G Type of S.A.S. Description of Soil 6 Nature of Repairs or Alterations(Answer when applicable) �- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been Is!md�xr �, oe_,9 ealtli. Signed Date '/ � Application Approved by Date -1' ,9pa,0 Application Disapproved for the ollowi g reasons Permit No. c�df .�� Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( graded( ) Abandoned( )by .� 2 4t 17�W e- at - `� d r61 71e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.JIQ22- 1 Y a dated Installer Designer ,,, R o The issuance of ' p t hall not be construed as a guarantee that the s st 11 funkio a ,/�e�signe, Date Inspector /I! ".1 t9 -- /—�------------------------------------ No. Fee 11-0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS liquar *pgtem Construction Vermit Permission is hereby granted to Co ct( )Repair 401 pgrade( )Abandon System located at 5 T 5 _66"4.1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by .� U TOWN OF BARNSTABLE Q ^ LOCATION SEWAGE VILLAGE / —+� ASSESSORS MAP 6z LOT/ INSTALLER'S NAME & PHONE NO. J ,p com e_ SEPTIC TANK CAPACITY ,UUG LEACHING FACILITY:(type) /� T (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER R BUILDER.OR.OWNER DATE PERMIT ISSUED: Ll' h� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No _ I �z9 ,z ti 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 'l f hereby certify that the application for disposal works construction permit signed by me dated ` U concerning the property located at meets all of the following criteria: J ��� • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) D B) G.W.Elevation +the MAX.High G.W.Adjustment=_ DIFFERENCE BETWEEN A and B SIGNED DATE: ®moo [Please etch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert • i �: s o � � �; �� G� .;�. � �, � 7 � ��l �� � �!� t� ' �� "� �=� �. � I �� Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 (508)564-6813 WILLIAM F.WELD Governor " ARG EO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �R " 1 � o8 Ig 51 David St.Osterville �� ��� d ress of Owner: Property Address: (If different) Date of Inspection: 417198 McDonald Name of Inspector: John Graci I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X_ Passes This Inspection is based on criteria defined In Title V code 310 CMR 16303.My findings are of how the system is _ Conditionall Passes performing atthe time ofthe Inspection.My Inspection does Needs Fur lieer aluation By the Local Approving Authority not Imply anywarrantyor guarantee ofthe longevity ofthe septic system and any of Ito components useful life. — Fails Inspector's Signature: Date: 418198 The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: AJ SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR'15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection'If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127S7) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: 51 David St Ostervllle Owner: McDonald Date of Inspectlon:417198 _ Sewage backup Or.hreakout.or. hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: " broken pipets)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: , Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND, SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersuppiy well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. -- The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid)' 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No".as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage in facility or system component due to an 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 cioggfl cesspool. SAS is in hydraulic failure. a - , (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 David SL Osterville Owner: McDonald Date of Inspection:VMS D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: a Yes No ` the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) 4 The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the,Department for further information. (revlaed04127l971 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property ert Address: 51 David SC Osterville III Owner: McDonald Date of Inspection:417198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with NIA. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. F x — Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is - unacceptable)[15.302(3)(b)) r ' (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51 David st osterville Owner: McDonald Date of Inspection:417199 FLOW CONDITIONS RESIDENTIAL: d/bedroom for S.A.S. Design flow: sM g'p' ' Number of bedrooms: 9 Number of current residents: D Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): n1a Sump Pump(yes or no): No Last date of occupancy: od1997 CO MM CIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: We Last date of occupancy: nta , OTHER:(Describe) is Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rVa System pumped as part of inspection:(yes or no)No If yes,volume pumped:D gallons Reason for pumping: rva TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool w Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: New System Installed In 1990 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 David St.Osterville „ Owner: McDonald Date of Inspection:417198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material Hof construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age Na . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H5.7"w4y10" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness: Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: Measured - Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) w Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. ` GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain} , Dimensions: nra Scum thickness:rVa Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle:rda Date of last pumping;,, Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2' Material of construction:_cast iron X 40'PVC_other(explain) Distance from private water supply well or suction line?own Diameter: ,,,_ t rv,Imments: (conditions of joints,venting,evidence of leakage, etc.) (revlsed 04127W) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 David SL Ostervllle Owner: McDonald Date of Inspection:417J98 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Capacity: nla gallons Design flow: rda allons/day Alarm level:_pja Alarm in working order?_Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) . Na I (mlaedOd1 POT) SUBS URFACE CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 David SL Osterville , Owner: McDonald Date of Inspection:anrgs SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by-non-intrusive methods) If not determined to be present,explain: nfa Type: leaching pits,number: 1000 gallon leach pit leaching chambers, number:Na leaching galleries,number: rda leaching trenches,number,length: rda leaching fields,number,dimensions:rda overflow cesspool,number:we Alternate system: nla Name of Technology:_nra Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Leach pK and all components are structurally sound and functioning property.system never had more than T of water In @.R was empty at the time of the Inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: r4a - Depth of solids layer: n!a Depth of scum layer: ria Dimensions of cesspool: nla Materials of construction: Ilia Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) nfa Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) roa PRIVY:_ (locate on site plan) Materials of construction: rtla - Dimensions: na Depth of solids: nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n/a (revised 04127197), i SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r 51 David St.Osterville McDonald W198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) C � _ Rc 6A ?q Page ! of 10 .(revleed04171197) , F � , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 51 David St.Osterville McDonald 417198 ' Depth of groundwater 12+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts I (revlsed04W19T) ?age 10 at 10 TOWN OF BARNSTABLE Q , LOCATION ;'/ �Gr��`� ,ST SEWAGE VILLAGE ASSESSOR'S MAP 6z LOT/#./ �Q INSTALLER'S NAME & PHONE NO. ;� CC7h'11Jr t�S�►1n�_ SEPTIC TANK CAPACITY ),000 (' LEACHING FACILITY:(type) /� (size) G 'NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �" ' 18^"1 o DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N® fI i i i \ �ae� 1 / r� i� e } LORV �y $ 30.00 No.....G9:�.�. Fes$.......... - ..._....._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratinn for Disposal Works Tonstrnrtion Va.utit Application is hereby made for a Permit to Construct ( ) or Repair P) an Individual Sewage Disposal System at: QcDonald 1 david Street Osterville .............__ ..__...--•--......_.._... ....------------------------------------- ...-----------------•............................................................................. Location.Addr.ess or Lot No. Owner Address W J.P.Macomber Jr. ---- -------- ... Installer Address dType of Buildin Size Lot............................Sq. feet U Dwelling-!No. of Bedrooms..............2..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures ............................ . .. W Design Flow...........................................Tgallons per person,per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft. . Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date...............:........................ ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--------------------------------------------------•---• -------------------------------•-------- •-------- •------ ------------------------------- 0 Description of Soil........................................................................................................................................................................ x ------------------------------------------------•-----------------------------------------------------------------------------------------------....................................................... U Nature of Repairs or Alterations— s en a cable. ............ - �00 g on tank I=IDIIO..-gallon p1t ----------------------------••---•------------------•---•---......-----•--------.............-----------------------------------------------------------------------------------....------------. Agreement: The undersigned agrees to.install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code The undersigned further agrees not to place the system in operation until a Certificate of Complia e has been ' sue by the board of health. Signed .. -.. -.lG!<- i 4/17/9.0----------- te Application Approved By .......--- r. ..-� ! . . .7.--.-. d------ D to Application Disapproved for the following reasons: ......... ..................................-------------------------------------------------- -------------- ---------------- -------------------------- --....................... ------------------ --------_----- ........... -. ----------------- ------------------------------------------------------------------......................... --- .---------..._---------------------- Permit No. .. Issued Date ------------ Date o No... Fms......$....- 0.00 _ THE COMMONWEALTH OF MASSACHUSETTS /� BOARD OF HEALTH _-�J' TOWN OF BARNSTABLE Appiiration for Disposal Works Tonotrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair (KX) an Individual Sewage Disposal System at: ..... 51......D.avid Street Osterville . . .... __......_ -._......_...-•----•----••---•----------------------------------• -•-.. . ...... ... ..........._._._.... -- • -- Location-Address or Lot No. McDonald ....--•--•--••---------------•----.......................•--•-•--•--•-- ••....••••............•••-•--•-••••.........-----••--•-•---••-•-•--•-••-•--•-••---..............-- Owner Address -r 7-� 7�� y, M -r W tl .P.MaooMhe_,r..cA .e.................".'....__..._. ............................ .................................................................................................. Installer Address dType of Building Size Lot----------------------------Sq. feet Dwelling X No. of Bedrooms............2.............................Expansion Attic ( ) Garbage Grinder ( .) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a --------------------------------•--- d Desi n Flow fixtures -------•---�--•-gallons per person per day. Total •- W g g P P P Y daily flow............................................ .W Septic Tank—Liquid capacity............gallons Length---!............ Width................ Diameter................ Depth.............. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �l Percolation Test Results Performed by.......................................................................... Date...................-....... -------------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..--.......--.--........ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................- 0 Description of Soil........................................................................................................................................................................ W Sand & Gravel x --------------------------------------------------------------•------------------..........._. ----•------------.1---------------------------•-••••--•-••-•----•-----•--•------•---••-•••-••--•----- V Nature of Repairs or Alterations—Answer when ap licable...................................................................................•............ --------••--------------------------•-------------•--------------1-1000- alon tank---1-1�00__ allon. pit ........................................................................................................................................................................................................ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the board of health. Signe r.Ae� �../ ..T..1.. ............ / 1 Dm Application Approved BY ----...----� '� ^J.-.. '...` �- -- --...... ------ Date Application Disapproved for the following reasons- ---------------------------------------------------------------------- ............................................................ . . . --------- -----------------------------------------------------•------------------------------.....----- // Da[e i PermitNo. ��-- /...89- '`.................. Issued ......................................................---....------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifirate of (�omylinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( XX) . by-- . ............................................................. ----- ....----- -------- Inmk, at .......51m.-P'I d....Stx'eey....Qate.x�.v..i.��e------------------------------------------- ----------------------------------------- ............---................................ has been installed in accordance with the provisions of TITLE 5 of The State Environmental 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�ILL FUN CT N SATISFACTORY. DATE................ ( ........................------...........------........---............--------.. Inspector - -----........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / F BARNSTABLE No..�n..`..�!..��. TOWN O FEE..t Qrl...!?n... Raposal �Works Tunstrnrtion rrrmit Permission is hereby granted...)J.t acombex•.Jx'.-............. .....•-- to Construct'( ) or Repair (KX) an Individual Sewage Disposal System at No...51--Uag d.-Su et Ostexvi�.le..........--••-•--•............................................................................................... ....... Street as shown on the application for Disposal Works Construction Permit No-_1_4-9P- Dated.......................................... ............................� ,_ .. _ C-/ - 17-�� ..................... ........ Board of Health DATE----•--.....-•---••-- FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS