HomeMy WebLinkAbout0074 HINCKLEY CIRCLE - Health 74 HINCKLEY CIRCLE, OSTERVILLE
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DATE: 8/6/v9:8
PROPERTY ADDRESS: 7=4 Hi-'tckley 'Circle 4uo
Osterville,Mass. T0�►'Or 1998 r
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02655 �� J
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On the above date, I Inspected the septic system at the above. address.
This system consists of the following:
1 . 1 -1500 gallon septic tank.
2 . 1 -bistribution box.
3 . 4-infiltrators packed in stone.
Based bn my Inscuactlon, I certify the following conditions:
4 . This is a title five septic system':'� '=
5 . The septic system is- in proper working order
at the present time.
81GNATUR!7,:
Name: J . P.Macomber Jr... i
-------►---------------
Company:_`. P_MacoMber & Son'_Tnc , r
Address:
__Cente�rvilLe AUs__0.2.632
Phone:___5Q8-_Z7.5_.333a------- • I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
•
rJXOSEPH P. MACOMBER & SON, INC.
Tanks-Ceupools-Le"hf IaIds
Pump♦d 4 Inst.alla-d
Town Sewer Connectlons
P.O. Box 66' Centerville, MA 02632.0066
77.5-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617.292.5500
WILLIAM F.WELD TRUDY COXT
Governor SC(:retan
ARGEO PAUL CELLUCCI DAVID B.STRUft
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions
PART A
CERTIFICATION
Property Address:74 Hinckley Circle Osterville Address of Owner:
Date of Inspection: 8/6/9 8 Mass. (If different)
Name of Inspector: Joseph P.Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: J-P Macomber & Son Inc.
Mailing Address: BOX 66 Centerville,Mass. 02632
Telephone Number.5 f1 R—7 7 5—'I 13 R
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:
_,e/Passes
— Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: O"
The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inspection. If the system is a shared system or has a design flow.of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) SYSTEM PASSES:
es 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.
COMMENTS:
61 SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the `Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;,or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:l/www.mapnet.state.ma.us/dep
Printed on RecycJed Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 74 Hinckley Circle Osterville,Mass.
4<.i) r.•�i ... _ Joseph Callahan
Date of Inspection: 8/6/9 8
BJ 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
dO 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
C)JURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
�Iln 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:
il4 Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
4 ZD The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
q(Q The system has a septic tank and soil absorption system and the SAS is within 50 feet of.a private water supply well.
4�0 The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance .eL41 (approximation not valid).
3) OTHER
�9 A
(revised 04/25/17) PeQe 2 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:74 Hinckley Circle Osterville,Mass.
Owner: Joseph Callahan
Date of Inspecticn: 8/6/9 8
D) SYSTEM FAILS:
You must indicate ei;�.er "Yes" or"No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
,_,I/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesapoal-is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped d .
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 well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
iIUF the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall 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.
(swlsed 04/25/$7) Z1&9. 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 74 Hinckley Circle Osterville,Mass .
Owner: Joseph Callahn
Date of Inspection:. g/6/9 g
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes ' No i
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
x _ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, eWfuding the Soil Absorption System, have been located on the site.,
_ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/35/97) Page 4 o1 10
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SU8SURfACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Piopenr Address: 74 Hinckley Circle Osterville,Mass .
O.;ner: Joseph Callahan
Date of Inspection:$/6/98
FLOW CONDITIONS
RESIDENTIAL:
Design flo». ,'- R•pn.dJbedroom (or S.A.S.
Number of bedrooms:O�
Number Of Current residents:
Carnage grinder (yes or no).�
Laundry Connected 10 system (yes Or n0).A=--
Seasonal use (yes or no)._ ?, /.y /69 p aar
Water meter readings, if av ilab(e (last two (2) year usage'(gpd): I ftP Flat'.Dea" > % -
SvmO Pump (yes Or no):� / - L/440
;ast Case of occupancYLL �!(�,0
COMM FRCIAUINDUSTRIAI, �1
Type of establish nt: /eft
Design flow: allonslday
Grease Trap present: (yes or no)A4
industrial Waste Holding Tank present: (yes or no),.L&
-'son-sanitary haste discharged to the Title 5 system: (yes or no)"
Water meter readings, if available._ BIZ
A24
Last date 01 Occupancy: AW
OTHER; :Descrit>ei t),4
Last date of occupancy A�
GENERAL INFORMATION
PU."PING R CORDS and our a of information.
il
System pvmped as pan of inspection: (yes or no)
—40
If yes, volume pumped: gallons
Reason for pumping
TYPE OPYSTEM
V Septic tank/distribution bo Jsoil absorption system
d_ Single cesspool
Am Overflow cesspool
Privy
ZF Shared system (yes or no) (if yes, attach previous inspection records, if any)
WA VA Technolo etc. Copy of up to date contractf
Other �dd
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Se..agc odors detected when arriving at the site: (yes or no)
tr.vs..d ➢.9. 5 of 10
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SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 74 Hinckley Circle Osterville,Mass .
Owner: Joseph Callahan
Date of Inspection: 8/6 9 8
BUILDING SEWER:
(Locate on site plan)
Depth below grade;& �
Material of construction: _cast iron ✓40 PVC_other (explain)
Distance from private water supply well or suction line :Hl
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
Joints appaer tight;
vented through the house vent
SEPTIC TAN K:zpv#i ZdS
(locate on site plan)
pr
Depth below grade:,L
Material of construction: concrete _metal _Fiberglass _Polyethylene „_other(explain)
If tank is metal, list age d/A Is age confirmed by Certificate of Compliance Jam_(Yes/No)
Dimensions: /0rLod
Sludge depth.
Distance from top of sludge to bottom of outlet tee or baffle•
Scum thickness:�6� �-
Distance from top of scum to top of outlet tee or baffle;/
Distance from bosom of scum to bottom of outlet t or baffle:_ O
How dimensions were determined:
i
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.) p
place; Liquid level at the out 1
tank no si
GREASE TRAP:,d?a-o?
(locate-on site plan)
Depth below grader
Material of constructionR!dconcrete4/f*netal Fiberglass.��4Polyethylene,I�Qi other(explain)
AN
Dimensions:
Scum thickness:--AZd
Distance from top of scum to top of outlet tee or baffle:/_
Distance from bottom of scum to bottom of outlet tee or baffle:AA
Date of last pumping: .
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,-etc.)
Grease trap is not present -
(revised 04125/27) Peg• 6 of 10
Ub "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 74 Hinckley Circle Osterville,Mas"s.
Owner: Joseph Callahan
Date of Inspection: 8/6/9 8
TIGHT OR HOLDING TANK:Amdgank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade: Aii
Material of construction:AJAconcrete4L*netaINhFiberglass y�Polyethylenea/ilother(explain)
AM
)JA '
Dimensions: ►)A
Capacity: j1A gallons
Design flow: A gallons/day
Alarm level: Alarm in working order W Yes; No
Date of previous pumping: 04_
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tight or holding tanks arP not nresept -
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet inven: qf,�b
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.)
Distribution box has nnp 1 cetera l-No Pvi dPnrp of Gn1 ; rig (-,4r
No evidence of leakage into or nut of i-hp hnX
PUMP CHAMBER:,i2
(locate on site plan)
Pumps in working order: (Yes or No) 41
Alarms in working order(Yes or No),-'
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Pump nhamhar i c not
(revisal 04/1S/17) P&g• 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 74 Hinckley Circle Osterville,Mass .
Owner: Joseph Callahan
Date of Inspection: 8 6/g g
SOIL ABSORPTION SYSTEM (SAS):z1,.A1�T,*7jrf
(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::
leaching chambers, number: Jyi�,�7'W4�r�
leaching galleries, number:
leaching trenches, numberjength:
leaching fields, number, dimensions:
overflow cesspool, number:-426
Alternative system: AA
Name of Technology: I
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Loamy sand to medium coarse sand -Na�gi gnc r,f t yCjraj lic
f a i 1 nrgn or i nnrii nc y All ypgPtat i r)n i c nnrma 1
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: A114
Depth of solids layer:_
Depth of scum layer: Z1
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Cesspools are not present -- -
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Cesspools are not present
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.)
Privy is not present
(revised 04/25/97) page B of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropenY Address: 74 Hinckley Circle .08terville,Mass.
Owner: Joseph Callahan
Date of inspection: 8/6/9 8
SKETCH Of SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks housel
locale all wells within 100' (Locate where public water supply o
Cr41
WWII) Y.g. .i or 10
lr.vi.•d
SUBSURFACE SEWAGE DISK.;:.•,L SYSTEM INSPECTION FORM
it'0' C
SYSTEM INFOIt,.t .riON (continued)
Property Address.74 Hinckley Circle Ostervil.le,Mass .
Owner: Joseph Callahan
Date of Inspection: 8/6/9 8
)
Depth to Groundwater f Feet
Please indicate all the methods used to determine High Groundwater Elwation:
Obtained from Design Plans on record
Observation of Site (Abuttin ro erty, bservation hole, basemtrti'sump etc.)
Jz Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
--/- Check local excavators, installers
Use USGS Data
Describe in you.- own words how you established the High GrouncPxev-Elevation. Must be completed)
Used water contours map.
Gahrety 8 Miller
12/16/94
' s
(rrvised 04/25/31) Y&g- 'lbot 10
>•rwnr.r n ITTPIT trnrmr•�tt+.�"..>'t r..rm:nnTr.tr.tr�.+nRn.>t tTRM1L T>-•tn'nmil n'.'t
.TT•1TT�.TTR�:..t..t
'TOWN OF Barnstable BOARD OF IIEALTII
SUI)SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CER'rIFICATION
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\� fl^•TI•I�T•:: t�T,tIR�•T.TTI+>t mlT�lT•ITTtRt/f/"R1T.r t•i T!SVPR�RR�r-1'�r�t�t�.��
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
11 Hinckley Circle Osterville,Mass.
STREET ADDRIrSS Y i
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Jose h Call•ahan
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P Macomber Jr.
COMPANY NAME J•P•Macomber & S&I 'Inc.
COMPANY ADDRESS Box 66 Centerville,Mass. 02632.
street Town or City Stoto. iIF
COMPANY TELEPIiONE (508 ) 775 - . 3338 FAX ( 508 ) 790 -1578
.n
CERTIFICATION STATEMENT
I certify that I have. personally inspected the sewage disposal system ,
this address and that the information reported is true , accurate , and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of oI
site sewage disposal systems .
Check one:
Y Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con acted has found that the system fails t
Protect the pt►blic Health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
r , -
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF 11EAL1'll.
* If the inspection FAILED, the owner or "oporator shall upgrade ' the system.
within o'ne year of the date of the inspection , unless allowed or required
otherwise as provided in 3,10 CMR 16 , 306 .
partd .do
Ld
ti
S
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
t X. 1995
Acting Dircctc>r of tltc. L)' iuit ul WaIcr Pullt11ivn Control
ka, T WN OF BARNSTABLE
LOCATION a SEWAGE #
va:LAGE ASSESSOR'S MAP.& LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Z6, AC
;t
LEACHING FACILITY: (type) (size)
,NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility — Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet o le ility) Feet
Furnished by `
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// � '' '. '`` I�c�A1 .
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'� ��
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i�� _� � �
. /i � �
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1.
(.l't -
�:.+ -
TOWN OF BARASTABLE
LOCATION N SEWAGE #
VILLAGE bS `f" ASSESSOR'S MAP & LOT 1 YA r 7
INSTALLER'S NAME&PHONE NO. ' kAy'.3
SEPTIC TANK CAPACITY so a
LEACHING FACIL TIT: (type) T°-�� i` S. (size)
NO.OF BEDROOMS �� per M�
BUILDER OR OWNERl
PERMITDATE: "1 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland Leaching Facility(If any wetlands st
within 300 f et lea ng facility)) Feet
Furnished by
J
A9, �,,
V&A {1 S
.
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativat for Di-lipwial lVarkii Tomitrurtintt ramit
Application is hereby ina� fa Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Syst at
• e .
�a ��
.............. Loca-•-•-- = —
��/'� Locati n-:lddress �'7 e o,
............ [__� CCU y��kle.� j QS �! �N4: -
encr
d ess
..------� ►t�. ,���-5-•------•------------------ �Srn0., ....5 :..... �nQ ..rnu, oab�P9
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--..-..-._3-----------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -.-.- ........... ..... No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures ----------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow---------------------------------------.-..gallons.
04 Septic Tank—Liquid capacity............gallons Length---------------- Width.........------- Diameter_------------- Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No--------------------- Diameter.................... Depth below inlet.--................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.......-_.-._....--- Depth to ground water...-........--..-----..-
G14 Test Pit No. 2................minutes per inch Depth of Test Pit---:................ Depth to ground water........................
a ----• -•-----------------------••---•••-•.i• -----=--------------------------------•-•-•--------------------•----------------------------__...._---------
0 Description of Soil.....----- � .........':NXIC......................................
U ••-------•--------------••-----••••-••--•-•---•-•------•-•-•---•••-•--------•-•---------•••--•----••••-••------....-•----.•----•-•--•••---•---•--•-••--•----•--------•-----•----•-------
W ----------------------------- ------ ....-------- ---------------------
�� is- �16 Ce55 ud
V N ture of Rep irs or Alterations=Answer when applicable._. .—_Tn `� � -)
--- ------- H---
.. .• ................ .......... ...... ...
Agreement: �� Q�� �� �►
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 Compli e has been issued by the board of health.
Signed -----.-.
-- ------------------------------"'----------..------------------------------- --- -._:.« �:gY S
_ Dace;
Application.Approved By .......... --� - t----I--W--- S
Application.Disapproved for the following reasons- -------------------- ---------------------------------------------------------- -......- ..-. ........
....--..._...................... ......... -------------------- . ..lo...... iq-�
-. ��°°r� ���� �J � Date
Permit No. ----- F� ..--....-..... ./P- ------ 1-1-Is- -----------
.........-.. Issued � -
..--..-_. Date
Fizic..3.0 OD
THE COMMONWEALTH OF MASSACHUSETTS
{{' BOXeR® OF HEAL�H r
TOWN OF BARNSTABLE
Appliration for Dbripoml Work,i Tiontitriirtion tiPrmit
Application is hereby mla 1? Permit to Construct ( ) or Repair (Lo)n Individual Sewage Disposal
Sys at.•
ri
................
Location.:\ddress o� // i (4
------------ ------------------
f„. . • .`� -
Installer Address
U `..l Type of Building Size Lot............................Sq. feet,
w� Dwelling— No. of Bedrooms----------- ------------------------_.--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ----- ---------------------- No. of persons-----------_--_--.------ Showers ( ) Cafeteria ( )
dOther fixtures - ------------------ -------- ------------------------------------------------- ...............
' ...............gallons per person per day. Total daily flow..--.-.._._...._..._.
W Design Flow. -------•----:--: g P P P Y ------'--------•-------dons.
WSeptic Tank—Liquid capacity..-.._.----gallons Length---------------- Width---------------- Diameter---..r.......... Depth................
x 4 , Disposal Trench— No. .................... Width-------------------- __.
.-_...._._--_- Total Length..._---...._........ Total leaching area-..-----__ _.-_•__sq. ft.
Seepage Pit,No...................... Diameter...------'....------ Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank-( ) s
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.------ ..-----.-._- Depth to ground water........................
(Tt Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
---------------------------------------------------..........---......_._._................................---................................................
Descriptionof Soil------•----�['L"-------..... --------------------------- --------------------------------------------------------------•---------------
U ...........................=...............................................................................................................:.............................-......
W ----•-------------------• .................................---------------------------------------------------------------------- --------------•---......----•- ---•-- :.
M. P
U Nature of Rep irs.or Alterations—Answer when applicable...A?(riY-4... `.....-..-.V�_ CK�b�-'`l-- _ Ce55 ,
-. .
ems.. t,N .r4 anti ed S.to
---•-•--
Agreement: Lk° �y e-e.'t m a-`42r'
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 7ce has been issued by the board of health.
Signed --- - ---------- C--4 "'------------------- ---{ '....-�D 11?J` r`
Application.Approved BY . . �.-.. ..- .... -.-0�
- a '_ l -.-----------------
_ Dte
Application.Disapproved for the following reasons: .... -._._......... ................ ....... - --..................... ...... t.�j, .....-t�.�
F ................................n------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ....................................--.S
' •.. c,� .rn ! s Dare
Permit No. ---
I_ /- �J7 ...--- -------- Issued ...... 4�.:..t`0.�{ f ` J
T Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
QTertifirate of Contpliance
"�JS IS TQ CERTIFY That the Individual Sewage Disposal System constructed or Repaired
by ......T"A'
-------------------- ------------------- -------I..... ...z-------------------------------------------------------------------------
Installer
Is
at ----------------- -----------tVNQ--�...U-4 -------
I L4 --- ---- ---------- -------- ----
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ----7,57--------J-75-67- dated ----10-11.....9-57
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS;A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------........... . .... ---------------------- ---- ------- Inspector -----------------------------------------------------------------
------------------------------ ------------
THE COMMONWEALTH OF MASSACHUSETTS
P4V,edd:�-
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...?., 5, FEE
Tvaptnution tlgrmit
V-zo�s,,T- " Lv�,�j Permission is hereby granted-- -------------I..................... ...................................................................
to Construct or
— .4R..e.p..a..ir. ( , � Individual SeA e Disposal..S.
ysterl
atNo---------------- 1 . . ---------ma ..........................
-------Street
X�' - Dated---------
as shown on the application for Disposal Works Construction Pern�it . ...... CR5
......................................... --------------------------------------------I..............
,Board of Health
DATE_Awu.A . lo
....................7.............. . `s............................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
A a
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
P
I, �`� � I ������., hereby certify that the application for disposal works
w
construction permit signed by me dated 04, �' �t�� concerning the
property located at � i Nl meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : `\ DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER:�S
[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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