HomeMy WebLinkAbout0124 EAST OSTERVILLE ROAD - Health (2) L
AST OSTERVILLE RIDOCfl
ERVILLE
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D COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVE
JUN 13 2001
TITLES TOWEP
HEALTH RNSDEpIFABIE
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME �---
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
v
CERTIFICATION
Property Address: 124 E Osterville Rd.
Osterville
Owner's Name: Wozniak
Owner's Address: 0 —d
Date of Inspection:
Name of Inspector: (please print) Wi 1 1 i am E_ •Robi_nson sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
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 toSection 15.340 of Title 5(310 CMR 15.000). The system:
L Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails ,.
Inspector's Signature: w �7-0�'`�^^� ✓- Date: S 30-0
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh.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 the
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 that
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
1
Page 2 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 124 E. Osterville Rd.
Osterville
Owner: Wozniak
Date of Inspection: ''3 0 0-
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. yytem Conditionally Passes:
One or more system components as described in
.. „
y p the"Conditional Pass section need to be replaced or
repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existm tank is replaced with a complying septic tank as approved by the Board of Health.
•A m 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indica . g that the tank is less than 20 years old is available.
ND a plain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
ap val of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND a lain:
The system required pumping more than 4 times a year due to broken or obstnteted pipe(s).The system will
pass iz spection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND xplain:
• Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 124 E. Osterville Rd.
Osterville
Owner: Wozniak
Date of Inspection:
C. urther Evaluation is Required by the Board of Health:
onditions exist which require further evaluation by the Board of Health in order to determine if the system
is failin to protect public health,safety or the environment.
1. S tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
sy tem is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syste is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
rface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
private water supply well".Method used to determine distance
'This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and
th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fa ure criteria are triggered.A copy of the analysis must be attached to this form.
3. O er:
3
Page 4 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 124 E. Osterville Rd.
Os ervi e
Owner: Wozniak
Date of Inspection:
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections:
Ye No
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
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''/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
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.]
(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. rge Systems:
To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You m st indicate either"yes"or"no"to each of the following:
(The fo owing 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 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well .
If yo have answered"yes"to any question in Serxiva E the system is considered a significant threat,or answered
"ye 'in Section D above the large system has failed.The owner or operator of any large system considered a
sig scant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 .The system owner should contact the appropriate regional office of the Department.
4
Page 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 124 E. Osterville Rd.
s ervi e
Owner: Wozniak
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
`..Yes No
Pumping information was provided by the owner,occupant,or Board of Health
_ /Were any of the system components pumped out in the previous two weeks ?
r/ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site
Were the septic tank'manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
t/ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no `
(�_ Existing information.For example,a plan at the Board of Health.
_1'/1_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address- 124 E. Osterville Rd.
s ervi e
Owner:
Date of Inspection: 6•-3 o—D
FLOW CONDITIONS
RESIDENTIAL .
Number of bedrooms(design): Y Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 6 D
Number of current residents: 3
Does residence have a garbage grinder(yes or no): O
Is laundry on a separate sewage system(yes or no)-,0 [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):�D
Water meter readings, if available(last 2 years usage(gpd)): 2000 94 ,000 gal.
' Sump pump(yes or no):Al J1999 108, 000 gal.
Last date of occupancy: 3o,-cr 1
OMMERCIAL/INDUSTRIAL
T e of establishment:
DIER
n flow(based on 310 CMR 15.203): gpd
B of design flow(seats/persons/sgft,etc.):
Ge trap present(yes or no):_
Intrial waste holding tank present(yes or no):
Nsanitary waste discharged to the Title 5 system(yes or no):
Wr meter readings,if available:
Late of occupancy/use:
O (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as padof the inspection(yes or no):_&'0
Ifyes,_volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TY7�O17 SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
J`r1) 7
Were sewage odors detected when arriving at the site(yes or no): Ai o
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _. 124 E. Osterville Rd.
s ervi 11 e
Owner• Wozniak
Date of Inspection: 3 0 ® 1
B LDING SEWER(locate on site plan)
Dep below grade:
Mate 'als of construction:_cast iron _40 PVC_other(explain):
Dis ce from private water supply well or suction line:
Co " ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: l y'
Material of construction: %oncrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) 1
Dimensions:
Sludge depth: I
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: y �1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle /1/'
How were dimensions determined: 6 J!�C-A, ) K
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
76 z L
0
GRE E TRAP:_(locate on site plan)
Depth low grade:
Materia of construction: concrete metal fiberglass_polyethylene_other
(explain : — — —
Dimens' ns:
Scum t ckness:
Distanc from top of scum to top of outlet tee or baffle:
Distan from bottom of=scum to bottom of outlet tee or baffle:
Date o last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rel ed to outlet invert,evidence of leakage,etc.):
7
i
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) .
PropertyAddre424 E. Osterville Rd.
Os ervi e
Owner: Wozniak
Date of Inspection: `3 c—v
T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dep below grade:
Mate ial of construction: concrete metal fiberglass_polyethylene other(explain):
Dim sions:
Capa ity: gallons
Desi n Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
Da a of last pumping:
C mments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:Z(if 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 evidence of
leakage into or out of box,etc.):
G }�
PU P CHAMBER: (locate on site plan)
Pum s in working order(yes or no):
Al s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
J'
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 124 E. , Osteryille. Rd..
Osterville
Owner: Wozniak
Date of Inspection: C—3G—
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required)
i Y
If SAS not located explain why:
Type `
eaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): _
S ?a f-1 ,C Ce G 3
CESSPOO)(note
(cesspool must be pumped as part of inspection)(locate on site plan)
Number anration:
Depth—topd to inlet invert:
Depth of sor:
Depth of scr:
Dimensionpool:
Materials oction:
Indication dwater inflow(yes or no):
Comments ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: ocate on site plan)
Materials of c nstruction:
Dimensions:
Depth of so ds:
Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) '
Property Address: 124 E. Osterville Rd.
Osterville
Owner: Wozniak
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
ti
l �
10
Page 11 of 11
.r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddre1s34 E. Osterville Rd.
s ervi le
Owner: Wozniak
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water ) feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
served site(abutting property/observation hole within 150 feet of SAS)
✓Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
1 1,4-
LO>CAT ION
� SEWAGE PERMIT NO.
/-O �J tee✓`% 1
VILLA E
INSTA LL FRVS A & ADDRESS
h
BURDER OR _OWNER
DA T E PERMIT ISSUED
OAT E COMPLIANCE ISSUED/�_��
-----------
ra
r ,
No. < Fee$5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for Miq;pool *pftem Con6truction Permit
Application for a Permit to Construct( )Repair(xx)Upgrade( )Abandon( ) []Complete System El Individual Components
Location Address or Lot No. 12 4 E a s t 0 s t e r v i 11 e R cfwner's Name,Address and Tel.No. 4 2 8—2 3 7 8
Assessor'sMap/Parcel Osterville, MA Florence Wozniak
/ � Z _ 'V_ 124 E Osterville Rd, Osterville
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
WM E Robinson Sr Septic Service r_,f
PO Box 1089 , Centerville, MA 02632
Type of Building: 0
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no)
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 Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching repair
consisting of D-Box and 3 stonepacked heavyduty infiltrators.
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 d not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo of Health.
Signed ' Date L ' "" /
Application Approved Date`7---�l F`7
Application Disapproved for the following reasons
Permit No. Date Issued_�"
TOWN OF BARNSTABLE /
LOCATION L_-Z SEWAGE # 7- 7
VILLAGE S // ASSESSOR'S MAP& LOT `1 'O
INSTALLER'S NAME&PHONE NO. i
SEPTIC TANK CAPACITY —0
LEACHING FACILITY: (type) (,, 1G S (size)16
NO.OF BEDROOMS
BUILDER OR OWNER �-Z/a 1, t
PERMTTDATE: 2—/ —5� COMPLIANCE DATE: ,P��-- 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Y 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
TOWN OF BARNSTABLE
LOCATION ?r, SEWAGE #
VILLAGE S / ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. ZT 7 .7
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)s ^ �_2
NO :OF BEDROOMS v
BUELDER OR OWNER
PERWI'TDATE: COMPLIANCE DATE:.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Su" 1 Well and LeachingFacilityan wells exist.
.. Y
(H Y
e of leaching facility)
Feet
`or within 200 feet
on.site g ty)
Edge gf Wed d and Leaching Facility(If any wetlands exist
withi i 300 feet of leaching facility) Feet
Furnished by
r
7� $50.00
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,. MASSACHUSETTS
- f
01ppfication for Migogar 6p5tem Con!truction Permit
Application for a Permit to Construct( )Repair(x�Upgrade( )Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. 124 East Osterville dJwner's Name,Address.and Tel.No. 4 2 8_2 3 7 8
• Osterville, MA
Florence Wozniak
Assessor'sMap/Pazcel 124 E Osterville,Rd, Osterville
Installer's Name Address,and Tel.No. �4 —8776 Designer's Name,Address and Tel.No. f
WM E Robinson Sr Septic Service ;
PO Box 1089, Centerville, MA 0263
Type of Building: 'm "
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(n0)
Other Type of-Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow A gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title G
Size of Septic Tank Type of S.A.S. w
Description of Soil sand
a
he Titl/e -5t Leaching repair
Natuco°nsips�irig o atio�s(�o�eandn ps`taoln)epac a eavy utyinfiltrators.
Date last inspected:
;5
I
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 ode d not to place the system in operation until a Certifi-
cate of Compliance has been issued by this 13100A of I t /1 ` e 1-7Signed Date l 7
Application Approved V Date - 7_
Application Disapproved for the following reasons
ee=
,,,- ...
Permit No. L'" Date Issued
——-;———————————————————————————————————
THE COMMONWEALTH OF MASSACHUSETTS
Wozniak BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( x )Upgraded( )
Abandoned((� )b
at 124 last Osterville Rd, Osterville 4:2en cons c ed in/a cordf
with the r isi s nfTtl 5 and the fir Di osal S ste Construction Permit No. dated/
p vim Ro�3.nson sr Septlyc ' ry
Installer Designer
The issuance of this-�rmii shall not be-construed as a guarantee that the system will ft n(tion as designed.
Date U v Inspector
Zo. �"' --------------------------Fee $50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Mizpoar 6pgtem ConOtruction Permit
Permission is hereby gr t d to Construct( )Repj x)Upgrade( )Abandon( )
System located at 4 East Oster a V
Osterville, VIA
1115taller: m E Robinson Sr septic sry
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:C �ctiop��t b��,o,�leted within three years of the date
o�.•thi it. ��
Date: `// Approved`bil— r✓
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUI'DESIGNED PLANS)
I 6�v J J hereby certify that the application for disposal works
construction permit signed by me dated '' ` /1 fy pi ✓ , concerning the
property located at 1. GJ r 6 meets all of the
following criteria:
• There arc no wetlands within 300 feet of the proposed septic system
re are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
here is no increase inflow and/or change in use proposed
There are no variances requested or needed.
1-7
SIGNED : G� - -DATE:
LICENSED 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].
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67)No........... . .. FEE.
...............
THE COMMONWEALTH OF MASSACHUSEFT-f-5---Z.
BOARD, 0 HEA T�
OF . ....................
.. ........ .... ... ..... ....
Appliration -for Its patial Works Tattstrurtion Punift
Application is hereby'made for a Permit to Construct (41--or Repair an d i Indivual Sewage Disposal
11 Wstem ,-A. ...
..... . ....... ...... .............................
................................... ..... .............................
Locati ddress
, Lot No.
...... ...... . .......... -------------------------7 ------------------_---Alog... .......,,r....................................................
ow Address
..........
.............. ... . ... .. . ........ .. . . ..... ---------------------- .... ...................
- - --- - ---------------- _
Installer Address
Type of Building Size Lot-------/-20-0-0.Sq. feet
U Dwelling—No. of Bedrooms-------------- -----------------_-------Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons.--_____---____--_----_----- Showers Cafeteria ( )
04 Other fixtures ...... ------------------------------------------------ -----------------------------------------------------------------------------------------
Design Flow-------- -----6770...................gallons per per-son per day. Total daily flow._..........3..q.0............. ....gallons.
04 Septic Tank—Liquid capacity/e_-W-raTons Length________________ Width.__-_.._.._._--- Diameter....__._.__..... Depth----------------
Disposal Trench—No. .................... NV h--------------------.3;&al Length_-_-_____--__-- _ T leaching area--------------------sq. f t.
Seepage Pit No...../AX.0..... ----------------- ... . .... tal leaching area....3_q�ksq. ft.
Dosing tank 7-7
Other Distribution box )110_4 D
gth---------------- __ To leaching
_- - ---- tal lea,
:0�
-7-
Percolation Test Results Performed by----------- IV4.......... ate-----7. ---------f-----------
451-
Test Pit No. I----------------minutesperinch Depth of Test Pit-..___-----_-----__- epth to ground water------------------------
1:1A Test Pit No. 2----------------minutes per inch Depth of Test Pit.--_----_----__--__- Depth to ground water-.............._......__
Ix ---- --- -------------- ------ (----- . ............ ...................................
Description of Soil ............. .... ---------------------------------------
... .......------ ------------ -------11��4-----------
0 De .........
U ------------------ --------------------------------------------------------
------------------ ----------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b and of health.
gned . ...... .. ----
-----------------
I --------- -----f-
,
gate
Application Approved By.............. --- --- ------- ---- - ---- -- -- ...........L-------- 7
1, Date
Application Disapproved for the following reasons:------------------------------------------ ...............................................................
............................................................................................................................................------------------- -------------------------------------
Date
Permit No. Issued...... - -
R ----------
----------Date
No Fps.. . ....................
THE COMMONWEALTH OF MASSACHUS4-iTS
y..�- BOARD OF HEA J H
OF /�. ✓�rl -r/
...
A41iration -fir Dig wiai Ourks Towntrurtion Vrrmil
Application is hereby`made for a Permit to Construct or Repair ( i an Individual Sewage Disposal
7,4_,_4 5__v 4��al �z "(If/
.....................
......................
-------'-- - LocationlAddress or Lot No
i
O-A / %f,
a --•------.__/r--:-in'�jw^t-!rt.=......-.........`--✓`-". - "mil --•---••-•---••-•---•-------•---=f+".,, .!_,,/)/17� �1:.
Installer Address
Q Type of Building Size Lot------ ._..._F!.����---Sq. feet
Dwelling—No. of Bedrooms---------------
......_----------------------Expansion Attic ( j Garbage Grinder ( )
Other=Type of Building ___________ No. of persons___________________________ Showers ( ) — Cafeteria ( )
Other fixtures ......._
Design Flow-------------A__"sa:--------------------gallons per pet-son per day_ Total daily flow___________ 6 (1_------------_gallons.
a _____________ Width Diameter--------,------- Depth.-_--_____------
� Septic `lank—Liquid capacitvC'�-~eons Length___ �-
x.- Disposal Trench—No_ ____________________ �«;i.th____________________._ tal Length--------_________.. To leaching area............. ......sq. ft.
Seepage Pit No....1_Ct- `'D °f1 elf-* ......-�!�el�v i t 7' otal leaching area._O-�sq. ft.
Other Distributlon box ( Dosing tank ) � P ��4
W
Percolation Test Results Performed by-__..---___._ - _________-"_._ ,._ ate___. :.- `?_ _/______._-
Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- epth to ground water_..___---__________-. -
w
mo/ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-_-__-__-_-______---_
W -_ -
.- _ �_____________________ __
O
x Description of Soil------ - -'" "i -
----------------
-
- ------ -- ----- ------ -----
U Nature of Repairs Or Alterations—Answer when applicable------_----------_-----------------------------------------__--------__........_-__-____---__----
--------------------
--------•-------------- --- ........ .......:------------------------------------ ------------------- -------------•-----•------------- --
Agreement:'
The undersigned agrees`to'-install the .aforedescribed Individual Sew age'DisposaII System in accordance with
the provisions of Article 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 1
gned_ c44C � ............. `--!-- ---------- --------�' Ali ----
�l ate
Application Approved B __
Date
Application Disapproved for the following reasons_____________________________________________ ___ ___________________•--___________-_____._...__.._......______
••--------•------------•---------•---•---------------------•---------------------------------------------•---------------------•----•--------------•-----•---------------------------•--------.........
late
Permit No. = •-----••-•------•_.... "' Issued. �=....
•-O @.
Date
THE COMMONWEALTH-OF MASSACHUSETTS
BOARD OF�E_.ALJ.
%_' ertif rate of T"amphan''re
11
THIS IS TO CERTIFY, That the Ind iduat Sewage Disposal System constructed or Repaired ( )
bY-------•' 'fir°" ra-�.,c c--z� -' ,5 ` .�'4'/�''..............................
A le
has been installed in accordance with the provisions of.Ar clI.of The State Sanitary Code s des ibed in the
application for Disposal Works Construction Permit No:__ ------- $'_9""----------- dated__LZRANTEE
./ ��'-______________
THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATEInspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
1417 - BOARD OF HEA MH
`�---- �_
N o._.._... -�� FEE........................
��^rti� t �rrmi#
Permission is her bey granted---- r'-tom c . �1z-!-f
to Construct (,*/-)-or Repair ( ) an,Individual Sewage fDisKa,l,, /
, stem
mat No.---
Stre t
as shown on the application for Disposal Works Construction Permit N -,]Dated----
.. .........
___••__-•---•----------• _"""'_•_-_•_ -_-__'__{f%_•-__•____•-----••---____•-----•....-------
B '-
d
oar of Health '
DATE--- . f .�" 7.7
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .:
.Psino Data
ass • I 5 � t J_�
Single Family - 3 Bedrooms ... _
"o Garbage Grinder /s o. oa' _
( Daily Flow = 110 x 3 = 330 GPD 411 It4
Septic Tank = 330 x 150 % = 495 GPD
Use 1000 Gal. Zµ�
NO.. Pi r
pis osal Pit - 1000 Gal. rAAv
a Side gall ,Area = 150 S.
150 S.F. x 2.5 = 375 GPD
Bottom Area = 50 S. F. " \
50 q. F. = 1 .0 x 50 GPD --- {
; Total Design = 425 GPD
Total Daily Flow = 330 GPD O
N. E. WE TE �
Perc Test - 1 " in 2 min. or less E.95EME/V T
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