HomeMy WebLinkAbout0005 DEERFIELD ROAD - Healthr5 DEERFIELD ROAD, OSTERVILLE
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TOWN OF ARNS•TABLE
LOCATION SEWAGE
VILLAGE �yJASSESSOR'S MAP & LOT
(NAME&PHONE NO.
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS �—�-'
BUILDER OR OWNER q,
ATE: � � ATE:
Separation Distance Between 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 Facili (If any wetlands exist
within 300 fee of leaching ci ' Feet
Furnished
q
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0 6'
TOWN OF BAR STABLE
LOCATION SEWAGE #
VI LAG ASS R'S MAP & LOT
INSTALLER'S NAME & PHONE NO. ✓
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL ORp TF'R y
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COZIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)292-5500
R�cE�VED TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor 2 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INS TIRM 2000
OF
PART A 8
HF g
g cEaTuacanoN RNS
Goering AlT TA
8 H c DFpT t=
5 Deerfield Road -
Pfop"Address: Osterville, MA 02655 Name of Owneriq' C-�exw��
Address of Owner:
Dace of Inspection: 12-09-99 _
Name of Inspector:(Please Print)Frio A 1.enarcl cm /V 6 ,
��^�
1 am a DEP approved s pit pu�anc to Simon 15.340 of Title 5(310 CMR 15.000)Company ✓
Nam_ JT1Le��'VIQ@ v1i1 r01)mensf
Maamg address: 5062. Greene. RI 02827
Telephone Number: 401 3926906
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:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ [Fails
Inspector's Signature: ('itir. Date: )Z 9
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the 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.
NOTES AND COMMENTS
i
revised 9/2/98 Pagel of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Goering
property Address: 5 Deerfield Road
Owner: Osterville, .MA 02655
Darts at Inspection: 12-09-99
INSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
Any failure
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.
criteria not evaluated are indicated below.
MMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined tY.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 lettachad)indicating that the tank was installed within twenty 120)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 complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipets)are replaced ,
obstruction is removed
distribution box is levelled or replaced
_ - The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
{
revised 9/2/98 Page 2of11
. � �
< "'a 4
g � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
X PART
Goenbg ' CERTIFICATION lcontinued)
14, w
° S Deerfield Road
PiropertyAddress ems: ?s�� f
owner, Oste1 ui11e 'Ml,0265 S
Date ot:Inspacf on�k2 M9 99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conons east which regwre 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.
A
1) SYSTEM WILL PASS�UNLESS BOARD.OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(7)(b)THAT THE SYSTEM
IS NOT FUNCTIONING N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within50 feet of surface water
Cesspool or:pnvy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Y
21 SYSTEM VALL FAIL UNLESS THE BOARD OF HEALTH LAND PUBLIC WATER SUPPUER.IF ANY)DETERMINES THAT THE SYSTEM is
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
— tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone i of a public water supply well,
The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than,5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
' J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Goering
5 Deerfield Road
Property address:
Owner. Osterville, MA 02655
Data of Inspection: 12-09-99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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 into facility-or system componentdue-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 clogged SAS or
cesspool
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).
Number 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 I of a public well.
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. 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" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ortl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
ti
Goering
ProI"t'Address: 5 Deerfield Road
Owner:
Date of Inspection: Osterville, MA 02655
12-09-99
Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following:
Yes No
— Pumping information was provided by the owner,occupant,or Board of Health.
None of the system components have been pumpedLfor-at,least two weeks and-the
— system has daaen•receiving wornral flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
— As built plans have been obtained and examined. Note if they are not available with N/A.
— The facility or dwelling was inspected for signs of sewage back-up.
— The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
— All system components,excluding the Soil Absorption System,have been located on the site.
— 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.
The size and location of the Soil Absorption System on-the site has been determined based on:
— Existing information. For example,Plan at B.O.H.
— Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
- — The facility owner(and occupants,if different from.owner)were provided.with information on the proper.maintenauca of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Goering SYSTEM INFORMATION
Property Address: 5 Deerfield Road
Owner: Osterville, MA 02655
Date of Inspection: 12-09-99
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0 g.p.d./bedroom.
Number of bedrooms(design).-:A- Number of bedrooms(actual):
Total DESIGN flow 3.30
Number of current residents:-
Garbage grinder(yes or no):N26 /�
Laundry(separate system) (yes or no):W o If yes,separate inspection-required
Laundry system inspected
Seasonal use(yes or no):�IO
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no):,W
Last date of occupancy:Cjfr'e;'
COMMERCIAL/INDUSTRIAL-
Type of establishment:
Design flow: qpd (Based on 15.203)
Basis of design flow
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)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection:(yes or nouhlo
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) Of yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank `Copy of DEP Approval
Other .3 CW�wl rL-S
APPROXIMATE AGE of all components,date installediif known)and source of•inforrnation: - C�_2s-`�- lawns CA^ '
Sewage odors detected when arriving at the site:(yes or no)
revised_ 9/,2/98 Page6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prey Address: Goering
Owner: 5 Deerfield Road
Date of Inspection: Osterville, MA 02655
BUILDING SEWER: 12-09-99
(Locate on site plan)
Depth below grade-3--
Material of construction:_cast iron ` 0 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,-etc.)
c
SEPTIC TANK-',
(locate on site plan)
(I
Depth below gradeX0
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is-age-confirmed by Certificate of Compliance_(Yes/No)
Dimensions: to y- 5-X
Sludge depth:- i I
Distance from top of sludge to bottom of outlet tee or baffle: 33 -"
Scum thickness:_ ii
Distance from top of scum to top of outlet tee or baffle: (0 �/i
Distance from bottom of scum to bottom f o�et t e or baffle:_
How dimensions were determined: A1,10 t
Comments:
(recommendation for pumping,conqmgn of tjWet and outlet tees or baffles,depth of liquid level' !elation to outlet in rt,structure(integrity,
evidence of leakage,etc.) s �rt C� ir^ � 1 01" tcv`
--tv'% S c) cR S $�,
GREASE TRAP: '
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Goering SYSTEM INFORMATION(continued)
5 Deerfield Road
Owner: Ads' Osterville, MA 02655
Dave of Inspection: 12-09-99
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX-
(
locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equ 1,evidence of solids carryover,evidenc$of leakage into or out of box, etc.) -
r` r" cA. c,-� v o iL
PUMP CHAMBER:
(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.)
revised 9/2/98 Page 8.ofII
a '
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
Goering SYSTEM INFORMATI6N(coritinued)
5 Deerfield Road
Property Address:
Owrrer: Osterville, MA 02655
Daft of Inspection: 12-09-99
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible;exca ation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type.
leaching pits,number:_ `
leaching chambers,number_3
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology: ,
Comments:
ote condition ofril,signs of hydraulic f ilureyy level of pon g, damp soil,condition of vegetatio , etc.)
1ti '"'C — slat.
Alt-
CESSPOOLS:_
(locate on site plan)
Number and configuration:
—... Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY'_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 Page 9of11
e
"`4SUBSURFACESEINAGE°DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-'INFORMATION (continued)
Goering
Property Address: 5 Deerfield Road
Owner: Osterville, MA 02655
Date of Inspection: 12-09-99
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)
Ju
15
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7
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Goering SYSTEM INFORMATION(continued)
Property address: 5 Deerfield Road
Owner: Osterville MA 02655
Dateaf of Inspection:
12-09-99
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater L Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
cam: A, C' -K
revised 9/2/98 Page 11of11
Y TOWN OF BARNSTABLE
LOCATION ,)rt C' Field SEWAGE # "" r
VILLAGEn,L/vine ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. Yhacwhe 5.7 17ftc.
SEPTIC TANK CAPACITY I n2o
LEACHING FACILITY: (type) 3'" eci�.ar,�er5 (size) 530
NO.OF BEDROOMS_
BUILDER OR OWN,E,R� q &=��
PERMTTDATE: � COMPLIANCE DATE: �`'' "' en
�a
Separation Distance Between 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
s��Furnished by #
1
/ 0vi
�oC)
No. K 0 Fee $ 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Migogal *pgtem Cougtructiou Permit
Application is hereby made for a Permit to Construct( )or RepairNXX)an On-site Sewage Disposal System at: !
Location Address or Lot No. Owner's Name,Address and Tel.No. 428-940 5
5 Deerfield Road Joseph Pattison
Osterville Mass. 02655 5 Deerfield Road Osterville M
Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No. 508-775-3338
J.P.Macomber Jr. J.P.Macomber & Son Inc.
Box 66 Centerville Mass . 02632 B
Type of Building:
Dwelling XX No.of Bedrooms 3 Garbage Grinder( )
Other Type of Building No.of Persons 2 Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3x 1 1 0= 33 0 gallons.
Plan Date K / 4/96 Number of sheets Revision Date
Title
Description of Soil L.... sand tc) medl:ttm fine sand.
Nature of Repairs or Alterations(Answer when applicable) Omit cesspools, Install 1-1 5 0 0
gallon tank;1-Distribution box; 3-330 rechargers packed in 3 ' of stone
with a pea stone cap.
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 issue y this Bo o ea t
Signed Date 5/24/9 6
Application Approved by Y
Application Disapproved for the following reasons
Permit No. CL �/ Date Issued 2
No. L +t Fee $ 40.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Migaar *pgtem Cow5truction Oermit`
Application is hereby made for a Permit to Construct( )or Repairx(XX)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No. 2 S-9 405
5 Deerfield Road Joseph Pattison
Osterville,Mass. 02655 5 Deerfield Road Osterville MA
Installer's Name,Address,and Tel.No. 5 0 g—'7 7 5—33 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber Jr. �J.P.Macomber. & Son Inc.
Box 66 Centerville Mass,.. O26 2 ox 66 Gentervillei .Mass . 02632
Type of Building:
1
Dwelling XX No.of Bedrooms Gatbage Grinder( 2)
Other Type of Building NA of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 55 gallons per day. Calculated daily now 3x11 0= 330 gallons.
Plan Date K /24/96 Number,of sheets Revision Date
Title
Description of Soil eamy 58
i N
Nature c t.Repairs or Alterations(Answer when applicable) Omit cesspools. Install 1-1 5 0 0
gallon tank;1-Distribution box; 3-330 rechar eg rs ;packed in 3" of stone
with a pea stone cap. ti
Date last inspected:
r '
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 issue y this Bo go eat
tr Signed Date5/24/96
Application Approved by
Applicationi Disapproved for the following reasons
t R:
eD
Permit No. `J[ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(xx)on
by J.P.Macomber Jr. for Joseph Pattison
as 5 Deerfield Road Ostervilln .Ms.ss. has been constructed in accordance
with the provisions of Title 5 and the for Disposal.System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth low:
---------------_------------ ----- ---
No. 1 Fee $ 40-00
THE COMMONWEALTH OF MASSACHUSETTS
r PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Xh5pont *pgtem Cott.9truction Permit
Permission is hereby granted to J•P.Macomber JR. `
to construct( )repair.ft j�an On-site Sewage System located at 5 Deerfield Roaa Osterville
Mass .
f 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.
All construction must be ompleted within two years of the date below.
Date: Approved by
3-330 Rechargers 21 invert. 1-Distribution bim, 1-1500
Gallon tank.
f y
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, J.P.MAeomber Jr. , hereby certify that the application for disposal works
construction permit signed by me dated 5/24/96 , concerning the
priperty located At 5 Deerfield Road Osterville,MA meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is .4 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED DATE: 5/_4196
LI 1ED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
DATE: 5/7/96
PROPERTY ADDRESS: 5 Deerfield Road
Osterville ,Mass. MqY rf�
02655 1 1
co
On the above date, 1 Inspected the septic system at the aboveWadclr 6. .
This system consists of. the following: ¢; '
1 . 2-61x81 block cesspools . -
2. . 1-1000 gallon leaching pit. ASSESSORS MApN(��
O
PARCEL N - �� Ls
Based bn my Ing:wctlon, I certify the following conditions:
1 . This is not a title' five septic system.
2. This. is a sewage system.
3. The system is in proper working order at the present time but
has to be failed because the leaching pit is on the neighbors
. 4., property.
Borad Of Heal th requires that a title
five be installed. SIGNATURE:
Name:_J_P _M_acomber Jr_.___ __ __ i
Company:J- P_Macomber &— Son-_Inc .
Address - Be-x-.66-------I-------
y
Cente!rvi11,eLMass__02632 ,.
kl
Phone:---548.- 7-7-5-3338-------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
. Pumpsd & Installed
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
775-3338 775-6412
. V
114,Z)
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
• Environmental Protection
William F.Weld Trudy Coxe
oovwmw 8—"7
Arg"Paul Uluccl David B.Struhs
tt Gcwmw C4mm4•1WMr
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION
Property Adel 5 Deerfield Road Osterville ,Mass AddreasofOwner.
Date of Inspection 5/7/9 6 i (If different)
Name oflnspector.. Joseph P. Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632 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 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:
_ Passes
_ Conditionally Passes
Further Evaluation By the Local Approving Authority
Ins toes si lure: %" Date:
P� ll� �������
The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the 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:
AI SYSTEM PASSES:
A,)LL I have not found any information which indicates that the system violates any of the failure criteria as derived in 310 CUR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
ID 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) .
4,VilT5 The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or enfiltration,-or tank h1lurs 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 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)55&1049 a Telephone(617)292.SM
i�Prim ytk Primed on Recd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddreaw 5 Deerfield Road Osterville ,Mass .
Owner. Joseph Paterson
Date of Inspection: 5/7/9 6
B)SYSTEM CONDITIONALLY PASSES (continued)
AbWSewage backup or breakout or huh static water level observed in the distrss moon box is due to on if(with approval of the Boar or obstructedd s f(a)
l or due to a broken, settled or uneven distribution box. The system will pass Peet
Health):
broken pipe(s)are replaced -
obstruction is removed
distribution box is levelled 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 pipe(s) are replaced
obstruction is removed
Cl 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.
F HEALTH EM IS NOT
1) SYSTEM WILL. ASS UNLESS P BOARECT D 0 PUBLIC HEALTH AND D SAFETY AND THE EINES THAT THE NVIRONMENT.
CTIONING IN A
ENVIRONMENT`•
HANDIER WHICH
�0 Cesspool or privy is within 50 feet of a surface water
',[d ss
Cepool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
TH
D PUBLIC
2) SYSTEM WILL FAIL UNLESS THE DETERMINES
THAT HESYSTEM BIS FUNCTION OF EING N(ApMANNER THATROTECT THE PUBLIC HEALTH AND
SUPPLIER, IF APPROPRIATE)
DETERM
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply 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 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
S) OTHER
rr .
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontlnuod)
PropartyAddrou: 5 Deerfield Road Osterville ,Mass . 02655
Ownor. Joseph Paterson .
Date of Inspootionr 5/7/96
D) SYSTEM FAILS& ' I
I haw datarmirwd that the system violates one or more of the following failure criteria as delSrud in 310 CUR 16.303. The bails for
this datarmlaation is idantIrwd below. Tha Board of Health should be oontactod to datormins what will be necasse.q to corroct the .
fhilura.
Backup of sewage Into facility or system component duo to an ovarloadad or dogged SAS or eosspool.
�J DIscharge or poading of eMuent to the eurfaoe of the Eround or surfaco watars due to an ovorloadad or clogged SAS or
cos,pooL •
e- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or can pwL
40 Liquid depth is ceeepool t leas than 6'below invert or available volume is less than 1/2 day flow.
Roqulrod pumping more tl=< tunes in the last you NOT duo to dogged or obstructed pipo(s).
Number of time.$pumpod
d&► Any portion of the Soil Absorption System, cesspool or privy t below the high groundwater elevation.
Any portion of a cos.+pool or privy is within 100 foot of a surface water supply or tributary to a surface water supply.
Any portion of a coupool or privy is within a Zone I of a public well.
Amy portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is lass than 100 foet but greater than 60 feet from a private water supply well with no
acceptabla water quality analyst. If the well has boon analyzod to be acceptable,attach copy of well water aaalysls for
coliform bacteria,volatile orl,anle compounds, ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to largv systems in addition to tho criteria above:
AL The system servos a facility with a do.rign flow of 10,000 gpd or groawr(Large System) and the system is a slgniUaat throat to public
health and safety and ths'snvironment bocauee one or more of the following conditions exist:
the ryetez is within 400 fast of a surface drinking water supply
the rystsm is within 200 fast of a tributary to a surface drinking water supply
the rystom is located in a nitrogen s4neitive area (Interim Wellhead Protoction Aroa(IWPA)or a mappod Zone II of a public
water supply well)
The owner or operator of LAYsuch system sha.l bring the system and facllity Into f1r11 com pliana with the prvundwatu treatment prop=
roqulrement, of 314 CMR 6.00 and 6.00. Plaa:9 corwult the local regional office of the Department for!hither information.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5--Deerfield Road Osterville,Mass. 02655
Owner. Joseph Paterson.
Date of Inspection: 5/7/9 6
Check if the following have been done:
,Pumping information was requested of the owner,occupant,and Board of Health.
,None of the system compone4ts have been pumped for at least two weeks and the system has been receiving normal flow sates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
,L/As built plans have been obtained and examined. Note if they are not available with NIA
zThe facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
Z7�hs site was inspected for signs of breakout.
YAll system oompoaents,.Wcluding the Soil Absorption System,have been located on the site.
yp,�The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baMes or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum
-/The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
Zfacility owner(and oocupants,if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
1 . The system has ben failed for one reason. only.
The leaching pit is on the neighbors yard.
(revised 11/03/95) 4
suBsURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddreaa: 5 Deerfield Road Osterville,Mass . 02655
Owner Joseph Paterson
Date of Inspootion: 5/7/9 6
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ns pf%�� 0 •
Number of bedrooms:1
Number of current residents:
Garbage grinder(Yes or no):y6p
Laundry connected to system(Yes or no):Y�.s
Seasonal use(yes or no):—A ' �/ � '� ,�i11 S e✓
Water meter readings, if available:
r
Last date of occupancy:
COMMERCIAL/INDUSTRIAL•
Type of establishment: l/9 —
Design flow:_424__gallons/day
Grease trap present: (yes or no)A&
Industrial Waste Holding Tank present: (yes or no)AIA
Non-sanitary waste discharged to the Title 5 system: (yes or no)/!
Water meter readings, if available:
Last date of occupancy: !
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING ORD d source of information:
system pumped as part of inspection: (yes or no)
If yes,volume pumped: ons
Reason for pumping: t0 �(1/J
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool 3�_� � /� �r �iiD!/��P 1��ost/•
Overflow cesspool �h /=/bOUIJ/� dA'J .tA: Gv
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
ROXI TE AGE of all ponenw, date installed(if known) and source of information: �� 'alye/ r� � dld, o'P "O&IAW"
Sewage odors detected when arriving at the site: (yea or no)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 Deerfield Road Osterville ,Mass . 02655
Owner. Joseph Paterson
Date of Inspection:5/7/9 6
SEPTIQ TAm-AZ6 e— •
(locate on site plan)
Depth below grada:,A)/¢'
Material of construction A//�concrete metal FRP other(ezplain)
Dimensions: APt
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: A/A-
Distance from top of scum to top of outlet tee or baffle: AIA
Distance from bottom of scum to bottom of outlet tee or baffle: It
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baf les,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)'
,11v
GREASE TRAP:_&/4,,VC-
(locate on site plan)
Depth below grade: -V*
Material of coaetruction��concrete_metal_FRP_other(e:plain)
A
Dimensions: AIA
Scum thiclmew:N_
Distance from top of scum to top of outlet tee or baffle: AM
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
ev!4nce 91 leakage,etc.)
Nc Go.t2H',re� S.
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
P,oP.,typdd,.,s; 5 Deerfield Road Osterville,Mass . 02655
Owner. Joseph Paterson
Date of Inspection: 5/7/9 6
TIGHT OR HOLDING TAM-,&Aver
(locate an rite plan)
Depth below grade:—&&
Material of const:uction//Oooncrete_metal_FRP—other(explain)
AJ
Dimensions: AA
Capacity: Ally gallons
Design flow & pllonsiday
Alarm level:_._
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
DISTRIBUTION BOMA20N,
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note/ level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBFILAAWC
(locate on site plan)
Pumps in working order:(yes or no)AO
Comments:
(n� �� Tcbamber,'condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE LISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOWN ATION (oontinuod)
PropertyAddresa: 5 Deerfield Road Osterville ,Mass . 02655
Owner. Joseph Paterson
Date of Inspoot4on:5/7/96
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not rvqutrvd, but nuty tie approximated by non-intrusive methods)
11 not determined to be present, explaui.
Type:
leaching pits, number::
leaching chambers, number;�
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: __
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic faiiurv, level of ponding, condition of vegetation etc.)
Sand & gravel to fine sand;No signs of hydraill i n fai Biro or- „ending_
All vegetation is normal T,Panh pit on nip-"Unrg property System
must be upgraded to a title five septIC s3rsteM
CESSPOOLS:k
(locate on site plan)
Number and configuration:V
Depth-top of liquid to inlet invert:_
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspogj,
Materials of construction: n ^BTU 1h �_
Indication of groundwater: />Od�
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
SAmP a G shave
PR.IVY:4406
(locate on site plan)
Materials of construction: Dimensions: ,oW
Depth of solids: A, `O
Commen (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
aw
(revised 11/03/95) b
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddresa: 5 Deerfield Road Osterville ,Mass . 02655
Owner. Joseph Paterson.
Date of Inspection: 5/7/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM: •
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Centerville Osterville Marstons Mills
Water Company
428-6691
G cc T�
DEPTH To GROUNDWATER
Depth to groundwater. 2 0 I +feet
method of determination or a prouimation: New leaching pit installed in 1982. No water
encountered at 121 On nie at the Barnstable oar Health
(revised 11/03/95) 9
W �
v
i
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 221A of the
General Laws. Issued by The Department of Environmental Protection.
I
June 8, 1995
Acting Director of the ion of Water Pollution Control
r.-rrrr.+•t=-.•rr'+--�:rr.•ri-r_-rr..r...r..r.:- -rsr:. r_=-...cnr- ._ .._�. _.. .�... �. _ ._.. .rT•r,-r-r.-r-...- ..-
TOWN OF 'Ramms . bl e BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
• `� �•••T:•:�1•••.•; -�.tt.:••,�-nrr.:n•r.:rrs�s.TT.tr.TrlTr1'e-:r^.:rZTrlar•-t�'Ar.*.:re 's9 istr.nT*srrnrRv�TTTrrr•T..t.:rt-r•ir--rr
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 5 Deerfield Road Osterville,Mass 02655
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Joseph Pa *gI son
PART' D - CERTIFICATION r
NAME OF INSPECTOR Joseph P. Macomber Jr
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 775 3338 FAX ( 508 ) 790 1578
r.._ers�aa�rcres-es�-�•�a --
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
complete as of the time ofjinspection . 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 .
• u i I l i+ 1,
Check one:
Systeui 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 environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
XXXXXXXXSystem FAILED#
The inspection w}lich I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 3.10 CMR 15 . 303 , and' as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector 8ig t All J11 Date 5/1'7/96
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF HEALTII.
* If the inspection FAILED, the owner or operator shall upgra►de ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 , 305 .
No...79".1-••-•--- Flms..S.L.D.0.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town Barnstable
I� ------------------- -- ----------- OF...........................-...........------------- .... ---------.-.
Appliration for Disposal Works Tonstrurtion runtit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
�' Syst Vie) I
Dee Dr. Osterville Ma
................_.......�...�.�. . . .r •---------'....---................. --------------
•--------------------------- ...--....----.......- ------....
Ralph G. LaFren°ftereddress Deerwood Dr. , (S§fie'Pville, Ma.
__......._.....................•--•----------------------...........----- -----------•--••---•-•--------......._..................----------- ....---.........----
a A & B Cesspool Se°fV1ce 128 Bishops Ter�96s6, Hyannis, Ma.
.......-• ........................... ........
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.........3................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.........2................. Showers ( ) — Cafeteria ( )
� Other fixtures --------•--•-------------------•-•--------------•-•---.----•-•---------------•--•--------------------------..........-----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench_No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet..............._.... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by -----------------------------••-•--•-------••-----------••---------. Date
Test Pit No. 1................minutes per inch Depth of Test ...........
Depth to ground water......--................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•------------------------------------------------•------•--.....----..........---•--•-----_--•---.........................................................
0 Description of Soil..........Sand------•------------------------ -------------•.................................................................................................
U .--------------------------•--------•--•--•---------•--....-•---•-•-•-•--------.....------......------....-----------•---•--•------------•----.......---•--...........-•----------••--••------•----•-----
W
---------••------------------•-•••--------- ....=
V NNature of airs or Alterations—Answer when ap licable._.....Installation Of a 1 000 Orie
thousank gallon stone hacked leach pit.
. ..... . ....--••--. ....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 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 bythe board ��`' l
Si eG% k --.-. 320��9.-_....
Application Approved BY---..---- r'l` l.(/�✓� 3/2&/79
% -----------------
Date
Application Disapproved for the following reasons:--- •-----•--- •--------------•----------------•-------••------Da.t.e.....------•--
--- --•---•.....................-•--------------•----------------------------------------------------
Date
Permit No......79........................................... Issued...............3�/2-0-/,79-----•--------------.
Date
LOCATION SEWAGE PERMIT NO.
.0256 iz
VILLAGE
INSTA LLER'S NAME & ADDRESS
BUILDER OR OWNER
i
DATE PERMIT ISSUED �02®�
DATE COMPLIANCE ISSUED _��
e
��
��
4�� ,�Y
No`.31' G
F
THE -COMMONWEALTH OF MASSACHUSETTS W;
as-<p
BOAe.RD..OF'..,I=LENLT.H..
Town Barngabe r
�.���r�istt#il�n� fur-�t��u��a1 nrk� Cnnn��rns�iun• rani# �, ..
Application is:hereby made fora Permit'to Construct ( ) or Repair" (X) an Indididual, Sewage Disposal
Sys
Deer . . Nterville�," eta.
... :..... . .............. .......................... .........• ........ ................. :
g 'w Lo tion-Address
e1p . nerr.ca - .... Derw®oc� Dr. , 0cav1I , pia.
... ....... ...... ........ -----•--•-•-•--...... ......
W A & 'ea P"and. S4)fVire 128 Bishops T€�r#96s�, Byazxl t Z r Via.
.. .............•-•-•---•-•-••-••-••-----_. .... ......... ..........----•---... .... ......... ..•.... -•--.....-•----
---
g Installer Address
UType aBuildingg _ Size Lot'-- = > -.Sq. feet
g 3 __________ _______ p (. ) Garbage Grinder ( )
D"Off "No of Bedrooms.._. Ex ansion Attic
p, Other' Type"of'Buildin ________ ______ No. of ersons.___..... _..:_ _ ". Showers —
g P ( ) Cafeteria ( )
xI ;Other fixtures ........................................-----•-••---••....--•-••-•-'--•-••••--•-••-•-'---•'•----------••.............•.
W Design :how .......................gallons per person per day. Total daily flow........._..._._............:.: gallons.
WSeptic n�C` I iquid4 capacity..____.____gallons Length................ Width................ Diameter___.._ .. Depth -____-______-
xDisposa��,:lTre}ich No ................. Width...:_............... Total Length---_................ Total leaching area:.:_ sq. ft.
Seepage;Pii,--*�Nd. Diameter..................... Depth below inlet.................... Total leaching area:`: ....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percollfiion}Testn Results Performed.by.............................I...........--•-• - Date.. :.
a
Test Pit ,Na 1................minutes.per,inch Depth,of Test Pit.,................... Depth to ground water
T st Pit No 2 _.. minutes per inch Depth of Test Pit____________________ Depth to ground,.water
k
pT..
xo ; ....................................................................................... .... a nd
Ai....................
Descri ofSi �......................................................------------•----'------ '-•-------••......•-- .............
I
r-- --_•_ --•----_-•- v
------------------
-----•---•-•--••-•••--•----- r
,b rr Ihstal aka on? off' a...........c b;y(nne�
U ature of airs or Alterations—Answe w en a li ble ______ _________ _________ ' ..
t ou. err' s 7.onone ' � =$ 1 ' c
-• ----------------P ` P
v r,.
------------------
Agreettiettt
Ttttll,,,jt�� -,t,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
,� 2 l ' Y ,
the provisions of �1T i iE 5 of the State Sanitary Code The undersigned furt,. r agrees not to place the system in
operatint>l a Certificate of Compliance has been issued by he board 4
( ,'Fr��r Nkik'�xr'0sV.5.1..�.:.
Apphc onApproved BY ....'� z4 •---
,,,............. 9
Date
Application Disapproved for the following reasons:...............Y...•.........................................................................:.-----........._
7
f ) h.............................................�..... ._...._......_......._.__..._.__._......__...._......... .._.
... .................................
k �S
ILA e
i Dat
permit No
.......................................................... Issued............- •,0 -. .. ..........
Date4
` r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T(�EY21 BAMS tab1 e
O F.....................................................................................
� -��-�-�� � �rrtifirtt#r laf f�unt�rltttnrr
Tff�L$ IS TO CERTIFY, That the I o u e a e Di osal System nstruct d ( or e a (X )
vat Service i f 0 pe erra'ce� ` yann s. a.
by -- --... ........
Dr, a e ary 11 `, d ;a"=- �1ph G. LaFt4i 1.�re r
at .. -_. .._--••• •--•----•-------•-••.---• --••- •.•---- ------. ---_-•... ----.••---
4.t"r a _ .._.,.. ._._.__"...._.__.
has been� 41,led in"accordance with the provisions of Tj he 'State Sanitary Cod���gsr:�bed in the
application for Disposal Works Construction Permit.No.
.............. ............... dated................................................
Tg M ANdE OF THIS CERTIFICATE SHALT. NOT BE CONST E® AS GBJA NTEE THAT THE
SYSTEllfWILL FUPICTION SATISFACTORY.
1. Y
DATE " Inspector^ t' z 7r ...... ............... ................................ ..._.. .._.._ --.... ............. .. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
No........". S_...:. Town ..........OF...........Barnstable.
• •••...... .•••...................•••....................
$5.00
FEE............:...........
Disposal Worko Ou0notrudion rrntit
�► B Ci' (� R Z2hop Ter` �...Hyannis
Permission is here ted ...................... ----••••............................... .... ..y......----•-
to Construct ( ) ;or e • �X) an Individual Sewage Disposal'System
at No................jDeO : .....rA..R...Aate :, a�.� ... .®... Fre'n ex .
Street
as shown on the application for Disposal Works Construction Per No. .'.r _.... Dated...3J___0/7 ..................
DATE...- . 2 ! r Board of He
. .._......-••••-•--...r. ............................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
,.