HomeMy WebLinkAbout0070 ICE VALLEY ROAD - Health 70 Ice V allev Road
Osterville' v
A 096—004 - 004
� I
v
Commonwealth of Massachusetts y �9� �
Title`'- fficibal Ins- a ti, n or
_ s Subsurface.Sewage Disposal System Form Not for Voluntary Assessments
70 Ice Valley+rd 3>. _..
Property Address 11-A
. .. Iw
> y
Joseph.Berkeley
Owner Owner's Name - O?
information is
required for every OsterVille Ma 02655 5/2/16 7—
page. City/Town State Zip Code Date of Inspectiew
Inspection results must be submitted on this form. 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"Dnforma BOB9
on the computer,
use-only the tab 1. Inspector:
key to°move your
cursor-do not Michael DiBuono . r :•
use the return _ -Name of Inspector
---------__ .._ __-_.-------_....
key.
DiBuono Sewer and Drain
rab Company Name -
8 Johns path - ?;
Company Address
S Yarmouth Ma 02664
CityrFown State Zip Code
508-364-9587 _ S103522 e
`-Telephone Number License.Number
' B. Certof ceti®n
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 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation b the Local Approv f.g Authority
5/2/16
Inspector's Signature Date
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
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office.of the DEP.-The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
t5ins-3/13 i� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r,-
C®msva®hwea0th of Massachusetts r
Title 5 Official Inspection; Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 -:'701ce Valley rd
M
CjP,roperty Address
- Joseph Berkeley
Owner . Owners Name .
information is Osterville
required for every� Ma 02655 5/2/16
page. ;�City/Town ____ _ .... State Zip Code Date of Inspection
'B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/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: i...
=: System contains a2000 gl'septic tank as well as a Dbox and two 6'x12' leach pits. Pits are
functioning properly and dbox shows no signs of push back
13) 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.
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): W
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
N Title 5 Official . Inspection Form
Subsurface Sewage Disposal System form - Not-for Voluntary Assessments
G1M
70 Ice Valley rd-
Property Address _
Joseph Berkeley
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired: ,
B) System Conditionally Passes (coat.):
❑ 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 ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y :❑.;N=.: E 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 L: ❑ 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.
1. System will pass unless Board of Health determines in accordance with 310 CIVIR
- — - 15:303(1)(b)that the system is not functioning in 'a manner-which-will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh -
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
a✓®mmonv✓eaRh of Massachusetts .,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;
70 Ice Valley-rd
Property Address
Joseph Berkeley
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/16
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 hz s'a�septic-tank arid'so'il'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 systerri has a septic tank and SAS'and the SAS is within 50 feet of a private water
supply well.
- t` ❑ The system has aseptic tank and SAS and the SAS is less thanA 00 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑. ® Backup_of Sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwea8th of Massachusetts
Title 5 Official. Inspection Fo-rm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owner's Name
information is
required-for every Osterville Ma 02655 5/2/16'
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last'year.NOT due to clogged or
obstructed pipe(s). Number of times.pumped:
El__ z -Any portion of,the SAS, cesspool-or privy is below high-ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
-tributary to a-surface water supply.
❑ Z. Any portion.of a cesspool or privy is within a Zone 1 of a'public well.
❑ ; , ❑. . ., . Any portion-of.a cesspool or privy is within 50 feet of a.private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal.coliform bacteria in 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.]
❑ ® -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 15,000 gpd.
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
❑ ❑ 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
E] ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)'or almapped Zone ll'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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
a_
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owners Name
information is
required for every Osterville Ma 02655 5/2/16
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?
. r El ® Have large volumes of water been introducetl to the system`recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were•all system components, excluding the SAS, located on site?
® ❑ Were the.septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® 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:
® ❑ 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)]
®: System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
qi Title_ flceal-Ins ecc® Fr
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
,M 70 Ice Valley rd
_ _Property Address --
.. _.. -.. . .__ _
Joseph Berkeley
Owner Owner's Name - -
-information is
required for every Osterville Ma 02655 572716
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
System contains a 2000 gl septic tank as well as a Dbox and.two'6'x12' leach pits. Pits are
functioning properly and dbox shows no signs of push back.
Number of current residents: 2
Does residence have a garbage.grinder?, , [I Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 108 GPD
9 ( Y 9 (gp ))�
Detail: "
Sump pump? El Yes ® No
y .5 ..
Last date of occupancy: Date
Commercial/industrial Flow Conditions:e r
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 Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth.of Massachusetts G
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 70 Ice Valley.rd _
Property Address
Joseph Berkeley
Owner Owner's Name l
information is
required for every Osterville Ma 02655 5/2/16
page. - --City/Town State Zip Code _-Date of Inspection
D. System Information (coot.)
Last date of occupancy/use: occupied
Date
Other(describe below):
General Information
Pumping Records:
Source of information: pumped 5/1/14,
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):
t5ins•3/13 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection or
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owner's Name
information is required for every Osteryille Ma 02655 512/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) Y
Approximate age of all components, date installed (if,known) and source of information:
installed 1991
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3.5
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.):
System is vented throught the roof -
Septic Tank (locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
® concrete ❑metal ❑ fiberglass ❑ polyethylene ❑..other(explain)
2000
If tank is metal, list.age c: ;E
•, _. t,y, . 1. .. t ,, years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title icial In's- pe'llctio h, Form.
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owners Name
required for
is every Osterville
required for eve Ma 02655 5/2/16
page. City/Town ____ State Zip Code Date of Inspection
D. System Information (cont.)
. .
Septic Tank (cont.)
_ - pistance from top of sludge to bottom of outlet tee or baffle 2411
Scum thickness
Distance from top of scum to top of outlet tee or baffle
_ ."
Distarce from bottom of scum to bottom of out tee or-_.baffle 1 -Sludge--stick
How wire dimensions determined?
Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of leakin ,Tees and or baffles in place at time of inspection
Grease Trap (locate on site plan): .
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for'Voluntary Assessments
70 Ice Valley rd
Property Address-
Joseph Berkeley
Owner Owner's Name -- -
information is
required for every Osterville Ma 02655- 572/16
page. CitylTown State Zip Code Date of Inspection
D. System- Information cont.
Comments (on pumping recommendations, inlet and outlet tee or baffle'condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees are in place and levels are normal.
Tight or.Hoiding Tank (tank must be pumped at time of inspection) (locate on site plan): :.
Depth below grade:
Material of construction:. . i, .
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes 0 No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts . g
W Title 5 Official Inspection Form -
? Subsurface Sewage Disposal,-System Form Not for Voluntary Assessments =
0
4
,M 7 Ice Valley
0 s•' e r d
Property Address
Joseph Berkeley
Owner Owners Name
information is Osterville
required for every Ma 02655 5/2/16
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
-level;and at•normal°levei,with no signs of carry
over
Comments (note if box is level and distribution to ouflets equal, any evidence�of solids carryover, any
evidence of leakage into or out of box, etc.):
r:
.(, j.., .. ..t ..
Pump Chamber(locate on site plan): w
Pumps in working order:. ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fob
Subsurface Sewage Disposal System Forerr>t -,Not for Voluntary Assessments
70 Ice Valley rd
Property Address.
Joseph Berkeley
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2 6'x12'
leaching chambers - number:-
❑ leaching galleries number:^
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure,-level of ponding, damp-soil, condition of
vegetation, etc.):
No signs of failure
Cesspools (cesspool must be pumped as part of inspection) (locate-on.site plan):.
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
W Title -5 Official Inspecti®n F®rm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owners Name
information is
required for every Osterville. Ma 02655 5/2/16
page. City/Town _.. State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil,,signs of hy el,ofdraulic failurejev pon,ding,.condition of vegetation,
. .. ry _ -
_No.'porid.in .n abreak.out•
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5• fficlal Inspection Form -.
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments_,
70 Ice Valley rd
Property Address �.
Joseph Berkeley
Owner Owner's Name
information is required for every Osterville Ma 02655' 5/2/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
❑ hand-sketch in the area below
® drawing attached separately - -
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
;c
Commonwaa8th of Massachusetts.
Title 5 Official -Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/16
page. Citygown- l State Zip Code Date of Inspection
`El:�SYMe"m I nformatio ri* (cont.)
Site Exam:
❑ Check Slope
❑ a
--- Surface water- ,� � _. . .. >:3<. v;. •�� 3��.
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+ ft
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
1991
If checked, date of design plan reviewed: Date
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
NGEat12 +ft
Before filing this lnspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
5/6/2016 Assessing As-Built Cards
• 07O TOWN OF BARNSTABLE
7`;757
LOCATION SEWAGE
VILLAGE CS7,;c&IGLF ASSESSOR'S MAP LOT 4'
INSTALLER'S NAME& PHONE NO.,Eg�i0 lST_
SEPTIC TANK CAPACITY c
LEACHING FACILITY:(tgge) �f'TS �.L� (size)
NO. OF BEDROOMS' `� PRIVATE WELL PUBLIC WAT R
BUILDER O OWfpv%s�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
http://www.town.barnstable.ma.us/assessing/H M displ ay.asp?m appar=096004004&seq=1 1/2
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 70 Ice Valley rd
Property Address
Joseph Berkeley
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2116
page. Cityrrown State 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
-\ GOMNIONWELTH`OF;MASSACHTJSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL;AFFAIRS
DEPARTMENT"OF ENVIRONMENTAL TROTECTION ;
. 4
(TITLE
OFFICIAL INSPECTION FORA47 NOT FOR VOLUNTARY ASSESSMENTS
SUESURFACE.SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION'
Property Address: kl/V:i> x. f 2
Owner's Name: '
Owner's Address ( '
Date of Inspection:. . _1 r
, ° q
Name of Inspertox-z-fplease Drint)
Company Name? "J7.
Mailing Address: b+ � � Ns
Telephone Number: `*
CERTIFICATION STATEMENT
I certify that I have personally inspected the.sewage disposal system at this'addfes`s and that the Mforma 1 nn repoiaed
below is true, accurate and complete.as of the time of the inspection. The inspection was performed based on mj "
training and experience in the proper function and maintenance of do site sewage disposal systems. I am aaDEP r
approved system inspector r pursuant to Section 15.340 of Title 5(310 CMR 1-5.000). The system:
"
1 aY
V1.Passes
conditionally Passes - -~
Ne Further Evaluation by the Local Approving Authority
Inspector's Signature:. _ -- Date: �;24J
t
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 has a design flow of 10,000
g'pd orb eater,the inspector and the system owner,shall submit the report to the appropriate regional office of the
DEP.The orieinal should"be sent to the system owner and copies sent to the:buyer;if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection,and under the conditions of use at that
timer This insper_tion'does not address how the system will perform in the future under the same or different
conditions of use.
Title.5 Inspection form 6/15/.2000 page, l
t J
Page 2 of I 1
s `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEIYI INSPECTION]FORIYI
PART A
CERTIFICATION (continued)
Property Address: l.d
Owner_ f
Date o, I spectio'n: D
Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D
A. S.stem Passes:
I have not found any information which.indicates that any of the failure criteria described in'10'CNIR
15.303 or in 310 CMR_15.304 exist. Anv failure criteria riot evaluated are indicated below.
Comments:.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health; will pass.
Answer yes,no or not determined (Y,N;ND)in the for the following statements. If"not determined":please
explain.
The septic tank is metal and over 20 years olds 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain;
The system required pumping more dean'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
obstruction is removed
ND explain:
1
Page 3 of 111
OF, INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWACE.DI.SPOSAL SYSTEM IN FORM
PART A
CERTIFICATION (continued)
r .
Property Address:. tj :C�
Owner:. %
Date of In ecti.
C. Further.Evaluation is Rquired by the Board.of Health.
Conditions exist which require further evaluation by the Boardof Health in order to determine if the system
is failing to protect public health, safety or the environment.
L .System will pass unless Board of health determines in accordance with 310 CNIR 15303(i)(b) that'the.
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within.'50 feet of a`surface water,
Cesspool or privy is within 50 feet of a bordering veeetated-wetland or,a salt marsh
2. System will fail unless the Board of Health{and Public Water Supplier,)f.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
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.] 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 welt_
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 coliform
bacteria and volatile organic compounds indicates that the well is.free'from pollution from'that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that-no other
failure.criteria are triggered. A copy of the analysis must be attached to this form:
3. Other:
Page 4 of.I 1
OFFICIAL: INSPECTION FORM NOT FOIE VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property Address:AFr
,✓ y �
Owner. :_
Date of Ii pectin: (
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No
. Backup of sewage into facility or system component due to overloaded or.clogged SAS or cesspool
_ Dischar e or ponding of effluent to the surface of the around.or surface waters due to an overloaded or
clogged SAS or cesspool _ V
Static liquid level in the distribution box above outlet invert due to an-overloaded or clogged SAS.or
cesspool.
Liquid depth in cesspool is less.than 6" below invert or available volume is less than %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
_ a Any portion of.the.SAS, cesspool or privy is below.high ground water elevation.
_ __ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a.surface
water supply.
. Any portion of a cesspool'or.privy is within a Zone 1 of a,public well.
_ Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is.,less than 100 feet but greater than.50 feet.from a private water
supply well with no acceptable water quality analysis. [This system p'assesif.the,well water analysis,
performed at a DEP certified.laboratory, for coliform. bacteria and volatile organic compounds
indicates that the well is free from pollution from'that.facilityand tlie;presence.of ammonia
nitrogen and nitrate nitrogen is equal.to or less than 5 ppm, provided that no other failure criteria
are triggered..A copy-of the analysis,must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as
described in 310 CMR 15.303,therefore the system fails. The system'owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a.facility with a design flora,of 10,000 gpd to 15,000,
gpd
You must indicate either"yes" or"no"to each of the following;
(The following criteria apply to large systems in addition to the criteria abode)
yes no
the system is within 400 feet.of a.surface drinking water supply
_ the system is within 200 feet.of a tributary-to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped
Zone I1 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 3.10 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of l ]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
a
Property Address: 0 jv'z' llzbe
14
Ovine -" �
L �: _ �� AL
_
Date of n'pectin : ate,
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 systern 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
r.� Were as built plans of the system obtained and examined?.(If they were not available note as N/A)
c/ 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
1/
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
d the baffles or tees, material of construction, dimensions, depth of liquid,.depth of sludge and depth of scum
—64. Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
-7
The size and location of the Soil-Absorption System(SAS)on the site has been determined based on:
Yes , no
Existing information. For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.-302(3)(b)]
Page 6of11
OFFICIAL rORIVI
INSPECTION a —NOT FOR VOLUNTARY:
O NTH>RY ASSESS
MENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: -O (Lt Z J-'m 16'e .
Owner:
Date,of Irtsrection: C _A (�5C: p
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): �j Number of bedrooms(actual).:�.
DESIGN flow based on 310 C A R 5.203 (forreexar9ple: 11.0 gpd x f of bedrooms): ?
Number of current residents ,t.
Does residence have a garbage grinder yes or no):
Is laundry on a separate sewage system A( es or no): [)if yes separate inspection required]
Laundry system inspected(ye .or no):
Seasonal use: (yes or no): JU M Z
Water meter readings, if available (last 2 years usage(gpd)): 7 'v/ � � - f
Sump pump (yes or no): ttl10 �
Last date of occupancy: / /L_.� �r .r'
COMMERCIAUINDUSTRIAL.XC
Type of establishment:
Design flow(based on 310 CMR 15.203)::. gpd .
Basis of-design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records �
Source of information:
Was system pumped as part of the inspection(yes or no): f�
If yes, volume pumped: _ gallons -- How was quantity pumped determined?;
Reason for pumping:
TYP,1?"OF SYSTEM
Septic iank, distribution box, soil absorption system .
_Single cesspool
Overflow cesspool
Privy
_Shared system (yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
p`proximate age of all conzponefn�ts, date installed (ii known) and source of information:
1, A 4t
Were sewage odors detected when arriving at the site (yes or no):
6
Page 7 of 1 1
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION(continued)
Property Address:
Owner.:
Date o pection—kL. j
BUILDING SEWER(locate on site plan) I
Depth below grade:
Materials of construction: . cast iron _40 PVC other(explain): _ _Distance-from private water supply well or suction line:
Comments (on condition of joints,venting, evidence of leakage,etC',y. '
SEPTIC TANK: 1•
/ocate plan)
on site
V
( )
Depth below grade:
Material of construction:,-concrete metal fiberglass_polyethylene
other(explain)
If tank is metal list aae:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
r
Dimensions: .! ? , ✓ �.
Sludge depth: °d
Distance from top of sludge to bottom of outlet tee or*baffle:
Scum thickness:(-Q °J
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tqe or baffle:
How were dimensions determined: �, "+L p �
Comments (on pumping recomme?datio is is nlet and outlet tee or baffle condition; structural integrity, liquid levels
elated to outlet invert, evidence of leakage; etc*
dj � (� '� j� �N �� j gay
GREASE TRAP:j�/61 (locate on site plari).
Depth below grade:
Material of.construction:_concrete_metal_fiberglass_polyethylene other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last.pumping:
Comments (on pumping recommendations', inlet and outlet tee or baffle condition, structural-integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.);
�. 7
Page 8 of I
OFFICIAL INSPECTION FORM.—.NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
jf f
Property Address: �t� �!� 1"J. ,
`✓z ,
1 y -
Date of pection:
TIGHT or HOLDING TANK:; (tank must be pumped at time of inspection)(loc.at.e on,site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain).-
Dimensions:'
Capacity: gallons
Design Flow: gallons/day
Alarni present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site.plan)
Depth of liquid level above outlet invert: z�La,
Comments (note if box is level and distribution to outlets equal,.any evidence of solids carryover, any evidence of
I kage into or out of bpx, et
PUMP CHAMBER d (locate on site plan).
Pumps in working order(yes or no):
Alarms in working.order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of l 1
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued).
Property Address:
Owner. = 1 9
1
Date of, ection: ` . 1 ?
SOIL ABSORPTION SYSTEM ((SAS):\t (locate on site plan,excavation not required) ,,
If SAS not located explain why:
Type/
Z leaching pits,number:
leaching chambers number:
leaching galleries, number:
leaching trenches, number. length:
leaching fields,-number; dimensions:
overflow cesspool,number:
_.innovative/alternative system Type/name of technology:
Comments (note condition-of soil, signs o1 hydraulic failure, level of ponding,.damp soil, condition of vegetation,
' ).sr;� 9 �, /J,ey.:�" `;� ✓�l.�.J.i�t'f �tQ��" .�/Jt)..�' �.f �,yr�, r! ./fir J
a '—�" :.�• �, <�ai . rev'✓"v �, �� _ C✓° "r eV 0..°/� ✓ -u .i ...
' � f/d!
CESSPOOLS:�V(, (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth'—top of liquid to inlet invert:
Depth of solids laver:
Depth of scum layer:
Dimensions of cesspool:.
Materials of construction:
Indication'of.groundwater inflow (yes or no):.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc-):
PRIVY_,AL0 (locate on site plan)
Materials of constniction:.
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
i
Page 10-of 1.1
OFFICIAL INSPECTION EARNS NOT FOR VOLU1 I.Tr RI(A$SESSMENT.S.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORIVIATION(continued)
Property Address:
Owner:\..? _
Date of I0p41 %.
f
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least-two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate.where public water supply enters the building.
j
a x V
f -
• Patre 1 l of 11
OFFICIAL INSPECTION FOMrvI-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM TNFORMATIO.N (continued)
1
Property Address:
Owner:\.
Date of(yr spectid'n:C.
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet y
Please indicate (check) all methods used to determine the high ground water.elevation:
Obtained from system design plans. on record-If checked, date of.design plan reviewed:
Observed site (abutting property/observation hale within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
V Accessed USGS database-explain:
You must describe how you established the high ground water elevation:.
11
j
Permit Number: Date:
Completed by: +
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location / (��'�= G'' >l✓'t d Lot No.
Owner: /' ' V Address r �^
Contractor: �' J d�l✓ Address.: _ r v
Notes: - _.._..
STEP 1 Measure depth to water table /•
to nearest 1/10 ft. ....:... ......... ........ ....... .:.....'.Date
month/aay/Year
STEP 2 Using Water-Level Range Zone-
and Index Well Map locate
site and determine
OA .Ap.propriate;index well ... ..: �.
OB Water level range zone ...
STEP 3 Using monthly report ':Current
Water::Resource Conditions
determine current depth to
water level for index..we ......:....................
month/year
STEP 4 Using Table of=Waterlevel Adjustments
for index well-_(.STEP:2A),.cur-rent-depth
to water-level for index well (STEP 3),
and water level zone(STEP 2B)
determine water-level:adjustm°ent .......
:.............::
STEP 5 Estimate depth to high water
by subtracting the water
level adjustment (STEP 4)
from measured depth:to water _
Level at site (STEP 1) ................. ................................... ...................................
Figure 117Reproducible computation form.
15
I � _
I � n�+..0 TT�� J'�m.G�Rars.T.egcnTn'rtitrtirn^I , �•-.•'_••_.• ..
r
.. - av+.w•wMrus..m^wM..�•..M - .: :`T"^"n"'.a.wnn.K•wnm�.,T„�
;70 TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE 05 af0/GI6 ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.;,9 e,- Ca' A!ST y �
SEPTIC TANK CAPACITY v z
LEACHING FACILITY:(type) I�TS �.Z� (size)
NO. OF BEDROOMS �— PRIVATE WELL PUBLIC WATER
BUILDER O OW s
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
r
VARIANCE GRANTED: Yes No�}
c
No................
THE COMMONWEALTH OF MASSACHUSETTS �.
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Uhipos al Works Tonstrnr#inn ramit k
Application is hereby made for a Permit to Construct �_e) or Repair ( ) an Individual Sewage Disposal
System at:
............... �x„ �f „�. !L �. '- _. ..................................
lo-lion-I r s or Lot No.
..... 1 �.� r , ' ---• . ...........---------------------------------------------------------------------------------------
Owner Address
W
Installer Address
U Type of Building Size Lot____z_Qz__y. Z__Sq. feet
Dwelling—No. of Bedrooms_______________ ___________________________Expansion Attic ( ) Garbage Grinder (No)
4 Other—Type of Building _____ No. of ersons____________________________ Showers — Cafeteria
a YP g P ( ) ( )
Q' Other fixtures ____________________________
d ---------------------- ----•-•-•---•------------------------------ ----------
W Design Flow________________S`'______.___.___.___.___gallons per person per day. Total daily flow______._.___._4k.,O....................gallons.
WSeptic Tank—Liquid capacity_...gallons Length,ll__��_______ Width.&.___to_.______. Diameter________________ Depth___✓'�___.___._-
x Disposal Trench—No_____________________ Width.................... Total Length........____._.___ Total leaching area..... .__sq. ft.
Seepage Pit No......Q---------- Diameter-----l4......... Depth below inlet_ �_�I___..._. Total leaching area___G__-�_�__sq. ft.
z Other Distribution box (x) Dosing tank
Percolation Test Results Performed by..................... _7i ....
Date---------7-16 ................
a
Test Pit No. 1____-&.......minutes per inch Depth of Test Pit...144........ Depth to ground water________________________
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' - ,-
79r
O D�escription of So" ___ ____�_____�____D__-o?A....____T Zi�__a___:
WC.D_9h g/ / --7 Q• � {- _I'. Cllf /._9.A!! V �-/-M = � ►rlP _
--i5R'�-----------------------•------•----------•------•----•-----------•••-•-••••-••••-•-••-----=-•--•-•---•----•-------------•-•-•-••...................................................
UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed---------------------------------------------.............................................................. I -------................................
Dace
Application Approved By .........
c� ,�,,f
----------------------------------------
� ..-- Dare
Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------------
-------- ----------- -................................. ----------------- ------------------_-------------------
Date
Permit No. .? __7--------7 5--?-------------------- Issued --------------------------------- -----...--- ----------------_
Dace
No.- _...... Fps: , ....._......P
1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apfliration for Disprrittl Works Cnnntrnr#iun ranfit
a Application is hereby made t°t it to Construct ,O or Repair ( ) an Individual Sewage Disposal
System at:
•----- -/ �/.�� �/.� ��.•,i_ i0 � �.r�.- '>. ..................................
-ooation-Add ss / -.• or.Lot No.
.2'?--... '�,�-�r!. . ------------------------------ -----.....-----------------...................---
_ Owner Address
W
Installer Address p�
} Type of Building Size Lot..... c23!..`4 __Sq. feet
V Dwelling—No. of Bedrooms.............. ___--_---__--_--__.-___-Expansion Attic ( ) Garbage Grinder (Nk)
'_l Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ____________________________ _
W Design Flow..................ram....................gallons per person per-day. Total daily flow..............6kjQ....................
1:4 ,Septic Tank—Liquid capacity��.---gallons Length 11.-L___.... Width_ ."to_..... Diameter---------------- Depth...3_.Z_.
Disposal Trench—No- ----------------_- Width.___..._.._._._.. Total Length.................... Total leaching area....................sq. ft.
f Seepage Pit No......a---------- Diameter.....19......... Depth below inlet-_�A ...... Total leaching area...G__�..sq. ft.
Z Other Distribution box ()o Dosing tank ( )
`-' Percolation Test Results Performed b _�AJ4. Dater}......J_2�4-lff-,-
aa Test Pit No. I.....Q.......minutes per inch Depth of Test Pit... Depth to ground water_______________
Li, Test Pit No. 2................minutes per inch Depth of Test Pit._____........._._.. Depth to ground water---- ---------_-_--_--.
1 0 ._ - ..... .4 � ..
O ------=-------- ----------
escrtonoo ...7 =#� 0 ; T�IA. � � 144
- - . _���__..
SA/ --------------------=--------------------- ---------------------------------------------------` -----------------------------------------------------------------•-----•----
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement: , ,`�,, •, °'ri l i ` . l ' �� !1f A E
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 Compliance has been issued by the board of health.
Signed ------------------------- -------------- ---------------........--- ------------------------
Date
Application Approved By ..--------- -- '`"�" ......................................
Dare
Application Disapproved for the following reasons- ------------ -- ---------_................................................--------- -------------------------------------
--...,.....--------------.........................................................----------------------------------------------------------------------------------------.................. .................................
Date
Permit No. -------- � ----------------.... Issued ----------------------�.e......----
E
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cger#ifirat.e of C araptiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------------------------ ----------------------------- - - --------------------------- --------------------- ------------------- _-------------- ----_- -------------------------------------------------
Installer �'j � n�
at -----------h�77-----� -Gl----------_ �.---------��!�' '�; :.o`'11r............... ^_"-�1J�-C1--------_---------_---------------- '
has been installed in-accordance with the provision o`NTITLE 5 9;,The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .........Q. .-.. `z..y ........ dated .f .�................ .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED,AfS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ,
DATE... -------------------------------------------------- ---------- Inspector . 1----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH _
Q� TOWN OF BARNSTABLE
No.•C7•c�:. ���. FEE.. ...........
Disposal Workv 01.31notrudivit unfit
Permissionis hereby granted..............................................................................................................................................
to Construct (>) or Repair ( ) an Individual Sewage Disposal System
atNo...... ` t +;2::. l/-o +_....CD. .._ p, x �=------`--•---••------------------•------------•------...---.......
Street '
as shown on the application for Disposal Works Construction Permit �._? 7.5_._ .__ Dated..........................................
/ _ (�TV V Board of Health
DATE ._...----I1-----------------•-•------............................... '
t
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
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BAXTER
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