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HomeMy WebLinkAbout0908 MAIN STREET (OST.) - Health 908 Maim Street _ Osteivi?le' i A= 117- 666 r o e _ IoN ALTA OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292.5500 t TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor r Conunissioner ^ hl� . -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A O hCERTIFICATION ' ©� ll(v m� _fill Property Address: r A S NI Name of Owner �. C to deer Address of Owner: C{� Date of Inspection: . Name of Inspector:(Please Print) 1 am a DE approved system inspecto�pursuant to�ection 15.340 of Trtle 5(310 CMR 15.000) Company Name: r MarTing.Address: r--- < Telephone Number: CERTIFICATION STATEMENT (. y I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurater and complete as of the time of• spection. The inspection was performed based on my training and experience in the proper function and <. maintenance of on-Site ser ge disposal systems. The system: F' Passes _ r;11 Conditionally Passes r _ Needs Further,Evaluation jW9 the Local Approving Autho s Crity Inspector's Signature: i D Pif The System Inspect r shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of-Environmentat Protection. The original should be sent toZfw: system owner and copies sent to the buyer, if applicable, and the approving authority. s+• NOTES AND COMMENTS o 9g ; i revised 9/2/93 r Page 1 of 11 '3 W. P—ted on Recycled Paper 3. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: , Owner: C, C'fCC r i Date of Inspection:�eC INSPECTION SUMMARY: Ghg-k .B, C, or D: A. SYS SSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM CONDITIONALLY PASSES: or more system components as described in the "Conditional Pass action need to be replaced or repaired. The system,upon comp on of the replacement or repair, as as by the Board of Heal , will pass. 1„ Indicate yes, no, or n determined (Y, fN, or ND). Describe basis of determination in all instances. If "not determined',explain why not: II _ The eptic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Com fiance (attached)indicating that the tank was installed within twenty(20)years prior to the date.of the inspection;or a, the s tic tank, whether or not metal, is cra ed, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will p ss i pection if the existing septic tank is replaced with a complying septic tank as appro ed by the Board of H Ith. Sewag backup br a ut o hi h sta ' water level observed in the distribution box is due to broken or obstructed pipe(s) or due t a bro en, a ed or even distn ution box. The system will pass inspection if(with approval of the Board of Health)• oken pipe(s) are replaced '. bstruction is removed distribution box is levelled or replaced The system re uired pumping more than four times a year due to broken or vtrstructed pipe(s). The system Will powS, inspection if(w h approval of the Board of Health): broken pipe(s) are replaced obstruction is removed o. i revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 CERTIFICATION (continued) Q Property Address: U©g Owner: C(pckPl Date of Inspection: ,,, p dl1 jq C. FURTHER EVALLUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) YSTEM(.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.W L.L.PROTECT,THE PUBLIC HEALTH AND SAFETY AND THE ENV160NMEhLTz. Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) S STEM WILL FAIL SS HE OARD OF.,HEAL ( DP IC WA SUPPLIER,IF ANY)DETERMINES THAT THE,SYSTEM IS :! CTIONING IN N T PROTECTS PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The sys am as 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 soil absorption system and the SAS is within a Zone I of a public water supply.well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from_a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the, well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less_ than 5 ppm. Method used to determine distance (approximation not valid). j 3) OT ER �J x revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �O Owner: 6 croc Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one qr more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. ., 'a s No — _ Backup of-vewage irrtofacility-or-system component,duego an overloaded or-cleg -SASor•cesspool. �-- j _ Discharge or ponding of effluent to the surface of the ground or-surface waters'due to an oyerload_ed or_clogged SAS or cesspool. Static liquid level in the distribution box above outlet in rt due an ov loaded or clogged SAS or cesspool.. Liq ' depth in cesspool is less than 6" below inver abl vol me is less than 1l2 day flow. 1 Required umping more than 4 times in last ear NOT a clogged or obstructed pipe(s). Number of - es pumped_. Any portion of t S I Absor on System cess of or rivy is below the high groundwater elevation. on of a c s or privy is in 100 fe of a surface water supply or tributary to a surface water supply. Any portio of -e i ithin a one I of a public well Any porti n cesspool or pn is n 50 feet of a private water supply well. _ Any po n f a cesspool or ivy i ess-t n 100 feet but greater than 50 feet from a private water supply well with no ' accep le ater quality an ysis If t we has been analyzed to be acceptable, attach copy of well water anelysis,for- f -�colif cteria, volatile rga c-compo ds, mmonia nitrogen and nitrate nitrogen. E. LARGE SYS I You must indicate rther ' es" No" o each of the following: The loll wing c teria apply large systems in addition to the iteria a The system serves a fa i,ty with a design flow of 10,000 gpd or g ater(Large System) and the system is a significant threat to,public health and safety an he environment because one or more of the fol wing conditions exist: Yes No th system is within 400 feet of a surface drinking water supply the system is-within 200 feet of -trilwtery-toasurfaoe l4nkiwg•w8ter"$u - ---- _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection A a• IWPA) or a mapped Zone 11 of a public; water supply well) The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30 21. Please consult the local regional, office f the Department for further information. revised 9/2/98 Page 4of11 a : SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address-, w /"�'1 F,, 34-, Oster L/{I/C owner: C, C(&k•p r Date of Inspection: 'C1 RE, Check if the f wing have been done: You must indicate either "Yes" or "No" as to each of the following: Ye N . Pumping information was provided by the owner, occupant, or Board of Health. None of the systemcornpooents."waboenpuwgs, for-atJeast'tawoweekc ara&tbe'iystemhasb wasctaidwgawssdtlow ` rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. E The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition.of baffles, or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Th size and location of the Soil Absorption System on the site has been determined based on:- Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable), (15.302(3)(b)) The facility owner (and.occuparits.if different from_owner).w are.prouided.withiafc=atiomDn?h un;w_maintaaaaa ^f ' A SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACI SEWAGE DISPOSAL SYSTEM INSPECTION FORM A.. PART C SYSTEM INFORMATION Property Address: Vb1- Ownw: C i Crocker - — Date of Inspection: QLc. Flow coNDmoNs r RESIDENTIAL: Design flow: g•p•d./bedroom. !r Number of bed�i//o66ms(design): Number of bedrooms (actual): Total DESIGN flow- Number of current sidents: Garbage grinder(yes or no):� _ Laundry(separate system) (yes or no) =' if yes, separateinSPectiOni required Laundry system inspected ly s er+te) Seasonal use(yes or no): d Water meter readings,if a le(last two year's usage(gpd): �/ 1 Sump Pump(yes or no):_ Sfr�t Last date of occupancy:f "/"1--�==9 COMMERCIALIINDUSTRIAL: Type of establis Design flow nt:: d ( Based on 15. Basis of design flow — Grease trap present: (yes o o) Industrial Waste Holding Tank a (yes or no)A0 Non sanitary waste discharged th le 5 system: (yes or no)� _ Water meter readings,if ava• le: ?. Last date of occupancy: OTHER:(Describ Last date of o upancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or n If yes, volume pumped: allons Reason for pumping: ✓02 TYP OF Septic tank. it absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) IJA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of.DEP Approval Other `= APPROXIMATE AGE of all components, date installediif known)-and source of-information: i Sewage odors detected when arriving at the site: (yes or not ,( y .. revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) operty Address: qD0 /Y1a le �`� � (✓!1 Owrw: C' C�©c{Cary ( p p/ Date of Inspeco«,:Oec, `,'T 7 Cl BUILDING SEWER: (Locate on site plan) f' Depth below grade:_ Material of construction:_cas 'ron 40 C other (explain) Distance from private water supply or suction line Diameter Comments: (condition-of joints enting,ev nce of leakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Fiberglass Material of construction: concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is(petal,list age_ Is_age.confirmed by C cate of Compliance_(Yes/No) Dimensions: Sludge depth: v.5a", Distance from p of s dge t ottom of outlet tee or baffl s� 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.✓ �� How dimensions were determined: e %/7 9p�Q /� IRA Comments: (recommendation for pumping, condition of inlet and outlet tSq or-baffles, depth of ligt;id level jD-LeJation to outlet invert, structuroHntegrity, evidence of leakage, etc.) Ore— GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete etal_Fiberglass _Polyethylene_other explain) Dimensions: Scum thickness-.-- Distance from top of scum to top of outlet r baffle: Distance from bottom of scum to botto of out tee or baffle: Date of last pumping: Comments: (recommendation for pu ing, condition of inlet and ou t tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, c.) revised 9/2/98 Page of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G p rn SYSTEM INFORMATION (continued) Property Address: Owner C. C(ocker Date of Inspection:�C TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass_Polyethylene_ot er(explain) Dimensions: Capacity: gallons Design flow: allons/day Alarm present Alarm level: Ala m in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, conditio of alarm and float switches, tc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: . (note if level and distribution is equal eviden of solids carryover, evident of leakage' to or o of box, etc.) —— PUMP CHAMBER:_ (locate on site plan) Pumps in working or er: (Yes or Not Alarms in working rder (Yes or Nc) Comments: - (note conditio of pump chamber,condition of pumps an ppurte ances, etc.) revised 9/2/98 Page 8ofII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6� /�tGir+~'1 V (UI Owner: C , Ccmwer- Date of Inspection-V� I I /^�� SOIL ABSORPTION SYSTFJ�I(4AS):_ (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: �. Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan\inve Number and config Depth-top of liquid Depth of solids laye Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pu a as rt o in -c • n) - o Comments: (note condition of soil, signs of hydraulic f/e,, Ievel \po *ng, condition of,vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construct_io Dimensions: Depth of solids: Comments: (note condition soil, signs of hydraulic failure, level of ponding, condition of vegeta n, etc.) revised 9/2/98 Page 9of11 r / SUBSURFACE SEWAGE � AGE DISPOSAL SYSTEM INSPECTION FORM PART C (� g /� SYSTEM INFORMATION (continued) Property Address: I0U ��1�� �� �U/Cl� //'[f� Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i i l 3 t Y revised 9/2/98 PagQ10of11 3 -,j SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM j PART C. SYSTEM INFORMATION(continued) Property Address:_ t v Owner: (', CrC ef . Date of Inspection: Dec. NRCS Report name - — - . Soil Type Typical depth t groun jwwater USGS Date website visited Observation'Wells checked i Groundwater depth: Shallow Moderate 'Deep SITE EXAM Slope Surface Ovatei Check Cellar '. y Shallow wells J Estimated Depth to Groundwater$eet00 Please indicate all the methods used to determine High Groundwater Elevation: 6 a 1+. Obtained from Design Plans on.record 47 Observed Site (Abutting g property, observation hole, basement sump etc.) termined from local conditions "" G ecked wit h local Board of health Checked FEMA Maps { 4 Checked pumping records Checked local excavators, installers Used US6S Data Y % Describe how you established the High Groundwater Elevation.'(M List be completed) ' F ./1✓ .4 C 5 + A x c 1 revised.'9/2%98 T, "age 11 or 11 4 „. TOWN OF BARNSTABLE U LOCATION I/ SE AGE # � w vie/ ". VILLAGE ` 'E' ASSESSOR'S MAP & L O � a INSTALLER'S�NAMf& fa L PHONE NO. ��� a 4 1 SEPTIC TANK.CAPACITY Jo LEACHING FACII.PTY: (type) (size) t. NO.OF.BEDROOMS ' � BUILDER OR OWNER ►` r �� PERMIT DATE: COMPLIANCE DATE: �l Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge'of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .� y ,� &_a No. Y�3� - .... w FEJ..-(9.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �- Appliratinn for Bili-pniial Work.6 Tomitrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal Sys t• ` .... ......................... .....•----•-------•-•-------•---•--- ---•-- ...............0_'�..r ................................... - Loncation pdress or Lot No. bb n r Address W � ^ s Installer Address Type of Building �j Size Lot............................Sq. feet ►., Dwelling— No. of Bedrooms._-J ...._.. Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Otherfixtures ----------_------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 1:4 Septic Tank—Liquid capacity___.__._...gallons Length................ Width---------------- Diameter_............... Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) II Percolation Test Results Performed by-------------------- ...................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit----- .............. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit__..____-._-____-_. Depth to ground water---------______-.--___-. 04 ..................... ------------••••••--•••••---•-•--------•-•-••-----•---••-••------'---------•------------------•--••---------.......----•-•-•-•--•---•• 0 Description of Soil........................................................................................................................................................................ x w -- ------------- --- .......... ------ -------------------------------------------------------------------------- ---U Nature of Repairs or Alterations—Answer when applicable....___ ._j�_ _____ ________________��_�...--�--._-----.---__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h be sued by the and of health. Signed .......... - - ---- - --- - - - - --- ------ ---- ------- -- --------.---... . .............. ...........; Dq Application.Approved By ............` � g`e= ��-- Application Disapproved for the following reasons- ---------------------------......... ....................._................__..._.... -- ... ............_..................------------------------------.............-----------------...--------------------.............---...-------- ----------...................-----------------.... ........................................ Dace Permit No. ?y_—`3�C-----------------_......-- Issued c -..^� �1r Dare NO.. - d6) r Fsss ... ...0:... K THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE '! Apphration for Bi-aipw3Ml Work.6 TPwitrurtiun Varaft A,plication is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at _........................... Location �dress or Lot No. tner . ', d................................................. s 6a � � --------•---. -------------------------------------•- ......... �- -Installer y# Address � Type of Building f` ' Size Lot............................Sq. feet ai1 Dwelling—No. of Bedrooms...-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type' of Building ...................... ----- No. of persons-_---_-_----_.-..-.--.-.- Showers ( ) — Cafeteria ( ) d ' Other fixtures ---------- ---------------------------------------------------------------------------- ------------------------------------------------------------- tW Design Flow---------------------------------- ------gallons per person per day. Total daily flow---------------------------------- ----_.--gallons. W Septic Tank—Liquid capacity-__---...._gallons Length----------------- Width...---..-.-----. Diameter---------------- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area-----------.........sq. ft. Seepage Pit No....-..-_-_-------- Diameter.................... Depth below inlet------ I....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by_----------------------................................................. Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 ` Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ n+ ---------.................................................................................................................................................... 0 Description of Soil------------------------------------------------------------------------------------ ------------------------------------`......-----------------------............---- U - - --------------------------•-•...... --- --- 00e UNature of Repairs or Alterations—Answer when applicable._..' .. ._- ..k. ...... --_----- V!�--��-.���__._�_�--- , ... ' ..� Agreement-. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmenta'1 Code —The undersigned further agrees not to place the' system in operation until a Certificate of Compliance has beep 'ssued by the board of health. r -- . Signed . - "..- •%% . - /�� �! . �,yM (.� Application.Approved BY -------------- } ` ��-- - - -------------- � ..� D.. te Applic'at on Disapproved for the following reasons; - - .... ....................................--------------.....---........- ----------- .L4��.t � � ----. ,-C...............Date I f`, `x ✓ PermifNo. =--- bot-.. - Issued .............. ...'. -"-/3 ................... t � $ Date -. " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE "ditira e of CZom liance !. , - THIS IS TO CER T'Y, That-the Individual Sewage Disposal System constructed ( ) or Repairedor- ) by ...._ �.... -... - - --------------- - ----------- --- - � � a!® Inu filer_ - ---------------- --_... .-1 `-t.,� )J/c------------------------------------------------- has been installed in accordance with the provisions of TITLE 5~R � p of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -- 5--, c -c.:.._---------- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................�. .... �' .`:...... f/. - Inspector -------- ....�..-..------------ --------._._--------------------------.--- _.�__._.�._.e_.�._J���._. � �.'"_a-.e�.sa�1l 'E�•I f ' .�.���. _ _��..�,...+�.�_ 17,7 THEE sCOMMONWEALTH OF MASSACHUSETTSwk*°*- t BOARD OF HEALTH <TOWN OF-BARNSTABLE J No s� ( m FEE ............... Dispoli t�1�IUD i lua�#rurtbani rrntit Permission is hereby granted....?!'.. !� ---- -------------------------------------------------•-----........... to Construct ( ) or Repair ( ) an Individual Serge Disposal System a s atNo..-----�..^ � 'q f._........��.../---------- ----------••---------.-. /,i �',@' 1 u� !� Street C� as shown on the application for Disposal Works Construction Permit Nol� n Dated--------- ....... ... -- ------------------------------------------------------- "� lJ Board of Health DATE..............-?.... ...................................................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS `r C14 TO", OF BAMSTABLE L.00ATION / SEWAGE # VILLAGE twit` ASSESSOR'S MAP&L0� ­d .::,:.INSTALLER'S NAME&PHONE NO. != %��Gl L . SEPTIC TANK CAPACITY f�d '.LEACHING.FACILITY: (type) (size) NO.OF BEDROOMS ':BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 77 4 Sepazation Distance Between the: f Maxum Adjusted Groundwater Table and Bottom of Leaching Facility Feet im ..:Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet :Edge of Wetland and Leaching Facility(If any wetlands exist Feet Within 300 feet of leaching facility) :Furnished by V. LO`CATION SEWAGE PERMIT NO. q f- S VULLA& E ' INSSTA,. LLEEV'S NAME i ADDRESS �ry B U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED -- ____ _ _______ r ,Si,JC pL �rJ r1,S�" .. ... // � ��� t� 1 K �� . i A ��2 �-3 • Fps � _. .. No................_....... ?'� .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH llq '404?® ............. Ji�I�.....OF.-.- �s ��l ) r.---••--•-----__-__--- Apphratiuu f or Biiivoiial Morks Tome rurfiuu ramit Application is hereby made for a Permit to Construct ( ) or Repair (,X) an Individual Sewage Disposal System at ... ' 2 :'.Y._0f.17.......................... .----------------------------•------ -- ------------------------...............__ Location-Address or Lot No. r� .._..C.rrc�e�.r.................................... � �>�� . -------- QW Address a ?..c --------------------------------------------------•---•---....._..........-----•---------------•- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) Cafeteria ( ) aOther fixtures ........_------------------------------------------------------------------------------------------------------------------------- WDesign Flow_________________________...................gallons per person per day. Total daily flow...............:.................:..........gallons. P4 Septic Tank—Liquid capacity............gallons Length................ Width_._ Diameter________________ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................-......................................... Date........................................ aTest Pit No. i................minutes per inch Depth of Test Pit....:............... Depth to ground water......................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �) ----------------------- O Description of Soil--•--- 4-Q� ' ---9•r� � ....... -- - -- ...................................... x 1 F. ' W ..........................._..............................................................................________________________________ ___ __ _._____ __.._. ____________..._.___. U Nature of Repairs or Alterations—Answer when applicable._J:,1,0,o,0__ ,1� ______ _____________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en ssued by the oard f ftalth. Signed_._._ Gc Date 11 Date Application Approved By_—,....----. '" --------r •-1= �-`---T.?...... Date Application Disapproved for the following reasons:................................................................................................................ ....-•--------•--••-•------••--------•---••-•-----------------------•.._..•-------------...--------•-----•-•-------•--••------•--•--••-•---------•---•---•-•-•-•-=------------------------_-------- Date Permit No......................................................... Issued_... ..........` --•--•------------------- D ��- ate C-7)? No.........a..2-3... Fss. %.:. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. t. si �.....oF. k....? c% , d.. a d..6 .c.---............---......---.------ '? Appliration for Di-quual Workfi Tontrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair (,A) an Individual Sewage Disposal System at: y'� "'• .Lofca_tion,-Address y'�' jj or Lot No. ......................••--•-----..... -•---�a'.r--`..x",A.__,4'...:?:.!� d._Sr.............................. •-------•-••---...-----• - ... caner �„ Address Sn Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder- ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures ------------------------------ = . W Design Flow............................................gallons per person per day. .Total daily flow.............................................gallons. ` WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ liepth................ x Disposal Trench—No..................... Width...0................ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet............:....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test. Results Performed by........................................................................... Date--...................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--__--__--_-_-__•-__---. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---__-___-_----_--___. ------------------------------;_-..---.--------....------•------•------...... ---•---------- :....... -------- -ClD Description of Soil.......�5�t�,�1/,!.-•---=----�== 1 --------------------------- 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been jissued by the,Yard,.0of Pealth. r� , zoo Signed - �-- ..... .............................. / f f Date Application Approved By-- �"� � . 1�:,'l �� ° �f f `=---7--?=------ ' Date Application Disapproved for the following reasons-----------------------------•-------•----------------........................................................... ..........-•-------•-------------•-----...........-•---------.....------....-----•----------•--•-•-------------•------••--••----.....•----••--•--•-•••--•-••----••-•--••---••-••--------------....----- Date PermitNo.......................................................- Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD''y OF HEALTH • t j� i yid..$'F'tr'\jzps.,..'.. ............�. :`.<?'-rc�r .......0F..:'� �C!. ... .... .C.......r,.t'.P.:wa................................... Trrtifiratr of ToanpliFanrr THI.VS T0.CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (}�) y by........ .:.4.... y t a e Installer at.......VZ ".....1 'I E2..---- J---......... ------•-----------------------------•----•-•-------- has been installed in accordance with the provisions of T �of The State Sanitary Code as described in the i application for Disposal Works Construction Permit No.___�....2.-..:-f................. dated_---f .f_. _`__ .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH %...'.OF.... t ^"' r'.M (a t ' ................................. �%� , N ��.... .�.: ' FEES. ...... %....... Disposal Vorkv Tomitrudion Prrntit Permission is hereby granted *'. � `..--------------------------------•--. to Construct ( ) or Repair (� ) an Individual Sewage Disposal System x Street as shown on the application for Disposal Works Construction Permit o____________ _____ Dated --./ ----�`. .. 7� ......................... ` Boar of Filth DATE........` �----•--�---�................................. V FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS