HomeMy WebLinkAbout0120 EEL RIVER ROAD - Health (2) OSTF..RVILI.,.F.
A = 116 095
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Diti-puuttl Works Tunutrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (04 an Individual Sewage Disposal
System at:
Location-Address rat No.
' 1 l-U/ f s -_... L �-��- ..�%�1-:
..............................
}1
Installer Address
UType of Building Size Lot............................Sq. feet N�
Dwelling—No. of Bedrooms..................: ___._____..___Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons----------------------.----- Showers ( ) — Cafeteria ( )'
P4 Other fixtures .._----------------------------- - -
w Design Flow........:........... ----------------gallons per person per day. Total daily flow.................V.................gallons.
WSeptic Tank—Liquid capacity/ ..gallons Length.-., ............. Width----------------- Diameter....------------ Depth................
x Disposal Trench—No. .......Z.......... Width......fP..._.__.... Total Length._ l• Total leaching area....................sq. ft.
3 Seepage.Pit No--------------------- Diameter-------------------- Depth below inlet.......f�C--... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----------------------------------------------------------------------•--- Date........................................
Test Pit No. 1----------------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 ---------------••------------•----..........._..........-•-•------------•-•-----•--......-•---------.........................................................
0 Description of Soil........................................................................................................................................................................
x:
w
U Nature of Repairs r Alterations—Answer when applicable----IN,f} -__:✓---:--.-. U..Y ...
''`t k l T------ VDT-----f------ ------. �°J���-'
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 Vbeen e y the board of health.
Signed ....... ..... ".....? ... ------------------------Application Approved By -- ...... . ...°
........ -- - - ----- ---------------------- ----'--...Date
------'--------
Application Disapproved for the following rear ....................._.---...--...................................---........
...................................... - ......--............................
Date
Permit No. 75-
.-......1. ...-.... Issued ----
M-11) It l R.0
ZZ
o....-----�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiutt for Biu.Vni3al Works Tuttutrnrtiutt Ilrrniit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
'fia Wit_ /C loErf�
......., :..:........ ... ......... I
Location-Address !, -
/V� V( l l U^'. J %c�- �� (/ f�t No. 6 _/�f�)l l4
.............................................................................
c�"A
Installer AZ �1.� 'mess
....................................................... ----- • ----------- --...-_
1 Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms___________________------____-_-___-_-.-_.--Expansion Attic ( ) Garbage Grinder
`L4 Other—Type of Building No. of ersons--------------_--__--.---- Showers
a � yP g ---------------------------- P ( ) — Cafeteria ( )
04 Other fixtures _ ______________________ _ _
W Design Flow................... ............. per person per day. Total daily flow..._._._.___....Vy�.....__._...__._.gallons.
WSeptic Tank—Liquid capacity X ..gallons Length________________ Width---------------- Diameter--...._-_.-__.._ Depth................
x Disposal Trench—No. .......1.......... Width...... ...._._____ Total Length-.J/y=`� Total leaching area..................sq. ft.
3 Seepage Pit No.-_---._.-_---_---- Diameter.................... Depth below inlet....... r___ Total leaching area...................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0-1 Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit-------------_...... Depth to ground water........................
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ....••-•-•-•------------•----•----••----•-------------------•---••••`•------•---••-•------------•---.........................................................
0 Description of Soil........................................................................................................................................................................
x
U
w
- -----------------•--------------. ..------------------------------------------------------------------------------...--------•-------------------•--------•-••----
U Nature of Repairs or Alterations—Answer when applicable.-..1.-N-J.� 'C-----A /ZU 5,d S j7.........
------------•-•-----------------------
U f / a:- _c..__!_ii /L�-----Ltd/ ....�,--------`S�...A!F=
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 Compliand e h s been iisss/iu deby the board of health.
Signed :...Y. %« .......................... _ /
4 o J/,�/� �` P Date
Application Approved By ✓f`= '--�--�---- ...�(_./(�' /i 1�'/�- --------------
�-
Date
Application Disapproved for the following rear ..................................
Date
Permit No. .......:.(.s. / Issued ......... --------------------
Darel �
----------- -------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gcrtifirate of C�ompliaare
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ................
„�G/e ;F(.a /'T/ C ol'i�i
Insrallcr /�/
at ......... ..................... /C} 1 �- ..�. ���- F` � ................ `1�- V!1.t:. --.--------------
has been installed in accordance with the provisions of TITLE 5 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 WILL FUNCTION YSATISFACTORY. ���%��,�r��,�������
DATE..... - ----...--- 4........ -....... > .,.7 ...----------------- ---- Inspect - �../:..
�Jy�. ----- ------------------------------.._._----
Z �- 9'5Tt 4
-------------- �Q - --------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
...A7 FEE......`.......... ..
Utupnuul Works Tomitrudion rrrniit
Permission is hereby granted......................... �.�...._._.-_�� 'J s i
to Construct ( ) or Repair (\,4) an Individual Sewage Disposal System r
Street - rl
as shown on the application for Disposal Works Construction P�'er_rn�rt'.No.__ ._...____p__ -
Date .:_.'.. ...........,...... L.- ..
5
---------•_-------_•-• / Bbaid of Health
DATE i
FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS
TOWN OF BARNSTABLE
LOCATION /00 C e6✓&C SEWAGE # /�oL
-DO/
VILLAGE ASSESSOR'S MAP & LOT 116 —G J
INSTALLER'S NAME & PHONE NO. ge'I-+ Uc-a�� G�ttiJST" j�= Z l►,
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) size)
NO. OF BEDROOMS Y PRIVATE WELL PUBLIC WATER
BUILDER OR OWNS �"tJc ' lbw
DATE PERMIT ISSUED: �7�y'�
9
DATE COMPLIANCE ISSUED;
VARIANCE GRANTED: Yes �No�
�.���
`�,
5' ,.
�°' ��. � '
5� ;
��
� �
PERCOLATION TEST FORMS
unTOR& �
IL EVAL 4
SOIL I ��� I �r
�00HE►okti Town .of Baz-nstable
P
(t nnar+srAetE• Dc��rhncnt of Idcalth, S:Ifcty, Intl Environlncntal Services
tMAM6)9•39 public Health Division
�e
Dt, 367 Main Street, I Iyannis Mn 02601
()Rice: 509-790-6265
PAX: 509-775-3344
y • ssess11 e nto
Sc e Dis 0,531
Sn1I 6U1ta w�
pS, SORS MP �(PAAJZ
PARCELR
It,laa�
Date:
NO
. Mite:
Performed By: �--
� l�-A rLI
Witnessed 13y: ��
(A��ncrr's Namc
L„calinn Address 120 At> pN� SV L�1-1-A 11
p I:9 Q w te<re—. AQT—:AZOA f � oswr`i Tn`n 0ST�"�✓1 u.� yArzV Ge To, 01 rlsiry
Address.and
Lot a:
. '1'elcphonc a
Asscssor;s Map/lwccl: 11(o /,I5 &U-T)
NEW CONSTRUCTION
REPAIR
O f_,�It ve_icw Yes t� Cad C3
Published Soil Survey Available: No �7Socr� Soil tnap unit
Year Published J Publication Scale _—
Drainage Class f J✓ Soil Limitations �'L �
Yes
Surficial Geological Report 75 Available:
on Scale
Year Published m
Geologic Material(Map Unit)
Landform
Flood Insurance Rate Map: Yes
Above 500 year Flood boundary No yes
Within 500 year boundary No
year flood boundary No Yes
Within 100 y -
Wetland Area: unit
National Wetland Inventory Map_(ma. p- unit
Wetlands Conservancy Program Map(map )
Current Water Resource Con Normal itions(USGS): Month NO
Mange; Above Normal Below Normal '
Other References Reviewed:
I)I:P APPROVED I-ORM- 12/07/95
so>il, l;vnLun•rc»t F0101
�✓ � ZL PaKc 2 of 4
I.,ocilion Address or Lot No.
site Review
7- 17-31-9� Time: lfJ Weather Si✓D�
Deep Hole Number Date:
Location (identify on site plan) I-12AV - �4- ,64-5,er -S'Vb
Land Use tSi�7// " - Slope M 3`£ surface Stones O
Vegetation f l'J& /_0414
Landform "r w &4 At aVN
Position on landscape (sketch on the back)
Distances from:
Open Water Body 3tO feet Drainage way feet
Possible Wet Area a2O feet. Property Line feet
Drinking Water Well — feet Other
DEEP OBSERVATION HOLE LOG
Depth from Soil HorizonMSol[Color Soil
Other
Surface (Inches) (Munse11) Mottling (Structure,Stones,G Boulders, Consistency, °�
g,✓2�,r L , s . J SmvGs1
u
7
'7 l o
Parent Material(geologic) w7 u-y�-� PkA!61_ DepthtoBedrock:
O
•n Weeping from Pit Face:
-Depth to Groundwater: Standing Water in the Hole: � -'—
Estimated Seasonal High Ground Water: �fS,
I,EP APPROVED FORM-12/0719S
rUlthl l l - Soil, L;VAII,UA'I',�,thll� )� �trI
//33
Location Address or Lot
miriatio�i or Seasonal Hi h Water Ta le
Deter
Method Used:
Depth observed standing in observation hole ..
inches
❑ Depth weeping from side of observation hole inches
❑ inches
Depth to soil mottles feet
El Ground water adjustment . . .
. ... .
Index Well Number .In1112.7-01 Reading
Date .hlo✓ 9'6 Index well level �•G
Adjustment factor Adjusted ground water level
De th of Naturall Occurrin Pervious Material
r feet of naturally occurring pervious mr�sysall tem�in a
Does ll areaz
at least four for the soil absorption
observed throughout the area proposed
If not, what is the depth of naturally occurring pervious material?
Certification
if that on 9 J y�idate9 I have I Protection and thatsed the soil luator the above anaays
tior
I certify
approved by the Department of Environments
was erformed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature
/ --Date lzJ `Jh
i
DFT APPRO%T..D FORM•12/01/95
FORM 12 - PERCOLATION TEST
Page 4 of 4
Location.,Address or Lot No.
MASSACHUSETTS
COMMONWEALTH OF
Massachusetts
Percolation Test
Time:,
Date:
Observation Hole #
Depth of Perc
Start Pre-soak
End Pre-soak
Time at 12"
Time at 9"
Time at 6"
Time (9,._6„)
Rate Min.11nch �SS cf'"r' �awAA � l��N
must be p
erformed in both the prirriery area AND
(Viinimum of 1 percolation test
reserve area.
Site passe
d Site Failed ❑ ......................................................................._._....................
Performed By:
Witnessed By: 7-7
.......:...
Comments: -
DEP APPROVED FORM•12/07/95
r
NOTE} ALL D/STANCES NOT SNOICN AS 'E.D..v.'ARE TAPED I CERTIFY THAT THIS ACTUAL SURVEY WAS MADE
ALL GB.S NOT SNOHN OTHERNTSE HAW DRILL HOLES. ON THE GROUND IN ACCORDANCE VATH THE LAND
I lDas ALL STAKES HAW NAILS COURT INSTRUCTIONS OF 1959 ON OR BETMEEN
DECEMBER 19.1984 AND FEBRUARY e.1995.
o GRAPHIC SCALE C
3AYo 20 w eo VEST : OATE Ti_131 5 _[�.,.•-..act.8...t,
REGISTERED LAND SURVEYOR
el:Mm ST.
a OSTE V UE,MASS.02655
(50e)42e-9131
�(p V AV, T DIRECTION OF ADSOLUTE ERROR •N04.53'Wv uev.
L / A ERROR OF CLOSURE•1 FOOT IN 18631.
J s
LOCUS MAP J OLD wlmU K"c
B.MD.
SCALE I 25,000
ASSESSORS A.P.RESIDENCE F-1
MAP 116 PARCEL 95 MWIMUMS
FRONTAGE-20'
FRONT SETBACK-30'
N-0• 4- 0�' SIDE SETBACKS- 15'
REM SETBACK-15'
n
NEW eulDwa HEIGHT-So
t CB.FIE.`fQ
�e � ar �� srK xT (OR u'SrowEs 1F LESS)
ti C A
��•�H66• h��° .. .�_ r., .o r to A.
C.B.FIND. 'o•'o ,a
5516 SEE DETAIL ABOVE Z •\i�i O,SU
C.B. FHO. SEE L.C.C.3145X / N
C.B.FND. io- C.9FMD. �
_ �,I• 0
se °,o o� �1 Jy• to.m4D.Qwfff o•./ \y
m SET 0•
'ur gym• .4 C.B. Ulk
'H1Y O\e
4
Y� \,4y
J V.solp 341• -..
= o-1 s�6,
\' LOT 10
t; o a _ 43,561 p.fLo.
$,
w T. / I
r N• / ^p N64'09.42•E L K
34.17
W' C.A.IMom. r`� / / a° yo of
o r ' %\NET
* 1 0 e as"%
o• / N
1°.I �D• /14 ,AGE
v 1 \
b •±o / ,N1,1f1<� N69�•�g Np g1�9 `` 1l *
LOT 11
y nl Z In E
C.B.FUR 44•872•a.CL
_. g 1.03•c•• ' � ad'rL1fA9 ruw
S.1- 21.4e \ °A
rV J o. ^1 1 }5• E.O,M/ CA rMD.
Qo O
t.G.FNO.
O.Mrr ^ k u$ N7s
c N NAL SET�/ • Iel.a> abe\i,yo'c
q
Mf.Y CL�I10.
6 �� E�o�.°�;ss ys PLAN OF LAND
N I ��6 D e. . `. IN _
BARNSTABLE PLANNING BOARD .BARNSTABLE (oSmmw MASS.
JW WOK HIT
APPROVAL UNDER THE SUBDIVISION h Orr - • a
CONTROL LAW NOT REQUIRED. Iv BEING A.. SUBDIVISION OF
E• '
DAT a J ..•. LOT .D 1 1 B AS SHOWN ON L.C.C. 3145 I
a I SCALE: 1"= 40' DATE: FEB. 13 ,1995
NOTE' NO DETERMINATION AS TO I ^ BAXTER L NYE INC. -
COMPLIANCE 1NTC THE ZONING REGISTERED LAND SURVEYORS v}�'• �`'�,`J
�i*T aL
ORDINANCE REauIRE)lENTS HAS o� � CIVIL ENGINEERS J M E
BEEN MADE OR INTENDED BY THE ^ OSTERVILLE• MASS.
ABOVE ENDORSEMENT. 91 M C.B.MISSTNO a f ,
EUGENE A. k ROSALIND B. PICDES. CTF.93334"NERS #95004�.
t
Aug 2415 07:37p p.18
5 -002
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
C.
r 130 Eel River Road Pam,
Property Address ti
Florence Mackie lm
rX
Owner Owner's Name / --- — c
information is Ostenrille •/ MA 02655 8-22-15 required for every
page. Cityrrown state Zip Code Date of Inspection
Wy
Inspection results must be submitted on this fort. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
a��Ntnulpgrri
on the computer, OF �'ii�,
use only the tab 1. Inspector: / J`��� •" •s9L;%,�
key to move your
cursor-do not _0 •'•�G%
James D. Sears �: JAMES =.N
use the returnvn
key. Name of Inspector SEARS
CapewideEnterprises,LLCirs
Company Name
r� P Y �• �`•••. RTIF\ p �.
153 Commercial Street — - - /,',���kr rr ins-Company Address
r Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
i
�1fLe a- _/mod 8-24-15
spectoPs Signature Date j
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or i
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 f
and copies sent to the buyer, if applicable, and the approving authority. E
****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.
15ins•W13 - -nlle 5 0,Mdal rnspeclJon Form:SrIDsurtace 12, ern•Page 1 of 17
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Aug 24 15 07:38p p 19
i Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel Rive
r Road
Property Address
Florence Mackie
Owner Owner's Name
information is
required for every OstenAlle MA 02655 B-22-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System 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:
The system is a 1500 Gal. Tank D Box and six chambers
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 repairr as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
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t5ins.W13 Tille 5 Official Inspecpm Form..Subsaface Sewage Disposal System•Page 2 of 17
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I Aug 2415 07:38p p.20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie _
Owner Owner's Name
ion is
requirequiredd for every Osterville MA 02655 8-22-15
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumpstalarms are repaired.
B) System Conditionally Passes (cunt_):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y 0 N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s)_ The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ' ❑ ND (Explain below):
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 public health, safety or the environment.
i
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health, `
safety and the environment: i
❑ 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
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t5ins•3113 Title 5 ONioal In ectirm Sewage Form:Submeace sp D"Lspooal System-Pape 3 or 17
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Aug 2415 07:38p p.21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments,
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is
required for every Osterville MA 02655 8 22-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ 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 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 from 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered_ A copy of the analysis must
be attached to this form.
3. Other:
- 1
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No i
r
Backup of sewage into facility or system component due to overloaded or j
El ® clogged SAS or cesspool I
❑ ® 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 is less than 6"below invert or available volume is less
than %day flow A 64P,sljAvC
Zins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I
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Aug 2415 07:39p p.22
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is
required for every Osterville MA 02655 8-22-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ 0 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.
0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
0 0 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 ana"is, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.)
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
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For large systems, you must indicate either"yes"or,"no" to each of the following, in addition to the
questions in Section D_ (�
Yes No
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❑ ❑ the system is within 400 feet of a surface drinking water supply E
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El 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 you have answered "yes"to any question'in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact,the appropriate
regional office of the Department.
15ins•Y13 Tflo ri OffiaW Inapoeban Lorin.sub—fA sa.ogo Uiap"al Syot« .nags s or 47 i
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Aug 24 15 07:40p p 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owners Name
information is
required for every Osterville MA 02655
page. City/Town State Zip Code Date of Inspection
C. Checklist
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?
® ❑ 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 NIA)
❑ 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?
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❑ ® 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:
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® ❑ Existing information. For example, a plan at the Board of Health_
® 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(5)]
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D. System Information
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Residential Flow Conditions: i
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Number of bedrooms (design): 5 Number of bedrooms(actual): 3 i
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DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•3113 Title 5 DRrlal Inspertion Form:Subsurfsoe Sewage Disposal System•page 6 of 17 .
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Aug 24 15 07:40p p.24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is
required for every Osterville MA 02655 8-22-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal.Tank. D Box and six chambers
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report)
Laundry system inspected? ❑ Yes ® No
Seasonal use? Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)): 2013-96,000Gais
Detail: 2014-91,000 Gal's
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Trtfe 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Tina 5 olvdal Inspection Forth:Subsurface Sawage Disposal System-Page 7 of 17
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Aug 2415 07:40p p 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
er
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is
required for every Osterville MA 02665 8-22-15
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancyluse: Date
Other(describe below):
General information
Pumping Records:
Source of information: 5127/11
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe): j
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15ins-3113 Title 5 Official Inspection Form sulmosce Sewage oisposa)System•Page 6 cf 17
Aug 2415 07:41 p p.26
Commonwealth of Massachusetts
Title 5 Official Inspection Form
$ - 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"" 130 Eel River Road
Property Address `
Florence Mackie
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1977 Permit #97-345.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
Septic Tank(locate on site plan):
Depth below grade: 20"feet
Material of construction:
concrete ❑ metal Q fiberglass ❑ polyethylene ❑ other(explain)
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If tank is metal, list.age; years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H-10
Sludge depth: 1
15ins-3113 Title 5 ORdal Inspection Form:Subsurface Sewage Disposal System-Pape 9 of 17
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Aug 2415 07:41 p p.27
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel River Road
Properly Address
Florence Mackie
Owner Owner's Name
information is required for every Ostetville MA 02655 8-22-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness Y.
Distance from top of scum to top of outlet tee or baffle a
ll
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? Asbuilt- Plan-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank at working level. Tank and cover's at 20" below grade. In and outlet tee's. No sign of leak
age or over loading. Note: Sprinker line over both cover's.
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Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction: I
❑ concrete ❑ metal .❑fiberglass ❑ polyethylene ❑other(explain): i
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle i
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: oar
!Sins-2/13 Title 5 Official Inspection Form:Subsurface Sewagn Diepaaal System•Page 10 of 17 I
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Aug 2415 07:42p p 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is Osterville MA 02655 8-22-15
required far every _._
page. city/rows state Zip Code Date of Inspection
D. System Information (cunt.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete metal fiberglass
❑ ❑ g ❑ polyethylene' [I other ex lain
( P )
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes . ❑ No
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Alarm level: Alarm in working order: ❑ Yes ❑ No
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Date of last pumping: Date
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Comments(condition of alarm and Float switches, etc.):
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`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Wh'a•Ono Tine 0 QMW.1 n ��w r�„.7uwvi raw conayv�ropvooi 3]otww•rayo i i yr i7 i
Aug 2415 07:42p p.29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-15
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage,into or out of box, etc.):
D Box is 16"x16"-26" below grade. Box is clean and solid w/two line's out. No sign of over
loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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* If pumps or alarms are not in working order, system is a conditional pass. j
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Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
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t5ins.3773 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 97
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Aug 2415 07:42p p.30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-15.page. Cityrrown State Zip Code. Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number
® leaching chambers number: 6
❑ 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.):
Leaching is six(cuiiec 330) chambers w/4'stone.Ck D Box and camera out to chambers,wet
bottom. No sign of over loading.
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Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
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Number and configuration.
Depth—top of liquid to inlet invert
Depth of solids layer i
Depth of scum layer
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Dimensions of cesspool
Materials of construction
t
Indication of groundwater inflow El Yes [] No i
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(Sins-W13 Tille 5 Official Inspection Form:Subarafaoe:ewaja Disposal System-Pege 13 al 17 i
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Aug 2415 07:43p p.31
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel River Road
Property Address -
Florence Mackie
Owner Owner's Name -
information is
required for every Osterville MA 02655 6-22-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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;sins-3/13 Title 5 Otfiaal inspection Form:Subsuftaoe Sewage Disposal System-Page 14 of 17 i
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Aug 24 15 07:43p p.32
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1W 130 Eel River Road
Property Address --- -
Florence Mackie
Owner Owners Name
in
formation is r —__
re wiredfired for every Osterville MA 02655 6-22-15 _
page. Cityfrown State Tip Code Date of Inspection
D. System Information (cost.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
O' hand-sketch in the area below
drawing attached separately
13-1 : J-�� GRRP r�3
P. g ; A O t
R-3- 3i C/O
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15i�•3113 - TWo 5 OfSdai vopecion romi-Subwrace$~Aiv Disposal syslurn•Page 15 D(17 l
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Aug 24 15 07:43p p.33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-15
page. Cityrrown State Zip Code V Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth t high ground water: feet
Please indicate all methods used to determine the'high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 12-31-96
Date
❑ Observed site(abutting propertylobservation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
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❑ Accessed USGS database-explain:
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You must describe how you established the high ground water elevation: i
T.H. on Design Plan 12-31-96 no G.W. at 10'+. Bottom of leaching at4'-6" below grade. Bottom
of leaching at 5'-T above T.H. Depth. _-
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3M Title 5 Official Inspeoiion Form:Subsurface Sewage Disposal System-Page 16 of 17
Aug 2415 07:44p p.34
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
130 Eel River Road
Property Address
Florence Mackie
Owner Owner's Name
information is required for every Osterville MA 02655 8-22-15
page. City/Town Stale Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D,or E checked
® Inspection Summary D (System Failure Criteria.Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins•3/13 Title S Official Inspection Fonrx Subsurrece Sewage Disposd System•Page 17 of 17 {
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migpoga[ *pgtem Con.Mruction Vermit
Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Add or Lot No.4 Owner's NaAddress and Tel No.
Assessor's /Pazcel / 4 ??/—40 Y
Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No.
r1®e u,�e Z)eco
Type of Building:
Dwelling No.of Bedrooms S Lot Size lr U 3 Ge-,so.ft. Garbage Grinder(Ala
Other Type of BuildingAVOM�fda&_p No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /`06 gallons per day. Calculated daily flow 15S6 gallons.
Plan Date / 3 ^q7 Number of sheets -2— Revision Date 1 -49-9-7
Title LOT // 21 0i5R- 9be ®STC2.
Size of Septic Tank Type of S.A.S. 1_401"lfIS �ff✓a�1 '.LS
Description of Soil A _
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction d maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the En ' onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been-' is B Health.
Sign Date '22-
Application Approved by r ' Date /
Application Disapproved for the following rea o s
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( t/)Repaired ( )Upgraded( )
Abandoned( )by .7-0F fG14A10 -- bECO CQA)S79.
at 1.01 /l EGIA- Al VE` ,e /26 057"V1LLE has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.<2 7- :2�ZJ'�dated`2'-'a•�
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed:
Date Inspector
"0 o
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
— Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pprication for Mi.5pozal *potem Construction Permit
Application'for a Permit to Construct(V)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Add Lot No. ( , Owner's Name;Address and Tel.No.
'57 .0
tea
Assessor's M /Parcel %
lei 1
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size + tl 3 G(-' sq.ft. Garbage Grinder(A/(-)
Other Type of Building'!Jl No. of Persons Showers( ) Cafeteria,( )
Other Futures
Design Flow / UEJ gallons per day.' Calculated daily flow 5 SIJ gallons.
Plan Date / ?2 q- Number of sheets __2_ Revision Date :7 F - q"Z
Title ' 1t)1 i0 l-'_9L f�tUj52 Rb 0,_,7_1CkV1(-�_6
Size of Septic Tank 11012 14-� Type of S.A.S. 1_E6CH/A/6
Description of Soil aA 4,G, 12.11;1A41
Nature of Repairs or Alterations(Answer.when applicable)
� t
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction nd maintenance of the afo"re described on-site sewage disposal system
in accordance with the provisions of Title 5 of the E 'ronmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bee. ' is B az f Health. °'-•i ,
Sig Date Z
Application Approved by Date
Application Disapproved for the following re 400 s
;a
" r
Permit No. Date Issued
—————————— ———————— ————— -
- r
. THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
' pert%fficate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ✓)RepairedUpgra�ded , ,) ,� ,
Abandoned( )by JO,L b I Yf All) — bF60 CQ )ST1z .
at kf L1 U T /1 f=EL Q( V F—,e RCS 0 57E .✓I LLE has been constructed in accordance
with th ;provisions of Title 5 and the for DisposalSystem Construction Permit No5 � Y dated"' .
Installer ( Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.t
.x ate i Inspector
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9 No. '� _ Fe j/-1 i&
t THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
1
Mi!6po.5al *pgtem Construction Permit
`Permission is hereby granted to Construct(GIRepair( )Upgrade( )Abandon( )
\ System located at Lid`! /( C F_L f�. (t!F C,5%Ir 2 V /L-L r_
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 st belom leted within three years of the date of thi .ermit. CI Q
Date:__4T/
f '7 Approved by ® �11
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