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Home My WebLink About0023 KING ARTHUR DRIVE - Health 23 King Arthur,Drive Osterville A = 145 - 060 C" Commornnreafth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 23 King Arthur Dr. Property Address Joan Koslowski Owner Owners Name information is required for every Cisterville MA 02655 7-1 t-13 page, Cityfrown State Zip Code Date of Inspection 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. Importfilling out A. General Information _ fiitln out forms `` j OF on the computer, �`�� ......... S 4ii use only the tab key to move your 1. Inspector: = ; cursor-do not - = JAMES 'm use the return James D.Sears =G�_ SEARS key. Name of Inspector _ pewide Enterprises,LLC Company Name Tir.,��, .. G�`\� 153 Commercial St. /�irrrr�r� �iNuSPI� �� Company Address �.. Mashpee MA 02649 Cityfrown State Zip Code 508-177-8877 S1623 Telephone Number Lioense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the- information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-11-13 pectors Signature Date i - • The system inspector shall submit a copy of this inspection report to the Approving Authority(ioard of Health or DEP)within 30 days of,completing this inspection. If the system"is a sharedsystq or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit", report to the appropriate regional office of the DEP.The original should be sent to the systenr&ner and copies sent to the buyer, if applicable, and the approving authority. ED ""*"This report only describes conditions at the time of inspection and under the condltiorWdf 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. , 15ina•3r73 T"5 OffK'69 'SuDad ew SG*Dpe Diapud System•Papa 1 or 17 l'd a01:80£l Zl In■-■ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address - Joan Koslowski Owner Owner's Name information is required for every Osterville 1 MA 02655 7-11-13 page. City/Town State Zip Code 7 Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): t5in6.3113 Title 5 Official Ineper-0on Form:Subsurface Sewage Disposal System-Page 2 of 97 Z.d e66 8081°Zl lnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address - Joan Koslowski Owner Owners Name information is required for every Osterville MA 02655 7-11-13 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont): ❑ 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 removers ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of.Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy it 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 Idle 5 Official Inspection Form:Subsurfew Sewage Disposal System•Page 3 or 17 C'd ei,1,:8006 Zl lnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name information is required for every Osterville MA 02655 7-11-13 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All'Systems: You must indicate"Yes"or"No"to each of the following:for all inspections: Yes Na 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 is less than 6" below invert or available volume is less than 1/2 day flow F4C11141e, t5ins-3113 Tde 5 of5dal Inspection Form:Subsurface Sewage Disposal System-Page 4 of V b'd t e66�80£l. Zllnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name Information is required for every Osterville. MA 02655 7-11-13 page, Cityfrown 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.- Any portion of the SAS,cesspool or privy is below high ground water elevation_ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,forfecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® 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 ❑ . ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has fair.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. t5in3-3113 Title 5 Official Ins pection Farm:Subsurtaoe Savage Disposal System Page.5 of 17 9'd eZ1.:80£6 ZI,Inr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn .Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owners Name information is Osterville MA 02655 7-11-13 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate'yes"or"no'as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? S. ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 23 ❑ 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)) D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 330 . p gpd•x#of bedrooms): t5ins-W 3 Title 5 Of Gal rnspedion Forth:Subsurfaoe Smogs Disposal System-Page 6 of 17 _ y 9-d la g0 C 1 Z l, Inf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Ureter Owners Name equir infortnatl fo isr every required fo Osterville NIA 02655 7-11-13 r page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank D.Box and Pit wl 674' stone field. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection (� yes ® No information in this report.) r. Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-57,000Gais 9 Y 9 (9P ))= 2012-43,000Gal's Detail: i Sump pump? ❑ Yes ® No Prestent Last date of occupancy: Date CommerciallIndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203):. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: bins•3)13 Tide 5 Official Inspection Form Subsurface Sewage Disposal System•Pepe 7 of 17. L''d eZL:9006 Zl• Inr i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owners Name information required for every Osterville MA 02655 7-11-13 page. Cityrrown State Zip Code Date of Inspedion Da System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 08/11 . Was system pumped as part of the inspection? t ❑ 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 t ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Stone field 6'x6' per asbuilt on file B.O.N. t5ins•3113 Title 5 offidel inspecdon Faum:Subsurface Sewage Disposal System•Page 8 of 17 g-d e£1:80£l Zl lnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 23 King Arthur Dr. Property Address Joan Koslowski Owner Owners Name information is required for every Osterville MA 02655 7-11-13 page, City/Town State Zip Code Date of Inspection D. System Information (cont,) ,, Approximate age of all components, date installed(if known)and source of information: Tank-field and pit 1981 permit#81 -324: New D Box 2006 Permit#2006-032. Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): 1 Depth below grade: 8wfeet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: ion feet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene) ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions:' 1000 Gal. Precast Sludge depth; 15ins-3113 Title 5 Official Inspection Forrn:Subsurface Sewage Disposal System'-Page 9 of 17 6'd e`;l 80�1 Zl Inf f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name information is required for every Osterville MA 02655 7-11-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" 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 3 7" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Tank at working level. Tank and cover's at 10"below grade_ In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal 0 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 OfficW bspeetion Fom subewfece Sewage of sposel System•Page t0 or t T 06,d e8l 8081 Zl Inf Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments 23 King Arthur Dr. Properly Address Joan Koslowski Owner Owner's Name information is required for every Osterville MA 02655 7-11-13 page. cityrrown 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per da 9 P Y 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 ❑ No t5ins•3113 Tide S Official inspection Form:Subswf2oe Sewage Disposal System•Page 11 of 17 6 l d' et,l,:80 E l, Z 6 1n•f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski owner Owners Name information is Osterville MA 02655 7-11-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 , Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-16" below grade_ D Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): `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: t5ift-all Tdle 5 Official Inspection Form:Subsurface Sewage Disposal Systain-Page 12 of 17 Z 6'd eb C 8O£L Z l• Inr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name information is Osterville MA 02655 7-11-13 required for every page. City/Town state Zip Code Date of Inspection D. System Information'(cont.) Type: ® leaching pits number." 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,,length: ® leaching fields number, dimensions: 6'x6' ❑ . overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 9 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is a 1000 Gal. Precast Pit. Pit and cover 16'below grade w/inlet tee, 26"water in pit. Pit has one line out wino tee,going to a 6'x6'stone_field. Camera outline clear,not holding water..No sign of over loading or solid carry over. 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 15ins•3113 ratio 5 OfrwW lnspeelion Fomr.Suhsurfsoe Sewage Disposal System•Page 13 of 17 I £6'd eb6:80£1Z61nf Commonwealth of Massachusetts Title 5 Official Inspection Form R a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name information is required for every Osterville MA 02655 7-11-13 page, Cityffown State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): Privy (locate on site plan): Materials of construction_ Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5Os 3113 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 14 of 17 t�bid eq 1,:90 C 6 Z 6 1nf Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owners Name information is required forevery Osterville MA 02655 7-11-13 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 LLi t�t c f( s I�I I I (I I '' v PP EA k 3` ,,) 3� t5ins•3M 3 TAIe 5 Official rnspection Form:Subsurface Sewage Disposal System-Pape 15 of 17 96'd e51.�80£6 Zl• Inf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name information is required for every Osterville MA 02655 7-11-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells FU Estimated depth tovigh ground water: 10*+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Hand auger 10'+ No G.W. Bottom of pit at T-4" Bottom of pit at 2'-6" above Auger Hole Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113• TNe 5 Oftal ln"don form:Subsufaos Sewage Disposal System•Page 16 of V 96`d e56:80ElZllnf Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 King Arthur Dr. Property Address Joan Koslowski Owner Owner's Name information Is required for every Osterville MA 02655 7-11-13 page- City[Town state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, 8, 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 i t5ins•3113 TO 5 Otfidel Inspedion Fomr Subsurface Sewage Disposal System•Page 17 of 17 L 6'd e9l,:90 E 6 Z l, 1nf Ivio I q L /&,4 L h.i 3� u • - . - �� - CLOSET C Oorvl M,41 I Al. ki o 7 A-k YYY �LoS�-T F C,a a 4 Z3 Y-1 N c AT-7-4vr De vc ao-b(00�� P,W- All -73fLjoil , h 1 1 . 1 a3 a b/b•d BS9'ON lN3Wd073A3Q'0n3/Wnn -�1RH I gMNHR L IHPT!PiT gfilLl7 Q7 I�H r f P. 1 COMMUNICATION RESULT REPORT ( DEC. 6.2005 4:48PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 550 MEMORY TX ECNMC DEU OK P. 1/1 -------------------------- --- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION_., ^ _ 1010 r Town of Barnstable Health Inspector Regulatory Services Office HOtas + . 8:30—9:30 � Thomas IF,Geller,Director 1:00—2:00 Public Health Division � sb�9' T Thomas McKean,Director 200 Main Street,Hyaanis,W 02601 , Office: 508=862-4644 ~: ' �rr�.8x: '�08.790-6304 VINESTY PRaGR�M AP LICANT,SEPTIC T'ES�'Y 1, GeneralInfoxmafiion: ' -of Proarty: Address: Map ,Parcel I Name: ,1��4 J' Phone#: ld 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty tmit) 2d. Please in a copy of the floor plans for the ewe property-Showing the existing rooms in the home plus the proposed amnesty apartment and/or addWon. Please label each room clearly-on the plans. Town of Barnstable Health Inspector oFt tom, Office Hours ti Regulatory Services 8:30-9:30 M ♦ ' Thomas F. Geiler,Director 1:00—2:00 i M BAMS B-�+�+.F A 1A,�� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 c 4` Office: 508-862-4644 �' � Fax 508-790-6304 r AMNESTY PROGRAM APPLICANT` SEPTIC QUESTIONNAIRE 1. General Information: Size of Pro erty: ). 'f . 6 Address: �nI4aj;b'Yj ' Map 1V.Parcel tZ Name: `b �/1/3 `9f 0/141�.1�1� ` Phone #: 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? jib If yes, how many? V 2c. How many bedrooms total are.proposed at this property(including the amnesty unit)`. 2d. Please include a copy of the.floor plans for the entire property-showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label . each room clearly on the plans. . 3. Is the dwelling connected to public sewer? YES or NO % Ifthe dwelni as.connected toY ublic sewer,`sla uestions#4 throe #9 be�w g 4. Location of dwelling is INSID or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO i 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO .8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO --------------------------—-----------_----- ---------------- --- - �i -- FOR OFFICE USE ONLY The Public Health Divi 'on has no ob'ection to bedrooms at this property. Special Conditions: i In. sw lee- 4 ce rc&ry Signed: Date: O;/health/wpfiles/amnestyapp f DEC. 6.2005 4148PM 0 �RN�STABLE BOARD OF HEALTH WIWI Town of Bar,.. table health Inspector Regulatory Services ' Offe•ise 116 s of Thomas•F.Geller,Director 1;00 a;00 Public Health Division Pit Thomas Me*ean,Director : d, Soo Mafia aftA NP21 s,MA 02601 Ofte: 508'862.4644 ,, 08-990.6304 AMESTY PROGRAM, c -.sir Szr 1 General idbrnad ! 97�o �: I•I Address• , ' ' map .Parcol0 Phone A •-D/ 2a., How MUny bedroom®exist at your property now? f 2b. Ara you planning to add any bedrooms? � f If yes,hove n=&y? , 2c. How a ny bedrooms total are proposed at ties property(ituluding the amnesty untt)' , 2d. Please include a copy of the floor plane for the Mtlr9 property-showig the-existing rooms is the home p1ui the proposed amnesty aporf�ent and/or addf#on. Mama label each room clearly-on the plans, ' 3, Is the dwelling ca¢=awd to public Sewer? Or NO a. Locstioia of dwe9liag is INSI� or OUTg= a Zone of Con to public supply wolle? 6P 5. Ye i dwelling co=cted to ea or to PU8L1C �',@�BR2 6. Io a disposal works amstrutlapermit on die? or NO 6a. If yoa,how mimy bedrooms were approved according to the puaz o ,_,�8edtoome. 9, Were any b�idiug pexits obtained for cO2r cticn of additiopei badroo=? YEI�' or NO A IS there an eaginemd septic system Alan on®le at the health DivisiaO Yes or NO 9, Has the septic syetem been in9p061ad by a DEP aorofied inspector wig the last two years? YES or NO FOR OFF U89 ONLY The Public Heath Di n has no objection to bedrooms at this Special Conditions: Fp ' t� Biped: 4 Q;�a�das�wp�lea/amnerty�P� tbiZ'd 8S9'0N 1N3Wd013A3Q'093/W00 33Hd1SNaUg WU2T:OT 9002'92'Ndf BORTOLOTTI CONSTRUCTION,INC. P. O.BOX 7049 MARSTONS MILLS,MA 02648 508-771.9399 508-428-8926 508-428-9399/FAX SEWAGE DISPOSAL SYSTEM EVALUATION \ Inspected B : Date:_ of dS~ p Y Propty Add s: - Map & Lot : ei/Bayer• , � Mailing Addre Ox- o S NOTE: A satisfactory a alua ' n does not guarantee that the system will continue to function, A Sketch of the property and sewage disposal components must accompany this form. RESIDENTIAL COMMERCIAL USE LotSize: Lot : No. of Bedrooms: 3 Type of Business: Garbage Grinder: Water ftener: Sq.Ft. of Bldg: Other Water Use(Appliances) Mp/pf Employees: Water Use Activity: Year Round: Seasonal: 0 Water Source Water Source: Septic S stem Installed(Date): o- Title V Yes ( No Component No. Size Length Type -Ft. to Ft.to Conditions Well Wetland Building Sewer Septic Tank 1QQ6 N A) Effluent Pipe Dist.Box F Dist. Pipe Leach Pit 4� MIA /a Flow Diffussors Leach Trench Stone Cesspool PUMP/Chamber Evidence of Ground Stain Yes ( } No ( ►-y Unknown ( ) Evidence of Breakout/Overload Yes O No (�4 . Unknown ( ) Evidence of Overflow to Surface Yes( } No ( 4- Unknown ( ) Evidence of Lush Growth around Pit/CesspoolYes ( ) No („fi Unknown ( ) Standing Liquid in Pit 1/2 or More Full Yes O No (v} Unknown ( ) Evidence of Excessive Pumping Required Yes ( ) , No 0 Unknown ( ) Comments 7L—' • , 6 ° e /72771 biE'd 8S9'ON 1N3Wd0-13A3Q'093/W0D 3-19d1SHNU9 WHET:OT 9002'92'NHf I IKE Town of Barnstable & Growth Management Department 8ARN6PAVAN, 367 Main Street, Hyannis, MA 02601 1639. Tel: 862-4678 Fax: 862-4782 D FAX COVER SHEET To: l�dL.�Jy� Date: s Time: Attn: Pa cover sheet T Number of Pages (incl. co :) From Comments: J7 a� biZ'd BS9'ON 1N3Wd0-13A3Q'003/W00 3-19d1SNdUg WU2T:OZ 9002'92'NUf No.. V D0 6 _UJ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:.f/ . PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Digpoor 6pEUm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System rZ Individual Components Location Address or Lot No. 2-S 1[; Vie'-bt,%Cf Owner's Name,Address,and Tel.No. r��zvrte TA„ Assessor's Map/Parcel �" � `aZ N 4 /y5 Pr�O a5 i2v��l� �'h►4 d2 �55 Installer's Name,Address,and Tel.No.GAPZwrde EaTEKP/,Xi LLLo. ,3ox -7&3r Designer's Name,Address and Tel.No. G°c�r�nvar/� sr�� oa�3t �iV/fir Type of Building: Dwelling No.of Bedrooms Lot Size �'$i?�� sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) R 0)*L P„ Z Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 1- 3 0 Application Approved by W✓- Date Application Disapproved by: Date for the following reasons Permit No. 20n b - 0 3 2 Date Issued / — 3U-0,6 0 aP y No.,. � U lQ —03 2 Fee ��U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:t/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ,.. Yicatiott for ai,5mml 6p5temc Construction Permit Application fo'r a Permit to Construct O Repair O Upgrade( ) ° Abandon O ;❑Complete System Individual Components Location Address or Lot No. 2 } 3 1t:C nc� p 2-NU„�tZ"b��V� Owner's Name,Address,and Tel.No. _ p 14 y i Assessor's Map/Parcel y s� Iervf p(00 -0 S r-E'r4 u Z a t 4,1 r4 6 L 5 ��ew,de 6Mt(,c Pi°ies Installer's Name,Address,and Tel.No.P 0. 13OX 't;.3 Designer's Name,Address and Tel.No. SoS 42-fl- 9-2.9 - Type of Building: Dwelling No.of Bedrooms Lot Size L$,7�� sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 3' Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets w Revision Date 1 Title Size of Septic Tank Type of S.A.S. ° Description of Soil Nature of Repairs or Alterations(Answer when applicable) R � sox Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envirdnmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date �" 3 O '2C Application Approved by c` �M/- Date /—3 U-0 6 Application Disapproved by: r Date for the following reasons Permit No. moor) " 0 3 2 Date Issued 1 30-UJa -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS {�- b0Y, rp Certificate of Compliance Y. _ THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructe 1.d ( ) Repaired (0<) Upgraded ( ) Abandoned( )by I 4t9ZtJi CU 1;�y1fief JLe SeS at 2-3 I�i,,C t42 I r' L�C�. has been constructed in accordance With the provisions of Title 5 and the for Disposal System Construction Permit No. d - 0 3 dated I Installer �.\ � � 1�2� Designer #bedrooms Approved design flow 3 L gpd The issuance of this permit shall n 'tbe construed as a guarantee that the s =stem will functfon as designed. Date f 3 0 fo Inspectbr- . No. �(JO�p' 3� Fee /00 THE COMMONWEALTH OF MASSACHUSETTS f PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=t9;Po!5a1,6p!9tem tou5tructton V'ermtt Permission is hereby granted to Construct ( ) Repair (k) . Upgrade ( ) Abandon ( ) System located at Z3 ld ✓ s, 14.2-A,_,r `-nf1rQ "i �2lJUr `P and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this ermit Date / 3 0 ' Approved by - 6vv' S v .r -�� 7U�1'C� � lJi n, i N(� i �s�� L� � i nrtr �L%D�IN-M � �� T�� oS7�►� Cr�,��S • ti® � ak s .......... -Dj Y � 1 f OCT. 19.2005 8:00RMjj128HKNS1HBLE BUHRU OF HEHL I H Nu.J_y1 F'.1/1 ,,f Town of BaXll�cable Health Inspector Office HoursRegulatory Services 8:30—.9:30 i a%RK6rA n.�, r Thomas.F.Geiler,Director 1:00—2:00 sbM¢ i ubhc Health Division Thomas McKean,Director 200 Ma' ' m Street,Hyannis,MA 02601 _ - z:•; Office: 508-'862-4644 ° . 4"e '& .508.790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC 0UESTI I. General Information: 'Size-of Pro er[y: Address: �,� ,/ '�- Map Parcel-Ad Name: fl®d�J' Phone 9: 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes,how many? _ lc, How many bedrooms total are proposed at this property(including the amnesty unit) 2d. Please include a copy of the-floor plans for the mike property-showing the'existing rooms in the home plus the proposed amnesty apartment and/or addition. PIease label . each room clearly on the plans. k 3. Is the dwelling connected to public sewer? YES or DO ,./;_,�„�: �•. '�•T' :V.J' .T�JJ i' ii1•.'K: °' •� f Ml,�'�l�f. T�7 II}7 '�� ,� "t .r• -' tt,,'}i,�,a,+.`. ;yyr.•f r., ,,.' •' . .e ..i $• - _ ,i7d1 1. .�}1 i'I'•5 'c'a3'�417,;' 4. Location,of dwelling is INSID or OU=E" 'a Zone of Con to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC FAMR? 6. Is a disposal works construction permit on file? or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building,permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plea on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO /C�n h,14VA j d, mR OFFICE USE ONLY - •••_�__._. -- (A C" J The Public Health Division has no object o t 0�5�� ooms �t this Property. Special Conditions: P p ' /��Q:/hCNJFA��F�•Jndnmst-+b339P �� AT � ��/...�_ �� Tam 4�� .�� BORTOLOTTI CONSTRUCTION, INC. P. O. BOX 704, MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 508-428-9399/FAX SEWAGE DISPOSAL SYSTEM EVALUATION . Inspected By: Date: Property Add s ,s: J Map & Lot#: �-,/Buyer: � � Mailing Addre` NOTE: A satisfactory evalua ' n"does not guarantee that'the system will continue to function. A Sketch of the property and sewage disposal components must accompany this form. RESIDENTIAL COMMERCIAL USE Lot Size: Lot Size: No. of Bedrooms: Type of Business: Garbage Grinder: Water Softener: Sq. Ft. of Bldg: Other Water Use (Appliances) Mp/pf Employees: Water,Use Activity: Year Round: ;,Seasonal: v Water Source. ' Water Source: Septic System Installed (Date): c?5 Title V Yes ( ) No ( ) Component No. Size . Length Type Ft. to Ft. to Conditions Well Wetland b Building Sewer Septic Tank Effluent Pipe , ` Dist. Box ILI Dist. Pipe Leach Pit- Flow Diffussors w Leach Trench Stone Cesspool Pump/Chamber Evidence of Ground Stain Yes ( ) No ( .;�� Unknown ( ) Evidence of.Breakout/Overload Yes ( ) No Unknown ( ) Evidence of Overflow to Surface Yes ( ) ; No ( a- Unknown ( ) Evidence of Lush.Growth around Pit/CesspoolYes ( ) No {,) Unknown ( ) Standing Liquid in Pit 1/2 or More Full Yes ( ) No, (✓) Unknown ( ) Evidence of Excessive Pumping Required Yes ( ) No (v' Unknown ( ) Comments t `c ) 'c V ; J bw rT-6a nI , l� �EZHE Tp� The Town of Barnstable + BARNSTABLE, MASS Growth Management Department ATED 367 Main Street Hyannis, MA 02601 Tel:508-862-4678 Fax:508-862-4782 October 5,2005 Mr.John C.Klimm, Town Manager GaryR- Brown, Town Council President Barnstable Town Hall 367 Main Street Hyannis,MA 02601 G� Re: Joan Koslowski' 23 King Arthur Drive, Osterville-'a single-family accessory unit Lynn Marble— 63 Ebeneezer Road,8stervilied-single-family accessory unit Francenete DaSilva— 297 Hinckley Road,Haynnis - a single-family accessory unit Mark Furtado — 614 Phinneys Lane, Centerville- a single-family accessory unit Gentlemen: This letter is to inform you that the Accessory Affordable Housing (Amnesty) Program has received requests for project eligibility letters under the Community Development Block Grant (CDBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the criteria for the Local Chapter 40B Program. This office is reviewing the requests.If the Town has any comments on the projects,please forward them to me so that they can be addressed in the site approval letter. This letter gives you official notice of our receipt of the above application(s). We will issue a decision as to the acceptability of the sites and the consistency of this development within the guidelines of CDBG. �. Sincerely, 1 ' E'f izabeth Dille. z I . Special Projects Coordinator t Growth Management Department cc: Town Attorney's Office Building Department ✓Public Health Department LOCATION. EWAGE PERMIT NO. VILLAGE. JIeAj INSTALLER'S NAME i ADDRESS x S U I L D E R OR OWNER e n GA T E P"'EItMIT . I S S U ED DAT E �CO'MPLIANCE ISSUED fps \1 1 I i .l Nolf-2. THE COMMONWEALTH,OF MASSACHUSETTS BOARD OF -HEALTH ...........Jd.tAu..,.+.Z.-..........OF.......Revr.. J....1._ ---------------------- Appliraation for 11isposaal Works 04instrurtion Frruat Application is hereby made for Permit W nstruct ( ) or Repair ( ) an Individual Sewage Disposal System a /� .......... r n ......"..Sc� .. ........ ....................Y..... ..................... ......... .... Locatio ddress t No. •••• - .......... -AA n. ' wne A• y drgss y�,y�y�� .......... ...�a►A-v.-�u�.•�-.... .....---G:12, j. Cl�6l............ ---------•-- .1....---.. �............... �..r—,--.P..Sq. r..r.CF.ct -. Installer Address Type o uilding Size Lot __ feet Dwelling—No. of Bedrooms............... .......................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixture -------------------------------------------------------------------•-------------------- W Design Flow............... .. ..... ...........__gallons per person per day. Total daily flow.......C3L �. ...................gallons. WSeptic Tank-4 Liquid'capacity/Odd.gallons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No..................... Width••-A79..... Total Length.....................Total leaching area-_62-1--"-/.sq. ft. Seepage Pit No.................. .. iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing t�� ( ) '—' Percolation Test Results Performed by...... ....._ ...: Y y. ............... Date... ,1 ,7 ._.. _-minutes per inch Depth of Test Pit...._.._.V.........:Depth to ground water.........,..a Test Pit No. l._�.� ......................... 44 Test Pit No. 2................minutes per inch e� of Test Pit.................... Depth to ground water........................ x .....-•-•..... .--.��.�.-----...••--...��` > ------------------ -----------..��s.��. ODescription of Soil........................................................ •-•--------------...-----------------------•--------------------------------------------------......•--.---• x U .....•••••••••••-•-----•••-•-•-••••--•••••••---•-•---••------•-•----•--•--------•-•-•••••••-•••••----••••...-•-•--•-••••----••••-•-•••••-•-••-----••••.............................•------••......------. w 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 iITLL 5 of the LStateanitary Cod —The undersi ned further agrees not to place the system in operation until a Certificate of CoAn . ' sued by the d Application Approved = :,1.: ----�-------------- -•-•--••.......•---••---•..............•••••.........• Date Application Disap ove t following reasons---------------------------------------------------------------------•-•-••-•••-.--- •-•-•--•--------...---- ............................. ....... •..........---•-••.............-•-•-•.........•-•---•.......•---•••-•--••---••---------------------••-••--•---------•---......-•••----Dau•••--...--•--- PermitNo......-............................................_.._. Issued....................................................... Date 7• ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .U..........0 F.... ...ek;; ►........................ Appliraffou for Uhipv�al Works Tonstrurtion. ramit Application is hereby Vmadefor Permit t nstruct or Repair an Individual Sewage Disposal System at: ............ ......rA. ................... . ..... ............................... ............... io ". _ Locatio ddress Lot No ............. I.AAS.....or)� *%Q.......................... ....... 2V "crZIr M;ne ------ .......... ..... .. . ...... ...... ... ... . . . ........ ............4_56" Installer f Address Type o!Building ze LotA J Si -------Sq. feet Dwelling—No. of Bedrooms.............._._____.,__._____._.____Expansion t .......................Expansion Attic/(, Garbage Grinder r Other—Type of Building ............................ No. of persons._.________-______:_________ Showers — Cafeteria Other fixture - --- ------- --------- --- ---- - - Design Flow_______________ _ 49--- -----* ------------------------........... -:gallons-per*personper-day. Total -fl,ow' .'.'.'..'.. ,.... Septic Tank Z Liquid capacity/ gallons Length................ Width___.____.__._... Diameter_______.__.___._ Depth.......... Disposal'Trench—No_.................... Width....__:___.6..... Total Length_.____._____.___.___ Total leaching area.._____t_'._/.sq. ft. Seepage Pit No_________________... iameter.................... Depth below inlet___..______......._. Total leaching area..................sq. f t. z Other Distribution box Dosing t-aAk Percolation Test Resulls Performed by... 5_x7ae.......X...../?y. ..e................ Date... Test Pit No. L.AZ..minutes per inch Depth of Test Pit__.____ _____. Depth to ground water________________________ rXq Test Pit No. 2................minutes per inch ,Death of Test Pit......../ V ............ Depth to gro water........................ ............0---415................................ ........ 4z;? .......... .......... . . .. 0 Description of Soil......................................................... W ............................................................................................................... U ......................................................................................................................................................................................................... W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...........................................................................................................................................................................I........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT IS 5 of the State Sanitary Cody—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-been iAued by the 10;hx�d, 1�061 ;? Si ....... ........ ...... ................. gn ...... ................... .... ...... ... ate ApplicationApproved By�: .............................. ........................................................ ........A........................ Date Application Disap ov� e or the reasons:............................................................................................................. ........................................................................................................................................................... V pt .............................. Date PermitNo...................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................... (L"Wrtifiratr of Tomplitturr THIS IS TO r_p�?TIFY, That the In6ivid a ewage Disposal System constructed or Repaired by--------------------------------11.9..ft 1 ............................ -le-I---al 5 e��.................................................................................... J 0 er �.. r........ ...... at................................................................. A.... ..I...................... has been installed in accordance with the provisions of TITLE 5 of Tle State Sanitary Code as described in the application for Disposal Works Construction Permit No_________________________________________ dated__..._____-_._.__.._._______...__._.._._________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... ............................... Inspector..... .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD��F HEA ........................................................ ..........................OF..V�;w.......................... FEE..P.................. Permission is 'ireby granted._._.V.mt�� ............ ----------------------*--------------------------........................------ iv s to Construct (A •to Repai an ?wa ge D'95b al System atNo.. ........z... ...... ... .................... Streit ,s ons�trctii_onli ;W I �,)Pet No as shown on the application fo, osal Works Constr Datedl........... .....61 .... ............ I4........ ........................................................... DATE................................................................... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS DQ.TP. z L ._ 5 -tc TLv.t� 33o,r trio % _ d-�S 6 Pt�. - . ry US -:;. .1:00C� 6A4t.. 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THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T 7 Appliration for Biopmtal Works Tonotxnrtion Famit Application is hereby made for a Permit to Construct ( �orRepair ( ) an Individual Sewage Disposal System at ................................ ..._----•---•-•- • Loc o -Addre or Lot� ' ^- . _. .. . ......................... .``t(u caner es Installer ddress Type of Building f' Size Lot__ ,__ ..Sq. feet Dwelling—No.-of fBedrooms._.....__;�..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building .............. No. of persons............................ Showers — Cafeteria YP g -------------• P dOther fixtures .........-•------•------------------------••---•------------------....-----•-----------........-------------...-•-----------------••••.......------••. W Design Flow ... ____________ 7.0._.........--.. lons. WSeptic Tank Liquid capacity/ gallons ,�.engtl .. Width................ Diameter---------------- Dep .•....... x Disposal Trench—No. .................... Width...... "_... Septic � --. Total Length..__.___..........__ Total leaching area. �. -----sq. ft. Seepage Pit No--------------------- Di eter............__...... Depth below inlet--...... T leaching area..................sq. ft. Z Other Distribution box (E� Dosing nk ( `° �� r/ Percolation Test Result 'Performed by.. � �� --------------••--•---•- Date-------�, 1!// _d_.. aTest Pit No. 1.._ __.minutes per inch " Depth of Test Pit____________________ Depth to ground water.................. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground-water---__-__:_--__---_-___. O Description of Soil.......................a. `.. ..- .--- ---•--�-- - U •-------------------------------••-----•••-•----•--------------•--------------------------------------•-•-•---.....---------------------•--------------------•-----......._......•........------......-- ------------------•------------------------------------------------------•--•----------•---------------------------------------------•-----------•------------------------------------..••--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITi:;,:. p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign -- ----- -- -- ------- '/G}/ Date Application Approved BY C ` Da K----•-------- ' te Application Disapproved for the following reasons:................................................................................................................ ----------•----------------------•----------•----------------------------•----------------------------...---•--------------------------------------------------......------------•--••-•--------•------- Date PermitNo...................---------•---•--------------•-------• Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS c—� BOARD OF HEALTH , ............................. V.PprtifirFatr of Tontpliatnr THIS ATO ERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by..... .-. ......................................................................... --- nstaugy has be installed in accordance with the provisions of TI j of The State Sanitary Code as described i the application for Disposal Works Construction Permit No.___ ___ __...tj 2._�(-_..... da.ted_-.�:".�_.� �.__.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector---------------------------_;--------------•-•---------------------.:...---------- THE COMMONWEALTH OF MASSACHUSETTS Fizz BOARD F HEA T 'Q .............OF...... .. Appliration for Dispniial Works C_vnuunrtiun Vamit Application is hereby made for a Permit to Construct (: r Repair ( ) an Individual Sewage Disposal System at ... :--- .. ..... ... • _. .. .. • or Lot �`" Loc o Add:e . .. ...................... J caner es w ••..... ..:......... ----k r�°r� ............................................... en.. ` ~� Address st,,�Lkr Yaf Type of Building �` Size Lot.. .Sq. feet U Dwelling—No. of Bedrooms....... ............................Expansion Attic ( ) Garage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( .) — Cafeteria ( ) a .,, .. . Q Other fixtures -------------------------- '=-- -------- ---------------..... ------------------ .............................................. n Flow. .. __ allons er erson er da Total,dail flow....:.. ._.......gallons. w g g P P, P Y Y WSeptic Talk LlquvOcapacity. gdthn_s_.c 1�' r t Total Length Width--' . Total leaching'-are'a. _-_:.....Sq. ft. x S page 'Trench .. . Diameter> _________________ Depth below inlet.:...� .._.... ..-To leaching area................. ft. � Seepage Pit No � p g q• , Z Other Distribution box & Dosing nk ( ' r '—' Percolation Test Results : Performed b C;✓ . :. Dates:': y . ._ . , . Test Pit No. l._.. minute per inch..`:Depth of Test Pit____________________ Depth to ' ound water.._....__.. ' p P g ,, (s,0-4 Test Pit No. 2...... _.._.minutes per inch Depth of Test Pit__,................ Depth to ground water .............. .' fYi ... •---•--•----•-•------••......-- 0 Description of Soil....... P -- x „. . . w ----•••----•------------- - ------------- -•---- -- --._.....------------------.._ .. .....--•- �a U Nature of Repairs or Alterations—Answer:when applicable______________________ `_.______.__.._.__.______._.._._. ..............._._.............. ..-•-- .4 - -------------------- .......................... ----- --------- Agreement The undersigned agrees to install the aforedeser&4 Individual Sewage Disposal Sysi<m in accordance with the provisions of TITL v 5 of the State Sanitary Code— The undersigned further agrees riot to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed............................... --------------------------- ---------------- ....-- -- ------------•---•-------•-- - Date Application Approved BY---- j '`"1C " / Datteo ... ��%'6 Application Disapproved for the following reasons----------------•-----------cee, .. -------------------------••-•-------•-------------•---------......---•----------------..................•.---....:------.------....---------------=-------------------------- •---------•-•--...•----- Date PermitNo.... -------•-•---------------------- Issued---------------------------= :.--_-----•--••--••-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L Wi/ ..........................OF... ..... :..,............................ Cnrrtifiratr of TomoItanrr " T TO RTIFY, That the Individual Sewage.Disposal System constructed ) or Repaired ( ) ...tr � � by ..... ---- �, st 116r Gz� ...................... ------------ has been installed in accordance with the provisions of TIT 5 of The State Sanitary� rde a scribe i the application for Disposal Works Construction Permit No........ ... :....................... dated_....___.`.------. ------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL N &06 ED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. •--•.......................••-••-•---......•--••--•------•-.: .. inspector.............. . `V ............................................. THE COMMONWEALTH OF. MASSACHUSETTS BOARD VOF H'EAL H17) !'} G .......4 ..•'................O F.... ........ ........ ....... ............. No.. �/ FEE........................ R111111 2014 Permissionis ereby granted........................................................................... •. ..... -•--•-•---••-----•--....---- •---••. to Const o>�I pair I � i Se-A> P_is S s at No.----i�--�� "- .... Street - dam" Street as shown on the application for Disposal Works Construction Permit No....._............... Dated.............................;_-------------- DATE---- "` RJR j._n________________________ FORM 1255 HOSES & WARREN, INC.,'PUBLISHERS