HomeMy WebLinkAbout0062 HICKORY HILL CIRCLE - Health ..�.62111CjoRY'IfILL-)CIR';OSTERVILLE
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' Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
Gorema
Trudy Coxe
Secretary,EOEA
' David B.Struhs
Commwione►
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
' Property Address: 62 hickory Hills Circle, OstervilleAddress of Owner:
Date of Inspection:9/21 and 9/5/9 5 (If different)
Name of Inspector.John Beckwith and Arlene Wilson
' Company Name,Address and Telephone Number:
A. M. Wilson Associates, Inc. Phone: (508)428-1450
911 Main St. , Osterville, MA Fax: (508)420-1856
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
' X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
/� M W'.1s-Associates, Inc.
Inspector's Signature: / ) � Date: lea
rle e M. Wilson i
' 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 repor, to the appropriate ree!onal office of the Department of Environmental Protection.
' The oneinat should be sen: :u me, stem owner and copse; lent to the buyer, if applicable and the approving aut�ohr .
' INSPECTION SUMMARY:
Check A. B, C, or D:
' Al SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
' passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
' imminent. The system will pass inspection if.the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
' (revised 8/ls/9si
One Winter Street • Boston,Massachusetts 1121,111 • FAX(617)556.1049 • Telephone(617,292-5500
Printed on Recyded Paper .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' CERTIFICATION (continued)
Property Address: 62 Hickory Hills Circle, Osterville
Owner: Robert Brown
' Date of Inspection: 9/21/95, 9105/95 & 10/12/95
61 SYSTEM CONDITIONALLY PASSES (continued)
' Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of 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.
' 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL,PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of'a.surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
' THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT.
_ The sv5iem, na= a 5eotic tangy: ana soli absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The systern 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.seatic 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.
' 01 SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below..The Board of Health should be contacted to determine what will be necessary to correct
' the failure.
Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool
_ Discharge or ponding of.effluent to the surface of the ground or surface waters due toan overloaded or clogged SAS or .
cesspool.
(revised 8/IS/951 / 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION (continued)
Property Address: 62 Hickory Hills Circle, Osterville
Owner. Robert Brown
Date of Inspection: 9/21 & 9/5/95 & 10/12/95
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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 dogged 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.
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 Weil water analysis for
coiiform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
q LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Lange 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:
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 IIWPAI or a mapped Zone II of a
pubiit water suuui% weir.
' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
1 •
t ,
(revised 8/I5/M 3
1
1
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 62 Hickory Hills Circle
Owner. Robert Brown
' Date of Inspection: 9/21 and 9/5/95 & 10/12/95
' Check if the following have been done:
R Pumping information was requested of the owner, occupant,. and Board of Health.
X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
N/AAs built plans have been obtained and examined. Note if they are not available with N/A.1)
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
NOAII system components, excluding the Soil Absorption System, have been located on the site. 2)
X The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of baitles or
tees, material of construction, dimensions.,depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
' X The facility ov-,e- ;and occupa^::. if di;ferent from owner; were provided with information on the proper maintenance of Sub-
Surface Disposal System.
1) Design plans and permits have been located.
Copies are attached.
2) Tank and leach pit were located. No Distribution Box exists.
None was required by applicable regulations at the time of
original design, permitting and construction.
(revised 8/I�i951 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION
Property Address: 62 Hickory Hills Circle
' Owner. Robert Brown
Date of Inspection:9/21 and 9/5/95 & 10/12/95
FLOW CONDITIONS
' RESIDENTIAL:
Design flaw: +550 gallons Per day
Number of bedrooms:
Number of current residents:None -- House is vacant and has been for several months
' Garbage grinder(yes or no):'N
Laundry connected to system (yes or no): Y
Seasonal use(yes or no):? 4 not ocP-p ed/ t ed for year >aomd use
Water meter readings, if available: f 9 - ��I gaI'
+ Spring 1995
' Last date of occupancy: —
COMMERCIAL/INDUSTRIAL: -- NOT APPLICABLE
Type of establishment:
' Design Flow: Sallons/day—
Grease trap present: (yes or not
Industrial Waste Holding Tanis 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 occupant}•:
GENERAL INFORMATION
1 '
PUMPING RECORDS and source of information:
Barnstable Septage Handling Facility/Water Pollution C'nntrol Rnard humped 3/7/91
' System pumped as part of inspection: (yes or no')NO 6/3/85
If yes, volume oumue<:. eallons
Reason for pumping:
' TYPFXOF SYSTEM
Septic tdnk/dKHi5KKafiKWVsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:.Date of installation: +Summer 1975
+20 years from records of Town Building Dept.
Sewage odors detected when arriving at the site: (yes or no1No
(revised 8/15/451 S
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
' Property Address: 62 Hickory Hill Circle, Osterville
Owner: Robert Brown
Date of Inspection: 9/21 & 9/5/95.& 10/12/95
tSEPTIC TANK•X
(locate on site plan)
' Depth below grade: 1 — — —
Material of construction: X concrete metal FRP —other(explain)
Dimensions: X w X
Sludge depth:
Distance from top oofrsludge.to bottom of outlet tee or baffle: N/A
Scum thickness: 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: "
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.)
GREASE TRAP: N/A
(locate on site plan)
tDepth belo%., grade:
Material of construction: _concrete _metal _FRP _other(explain;
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
flit. nce from b tnm i a 0, r)2!I.e. -
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. eft..,
(revised 8/.5/95) 6
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F .ORM
PART C
' SYSTEM INFORMATION (continued)
Property Address: 62 Hickory hall Circle, Osterville
Owner: Robert Brown
' Date of Inspection:9/21 & 9/5/95 & 10/12/95
TIGHT OR HOLDING TANK:N/A
' (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity:-------_gallons*
Design flow: eallons/dav
Alarm level:
I Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
I
DISTRIBUTION 8O00NE
(locate on site plan;
' Depth of liquid level above outlet invert:
Comments:
' (note if level and distribunc;:, equal, evidence of sohds ca.-ry-over, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order.(yes or no)
' Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
' (revised 8/15/95; 7
SUBSU
RFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION (continued)
Property Address: 62 Hickory Hill Circle, Osterville
Owner: Robert Brown
' Date of Inspection: 9/21 & 9/5/95 & 10/12/95
SOIL ABSORPTION SYSTEM (SAS): X - See attached sketch and attached Design Plan
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
' Type:
leaching pits, number: 1
' leaching chambers, number._
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
' overflow cesspool, number:
Comments: (note condition f s il, igns of hydraulic failure, level of ponding, condition of vegetation,etc.)
No sign of i°ailure
CESSPOOLS: N/A
' (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 ground-water.
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: N/A
(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 8/25/95) .8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 62 Hickory Circle, Osterville
' Owner. Robert Brown
Date of Inspection:9/21 & 9/5/95 & 10/12/95
SKETCH OF SEWAGE DISPOSAL
SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
' locate all wells within 100'
1
OLEAct-1 t��T.
O `
p
loop
5L-7r'ic Ta�JtG.
tiV �S
t
' DEPTH TO GROUNDWATER
Depth to groundwater:' ± appromatio
feet
meth of of t Best available information on nearby surface water and n•
wet ands; test pit intorma dtrieft +ffa�, attached
ac he,i
(revised 8/15/95)
9
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09-21-1995 11:04AM FROM 508-771-7626 TO 4201856 P.05
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PR Y ADG T20NING DISTRICT CODE SP-DISTS.I DATE PRINTED I STATE
ICLASS PC NBH KEY No."
0062 HICKORY . HILL CIRCL 11 RC 300 11C0 07/09/95 1011 DJ 29AC R12U D 2
LANOIOTHER FEATURES DESCRIPTION ADJUSTMENT FACTORS Y UNIT 'ADJ'D.UNIT
Land 62425
eyroare size Drmens_ LOC./YR.SPEC.CLASS ADJ. COND. P PRICE PRICE ACRES/UNITS VALUE D. iplion B R 0 W N. R 0 B E R T F MAP—
CD. FF-De 1NA—s #LAND 1 34,400 CARDS IN ACCOUNT —
L 10 18LDG.SIT 1 X .3 =10C 186 49999.9S 92999.99 .37 34400 #3LDG(S)—CARD-1 1 78.500 01 OF 01
A #PL HICKORY HILL CIR COST 1129
N BATHS 1 .1 U X C= 100 600OAC 6000.00 1.00 6000 d #DL LOT 46 4ARKET 94000
D FIREPLACE U X C= 100 3100.0 3100.00 1.00 31JO J #RR 0697 0133 1300 0117 INCOME
A #SR POPLAR DRIVE JSE
D
APPRAISED VALUE
D J k 112,900
A U PARCEL SUMMARY
T S AND 34400
A T LDGS 78500
—IMPS"
E TOTAL 112900
F EY CNST
E N DEED REFERENCE1 Typa DATE M A—d d R I O R YEAR VALUE
A T Buok Papa Inal. MO. Yr.p Sol-Prie. -AND 34400
T S 2321/210 00/00 3LDGS 78500
U rOTAL 112900
R
E I BUILDING PERMIT S T I MATED—8 3
S Number Dale Type Ae I
LAND LAND—ADJ INC ME' SE SP—BLDS FEATURES BLD—ADJSI UNITS
34400 9100 311743 6/75
Ii- - -onsi. Total e r Bull Norm. Obsv.
CLts' Unns Unns Base Rale AUI.Rale A I Age DeVr COne CND Loc as R G Repl Co51 New Ael Repl Value Slopes Meipttl Roden Rma Balba a Fia. Portywall Fao.
;OTC+ DJO 100 100. 63.30 63.30 75 75 19 80 95 75 104687 73500 1.5 6 3 1.1 6.0 I
—D�crpl'n Rale Square Feel Repl.Cost MKT.INDEX: 1.DD IMP.BYIDATE. / SCALE. 1/D 0.8 2 ELEMENTS CODE CONSTRUCTION DETAIL
j on$. luu j63.30 936 59249 UNUSS AREA ZlJ4U SINGLE FAMILY DWELLINGCNST GP:'
F:?:r $5 50 96 816 N *----1 2---*
T STYLE 04 APE COD 0.0
i001 63.301 168 10634 x FWD 8 5 ESIGN ADJMT J6--------------------D_O
R ! -_15 .42 -_ `9 L 936 24888
, -� ��•� I IcXT�R:tIAILS _OT �06 FRAME------- D.0
U i i ' *—__---- 36------*--$--- 4— 14---- EAfi/AC rtYPE 02 AS ---------------0.7
C I ------- 1 *1S8 ! InTcfF:F7NfSN -00 -- --i ; ! ! NTeR:LA-YOUT- -UT ------------------D.O.
U j ! 12 12 NTc9 4UACtY 02 nME A5 EXTER. D.OI
R I i - ---------------- I
i
LOUR-ST-RQCT- -GO -O.-O
A - -
L u I I W ! ! ! E LDViR-COVER- UU U -O
To,.' iA , - 96 ease= 1104 2b BASE *----14----* 00-F_TYPE---- -JO-------------------'O.O
t - _. _
BUILDING DIMENSIONS ! ! 'CEC TR IZ AL--- )0 � ----------------.-. �.O
T BAS W 36 N26 E36 FWD E04 NOS W12 ! ! OUKDATIbN- - -OQ - - -- 9v.9I
A ISO8 E03 .. 1SS E14 S12 W14 N12 ! ! ---- ------- --- -- -------------
-----vEI_i9cT0RH OD 2-VA D-S-TTCCE-- -
i BAS S26 ,.. 1
L ! LAND TOTAL MARKET
! ! PARCEL 34400 112900
-------------- AREA 3660
VARIANCE +0 +2984
STANDARD 25
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' t. ' r`S :"Pit ? do LF'S h�•{e.`a"iy}1 �Y!,�^i(��jdct4 �A;�i{'�.C_.'t'�t jk f # }k'+'¢`:?t'(11f 4 :!' Y+ 1'u, C j.E+ ,, � .!i+' .yi,i 5 .4 .._.r •r 1
N1. 61�t4?4ry�t' r K': ••a..`..=1tf�rv,, i t. ;,. L1
ardin the above
,hereby'agree to..conform to all. the Rules and Regulations of the Town of Barnstable rig 9 Iy
� , n r r-- r. �J y 'Y ! �'� - ,7 rk3 xj ( }!�„ I'f.c•1`r' 6: r�•: + tr + 1 t;t c
construction
.. i ?
Name . .� �'�l.. �!h•
..............
THE COMMONWEALTH OF MASSACHUSETTS
IIOARDQRF411 TH F.,..............
...........OF.......
. . . ... .. ......
-for Eli-opmal Marko Tonfitrurtion Verntit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: f— —
///.................. 4.c.......................................... ..................... ......
No.
eo io V ,1,
..........................UAW-V ...................................................or Lot ..............................................
)- Jr 107(Xf-1271f
. ...... 00 ...........................................
..................................................
Installer AO�V, Address
Type of Building ; I Size Lot............................Sq. feet
Dwelling-VNo. of Bedrooms------------Z----- ......................Expansion
Expansion Attic Garbage Grinder
-----
Other—Type of Building ............................ No. of persolis............................ Showers Cafeteria
otlxtures .....................................................................................................................................................
Design Flow KA, ........gallons per person per day. Total daily flow.....a 6 a ...................gallons.
...................
ai
---------/�44.gallons Length................ Width_............... Diameter.... ...._...... Depth........-.......
Septic 'l'.utk Liquid
Disposal Trench—No. ....................
Width............. e Le 'I. . e —...... Total leaching arca...................sq. ft.
/ ?A. 1pth — oiiMnet.................... Total leaching area..__---._._.._....sq. it.Seepage Pit No......../.......... Diameter.. ._
Z Other Distribution box Dosing tank /0C_- ,df-t_ — /A-— ?/ — rj—
P-4 .................. ... ...............................
Percolation Test Results Performed by........................................................ Date ......
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rr
t.....
on of ..
Description ....... .
.. .....
... ..................
S I ........ ........
.............. ..........
.......................... .............................................................................................................................................................................
Nature of Repairs or Alterations—Answer when applicable..........................................................................................•••••.
.........................................................................................................................................................11111,111*................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article X1 of the State Sanitary Code— The undersigned further agrees not t.o place the system in
operation until a Certificate of Compliance has been tied by the board of health.
Signe ....... ... .... .....2..... ...... ......................................... . ......t., .Date..7..A.......
Application Approved By..... .... .....
Date
7
Application Disapproved for the following reasons:........................................I.......................................................................I
..........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......?.. J/...... ..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ALTH
............
0 F..................... ..- ,e��- . .... ......;................
Tertifirate of (9nutittiattre
L, 11nosal �jstem constructed <or Repaired
THIS IS TO C' ER 11-YThat Lk-A01vidual Se a e 1:7
� _t e
.................................................................
by...Q0 — Ake* ....... a
Inst er
.. ..........
. . . . .... . ......... . . .......
'o f ArLiftX I Qf 'Elie State S a n i tar v Code as described in the
r
has been instilled in ccord. ice rll the,j,)rovisions
appli'cation for Disposal Works Construction Permit No. .. ......V.4.............. ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY,
DATE................................................................................ Inspector..................................I..................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
................
. . . ........ .........OF...........
N o.......... FEE. ,.................
.........
y granted Z
an ais posa�l teth-
to C el) Individual
0 . . .......................I.....................................
at N
? et
ate 7�
as shown on the application for Disposal orks Construction N ......... . .......................
-pp d....
..................
I Board of Ilealtl
DAT -7 ... ...............................
E..... .....1.,.. - . . -
FORM 1235 H0913.9 & WARREN. INC.. PUBLISHE '✓i
1
1
1
1
1
1
1
1
1
1
1
' 1
1
1
1
� �
TOWN OF BARNSTABLE
r
LOCATION 6 � C� Q SEWAGE # ' ," /
U-LAGE j,Z r�l_-Pna ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY (HIV
LEACHING FACE= (type) (size) NW1L
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 'Feet
1 r01vate Water Supply Well and Leaching Facility (If any wells exist
,on site or within 200 feet of leaching facility) t
Edge of Wetland and Leaching Facility(If any wetlands exist
°within 300 feet of leaching facility) Feet
Furnished by
0010 G VA
p loco Ga`
S L-7T'�c Tn►�Jt�
O
�4
.(J!>...... FizE...149................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDr HEA TH
V (�- ---------0 7,�&-- --- -------
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
� "
�- /^�� UAll" '����� _..��..�--_'���K��°� «w~ "�
z��u� �a�,� '
Type
of Building ' S�� Lot------.---Sn feet. DwcDiug��I�o. of Dodr000�o----��..�-..---_---. Attic (^-�� Garbage Grinder ( )
Other--Type of Building ---------------------------- No. of persons............................ Showers ( ) -- Cafeteria ( )
- _��--'es_ ---.--'--_-_--.--_-'----_-_---__----- .
D ' Flow. '��.��._---_ � - �nDoos per person per dun Totaldaily flow.-����.!�--------�aDous. |
S�*icIunk�-L�u@ i Length._'-__- \f�b6-----� D�m�rr-----' Dqu|`-----.
Disposal Trench 0u Width ft.
S��ya�� ��t I�o'.-.��---. D�u�toc..�'��g�-.'D�pHz Aelft;�����_.. Totallcachi��-area------sq� �� '
�c 0t6cc Distribution box ( ) Dosing �o ( ) �-� � ������� .
~~ Percolation Ioot Results Performed bv----------- ............................................................. Date----------.----_--'' . |
][e/t Pit No. l----------------minutes per inch Depth ofTest Pit.................... to ground water------- ----- �
Test Pic No. 2--_--- inntcvper inch Depth
Ix .. .
w �
--- -��=` ��� ^ ~- '
- -��'—'--'r-»�---'��"n�=�'=°�''-"���=~--=~`�--' -�r~�~~�w�''�------- �
�� ----------------'—'----.--------_-__--------_._---.__-------.-------_-_.
� �� Nature of Repairs or Alterations—Answerwhen applicable------ ----------- --------------- .............................. -------
.---.-----.-------._-'------_--_-------_-_----.-_--_----------------_-
Agrrnozeut: -
T6e� -----`"--- agrees to install the --------- lu6ividoa- Sewage Disposal System �u accordance with
K � �
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place theV
| operation until a Certificate of Compliance has
......................
Date
Application Approved 8y.'- --'��.-,�'���.`.������ `
~ u"u
Application Disapproved for the following rxuxons:-_—__.----
.-.-___-'---_-.---__---'_.-----
.................................................. �
| �
� --��.��1'.-�--'��Permit Issued ...-._-'___
Date
�
--~^^-------------------'---'--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD qF HFA TH
................
1
ApplirFatinat -for 131!i' oii al Works T anuitrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systema Lo o A dr ss----•-----........................ ..•-•-••..............................•--•or Lot
o
�__ f _!� .� inr U� ---- ----• ress ---•-------------•--- ---
...-- --------- ----- -----
Installer wl) _ Address
U Type of Buildin - Size Lot----------------------------Sq. feet
DwellingUNo. of Bedrooms---------- _''__________________________Expansion Attic (�"'S Garbage Grinder ( )
aaOther
—Type of Building ............................ No. of persons_::___-._.-____________•_.__ Showers ( ) — Cafeteria ( )
dOt xtures .............................-......----------------------------------------------------------------------------------------------------------------
Desi n Flow_ Mons per person per day. Total daily flow__-_rZ.�Q_________________________ Mons.
W g --------------------------g� P P P Y• Y --- g�
WSeptic Tank ."Liquid capacity -gallons Length-_------------- Width---------------- Diameter---------------- Depth--------........
x Disposal Trench=•No_ ____________________ Width-------------.___ a L Total leaching area__.__._._ .____._sq. ft.
Seepage Pit No... Diameter_ /_ o?ii .._..... Total leaching area.____-_ ___.sq. it.
--- -/ ---D---- P
Z Other Distribution box ( . ) Dosing tank ,�
a Percolation Test Results Performed by-------------------------------------------------------------------------- Date.............__.
Test Pit No. I................minutes per inch Depth of Test Pit--------------------- Depth to ground water--------.________.___..
44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_---___.________---____.
P4 --------- f 1 --- * � d .
D Description of S it-y Q- ��= erg --------
x
--------- :.Z = - r
W _. .�.._.... GaE,r,t : ------- " { ---------------------
r
Z --•------•----------------------------------------------•-----•------------•-------------------------------------_----------------------------_-_-----•-------------••--•---------._.-•---------------
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 • sued by the board-of health
r f R
Sijej gned-_ ____
Date
Application Approved BY .."
Date
Application Disapproved for the following reasons-------------------------- = -
•--•••-•-•----•-•---••------•---•---•-----•------------------•-••---------•-------••••-•••-••--•---••--••-----•-•---•...........--•--•--••-•......--------•--•------------.:=...--------•------•-•......
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF ALTH
•
. ............OF............:......: .., ••. .............................
(IrrtifirFatr of' Tontphattre
THIS IS TO CER IFY hat e vidual Se a e Dosal System constructed - ' ) or Repaired ( )
1 Inst er
at / -- -- •---- • . ------ • --•--••-• ... ........ ...
leas been installed-in accordance h the provisions of Art' XI of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No. _..__ .V-----•_____._- dated.._.y,�`:,A_—_�-�_"'.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.,
DATE................................................................................. Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEATH
It........OF.......... .. �_ 45V_-R.:.
,,.✓
No.......... FEE--- ..
Di-spoiitt nrk,i LIT Mr tion
Permis ionf is hereby granted ---- - -------s -•�-4- l
to Cons t o epai an Individual S"wa posal tern-
at No. 1r4
et
as shown on the application for Disposal orks Construction r it N Dated...._rJ7t.42._"'_75-1
...... s'• 4-------••-• -----
Board of ea
,
H 1t
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS.d'" ,
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