HomeMy WebLinkAbout0481 OLD MILL ROAD UNIT #A - Health (2) ?-4uO, Os Ile.
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111RAXTER & NYE, INC.
Professional Land Surveyors and Civil Engineers
812 Main Street•Osterville, MA 02655 Tel. (508) 428-9131
Fax. (508)428-3750
WILLIAM C. NYE, R.P.L.S., President STEPHEN A.WILSON, P.E.,Vice President-Engineering
RICHARD A. BAXTER, R.P.L.S.,Vice President JOHN R. ELLIS, R.P.L.S.
June 1, 1999
Mr. Edward Barry REC �0 '�
Health Dept., Town Hall
367 Main Street � J U N 2 1999
Hyannis, Ma. 02601 TOWN OF BARNSTABLE ' '
N. 1'.TH OPT
Re: N. Abraham �'�
88 Bridge St., Osterville
Permit#86-804
Dear Mr. Barry:
We have evaluated the capacity of the existing septic system at the above noted
address.
The system consists of a 1500 gallon septic tank and 3 flowdiffusors with a
minimum of two feet of stone. The 1500 gallon septic tank has ample capacity for four
bedrooms. The leaching capacity of the flowdiffusors is:
Sidewall (28' x 10')x 1' x 2.5 gpd/sf= 190 gpd
Bottom. (28' x 10') x 1.0 gpd/sf= 280 gpd
Total 470 gpd
The system has the capacity to handle four bedrooms.
If you have any questions or comments please call me.
Very truly yours,
Baxter&Nye Inc.
t en A. Wilson, P.E.
V.P. Engineering
cc: N. Abraham, S. Swain
#97064
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
/
No. 7
7 Fee /4,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
• el'-s
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Miopo!6al *Vmem Con6truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot o. �tg Owner's Name,Address and Tel.No.
Assessor's Map/Parcel v s /114 kUC'W.,1
//� Qom ;�t u s ff A9
Installer's Name,Address,and Tel.No. ,Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No. of Bedrooms Lot Size sq. ft. Garbage Grinder(N-)
Other Type of Building_�*fj No. of Persons Showers Cafeteria(�✓�j
Other Fixtures AIPAI E
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Dom: . I JP. )C r Q Number of sheets Revision Date 06-"L 100
Title
Size of Septic Tank Ci A-Lf Type of S.A.S.
Description of Soil i O 6AX-91—J`i A 14 Y f r&,"
0-1:, . 10 1-1 9 5
Nature of Repairs or Alterations(Answer when applicable)
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 Certifi-
cate of Compliance has been issued bv this Board of Health.
Signed L. Date
Application Approved by `� " _- c� 6l✓ ,C Date :�L S
Application Disapproved for the following reasons
Permit No. _ Date Issued Z l
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded( )
Abandoned( )by
�.
at t° < r has been constructed in accordance
with the provisions of Title and the for Disposal System Construction Permit No. --11-4 V' dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
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No. 5,
Fee � . �'Z
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
=iq;pool *pgtem Con$truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade bandon )
I
System located at
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 permit.
Date: Approved by
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Commonwealth of Massachusetts R E C E I V FEE®
Executive Office of Environmental Affairs
Department of JUL 2 5 1997
Hi
Environmental Protection Townos` LE `.
Wllliun F.Weld Trudy Coxe
oommor g.or i,ry
Argeo Paul Cellucci David S.Struhs
U.Governor commlaww r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART A -
CERTIFICATION
Craig Ne'riter
Property Address: 88 B r i d e St, O s t e r v i l l a Address of Owner. 11210 S Glen Rd
Date of Inspection: 4e—vl (If different) Potomac, MD 2 0 8 5 4
Name of Inspector. W.E. Robinson SR r
Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5-8 7 7 6 '.
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MAj
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate e'
and complete as of the time of inspection. The inspection was performed based on m t p pect' pest' pe y raining and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
— Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails A'
Inspector's Signature: I/ / � `(Jr/��' Date: 4/-4:7- 6
r The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B, C,or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
] SYSTEM CONDITIONALLY PASSES: '
One or more system componenteneed to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection. _,a
yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined" ee:&`lain why not)
_ The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
5
(rev ed 11/03/95)
7 1
;One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292•SM
'10 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address: 88 Bridge St, Osterville
Owner. Craig Venter
Date of Inspection: _t'y 7
B)SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 88 Bridge St, Osterville
Owner. Craig Venter
Date of Inspection: CF, ^1;11 1/1-
D) SYSTEM FAILS:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface.waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) GE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 11 of a public
water supply well)
The caner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req meats of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for!hither information..
(revised 11/03/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
0
Property Address: 88 Bridge St, O s to ry i l l e
owner. Criag Venter
Date of Impeotion:
Check if the following have been done:
1/Pumping information was requested of the owner,occupant,and Board of Health.
_E4one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
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.
J_,,/'he system does not receive non-sanitary or industrial waste flow
tThe site was inspected for signs of breakout.
_jelAll system components, excluding the Soil Absorption System, have been located on the site.
_1,�e 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.
JThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated non-intrusive methods.
//PP by
facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
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(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
property Address: 88 Bridge St, Osterville
Owner; Craig Venter
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:-
Design flow � ons
Number of bedrooms:L0^LJ
Number of current residents:�o
Garbage grinder(yes or no):_,!Z1'A1 _
Laundry connected to system(yes or no):4
Seasonal use(yes or no):-A,%S
Water meter readings,if available: 1996 — 9 7 , 0 0 0 a a 1 s
1995 - 87PQQ0g•a1 c
Last date of occupancy:
'G
COMMERCIAL/INDUSTRIAL-
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes,'vohune pumped: gallons
Reason for pumping:
TYPE OF YSTEM
ptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: Q Y S ✓� r/�/
0
Sewage odors detected when arriving at the site: (yes or no)&
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddrem 88 Bridge St, Osterville
Owner. Craig Venter
Date of Inspection:
SEPTIC TANK:1�
(locate on site plan)
Depth below grade: '
Material of construction:✓concrete_metal FRP_other(e:plain)
Dimensions:
Sludge depth: `'l1' )
Distance from top of sludge to bottom of outlet tee or baffle:-2-IL
Scum thickness: )^/ L %
Distance from top of scum to top of outlet tee or baffle:_F .)
Distance from bottom of scum to bottom of outlet tee or baffle:
LL
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) Ta •+_ /� �'a�� a,, `� z� y, s �1
G E TRAP:_
(loca on site plan)
Depth low grade:
Mate of construction:_concrete_metal_FRP_other(ezplain)
nsions:
thickness:
from top of scum to top of outlet tee or baffle:
from bottom of scum to bottom of outlet tee or baffle:
Comm ts:
(rem endation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evide of leakage,etc.)
(revised 11,11,95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddrese: 88 Bridge St, Osterville
Owner. Craig Venter
Date of Inspection:
TI HT OR HOLDING TANK_
( on site plan)
Depth grade:
Material construction:_concrete_metal_FR.P—other(explain) '
Dime no:
Ca gallons
flow: gallons/day
Alarm level:
Co ts:
(ooadi on of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) fi
PUMP C BER:_
(locate on 'te plan)
Pumps in rking order:(yes or no)
(note co tion of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddreas: 88 Bridge St, Osterville
Owner. Craig Venter
Date of Inspection Lr
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:_
leaching chambers, number.
leaching galleries,number:
leaching trenches, number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Co m ta: (note coition of soil, signs of hydraulic failure, level of ponding,condition of vegetation etc.
c 7t-I -d- o C,f Z/2 -e P rz >
C POOLS:
(lots on site plan)
Lr and configuration:
top of liquid to inlet invert:
of solids layer.
Dep of scum layer:
no of cesspool:
rials of construction:
tion of groundwater:
inflow(cesspool must be pumped as part of inspection)
Co nts: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.
P _
(11 on site plan)
Mate ' of construction: Dimensions:
Depth f solids:
Co ta: (note condition of soil,signs of hydraulic failure, level of ponding vegetation,etc.
condition of
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address 88 Bridge St, O s t ery i 11 e
Owner. Craig Venter
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
r 1
L g
1
�-n b
DEPTH TO GROUNDWATER
Depth to poindwater: 'L_feet
method of determination or approximation: 6
(revised 11/03/95) 9
z
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property bf-1, c 5+: Gib.
Owner' s name 6rC-A(el
Date of Inspection L y5_
PART A
CHECKLIST
Check if the following have been done: ,
Pumping information was requested of the owner, occupant, and Board of
Health.,
✓_ None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
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 site was inspected for signs of breakout.
All system components, excluding the SAS , have been located on the
site .
The septic tank manholes were uncovered,' opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
✓ The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
. . The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
10 11
12
1995
CO
5
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION -
FLOW CONDITIONS
If residential
3 number of bedrooms
9 number of current residents
garbage grinder, yes or no
laundry connected to system, yes or no ;
seasonal use, yes or no
If nonresidential, calculated flow.:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping re ords and source of information:
N(�
_ VC) System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
d-d opt neC6 -it jfy� b= 6' ys
Typp� 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) '
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
144 4 L q6 0`(
N0_, Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:
material of construction: `concrete metal FRP other(explain)
i m e n s i o n s:
sludge depth
X10" distance from top of sludge to bottom. of outlet tee or baffle
I scum thickness
distance from top of scum to top of outlet tee or baffle
S" distance from bottom of scum to bottom of outlet tee or baffle
Comments :
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert,' structural integrity,
evidence of leakage, recommendations for repairs, etc. )
DISTRIBUTION BOX:
( locate on site plan)
u depth of liquid level above outlet invert
_�omments
note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
F)UMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan , if possible ; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, .explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, nunber, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil signs of h d g y raulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc, )
CESSPOOLS (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 constructs
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments :
(note condition of soi.l ; 'signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etce )
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, recommendations for maintenance or repairs,etc. )
I
t
SUBSURFACE SEWAGE DISPOSAL SYSTEMI INSPECTION FORM
PART B
SYSTEM INFORMATION continued
I
cKETCH OF SEWAGE L'SPOSAL, SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
{
locate all wells within 100 '
�r
j a4
U
t `
DEPTH TO GROUNDWATER
�O depth to groundwater
16-thod of determination or a proximation:
I
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances .. If "not determined" , explain why not)
Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or ,
surface waters?
o Static liquid level in the distribution box above outlet invert?
_ Liquid depth in cesspool <61" below invert or available volume< 1/2 day
flow?
_ Required pumping 4 times or more in the last year?
number of times pumped
_o✓ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration?tank failure imminent?
Is any portion of the SAS , cesspool or privy:
�l below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
Aj within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
►�' within 50 feet of a private water supply well?
_ less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well ,
has been analyzed to be acceptable, attach copy of well water analys.-
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
� • a
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
:dame of Inspector lW, l l;gn� l ►Zc� >>� J !
I.ompany Name W.)XE Rob's�'' sc�f� s�• �,��
Company Address qt Cqp+ Eli,s c;9nc �lyrqno'*3
Certification Statement
I certify that I have personally inspected the sewage disposal . system at
this address and that the information reported is true, . accurate and
complete as of the time of inspection. The inspection was performed and
. �y recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maiitenance of on-site sewage disposal systems.
7Che k one:
_ I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this forme
I have determined that the system fails to protect public health and
the environment as defined in'`310 CMR 15 . 303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form .
-Inspector ' s Signature
Gate
C,riginal to system owner
Copies to:
Buyer -(if applicable)
Approving authority
}
—TOWN OF BARNSTABLE
e LC�:ATION v SEWAGE # /
VILLAGE QS ASSESSOR'S MAP &LOT 'i ®Z
INSTALLER'S NAME&PHONE NO. OUi 60A S_404G
k SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 3'N� �dN��i�'�vret1 (size)
.-.NO. OF BEDROOMS .�
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facili Feet
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LOCATION SEWA E�'ERMIT NO.
,7<F. 0 G E- S T-
VILLACE - -
IN ER' NAME a ADDRESS '
S UILDEE�R OR OWNER
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DATE PERMIT ISSUED
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DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
B0A RD OF HEALTH
.. ....................
Appliration for Disposal Vorks Tonstrnrtiun rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stun at:
..:..... .C?a._ ....... 1------------------------------------ .................................. ..........
cats dress or Lot No
ow Address ...........
Installer
Size
Ls
U Type of Building i
.. Sze ot............................Sq. feet
Dwelling—No. of Bedrooms....... . .........................--.......Expansion Attic ( ) Garbage Grinder
Other—T e of Building _......__..._ No. of ersons—....:.................... Showers
a Other—Type 'g -•---------r-- P ( ) — Cafeteria ( )
QOther fixt s .----------•--------------------------•=----------•---•••--•-----•.----••-••-••-------••--••-•-•-•-••••--
•. ••-•-•---••......--...•• g P P P y ..•...... ---gallons.
DesignFlow.............��. •- allons er erson er da Total daily flow.._:._.__:_.._._.__
W �
WSeptic Tank—Liquid ca.pacity� gallons 1}ength.__.�G...... Width----(P....... Diameter................ Depth................
x Disposal Trench-No. .....I............. Width.-.-�'._.......... Total Length...Gk�....... Total leaching area....................sq. ft.
3 Seepage Pit No......................' Dia r........._. Depth below inlet.................... 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........................
f� Test Pit No. 2.............,.minutes per inch Depth of Test Pit.................... Depth to ground water........................
Qi -----------------------------------------------------•---------•----••---------------...........------------•--------...-•-•--------
..........-----------
O Description of Soil....................................•..------------•------...... ........----------------------•------------------•-------...._...
x
w -•••--•-•••-•...••••---•----••......---•••••-••-----•.....••-•• •••-• ..........................
--------------------------------•---------------------...----- ----.--------
x =
U Nature of Repairs or Alterations, Answer when applicable...___: [ _ -�-..--..-- �� .q4 �Cr ....--••-.
` i
r .------•.--L r �---•--•---- ....zc ...............
Agreement:
The undersigned agrees to install the`aforedescribed Individual Sewage Disposal System'in accordance with
the provisions of LITis, 5 of the State Sanitary Code—The undersi ned further agrees not to place the system in
operation until a Certificate of Compliance rle� the bo d of health. Q
Si d---------- -- c S
at
Application Approved By.................... ....
Application Disapproved for the following reasons----------------------------------------•---------------•------.•------------....-----....-•--•--
........................••............•••........_..•• -•••---••-----•••••-••-•-----•-•---•••-••---•---...............•••••-•---••-••----•-•-•••••----••••......•-••--••----•--
Permit No...........
----- �• Issued.:.. hate M
- ,Date ��
60&
4/
No. ..................FS Fins
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..... ............ .............__...OF
.................................
Appliration for Uiiipasal Workg Tonstrurtiati jiumit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
-......2 Q� C--,C, C_ .,Z—>�� 11
........... ...................................... V....... . ................................ �---- 9
calio:VA d or Lot No.
.................... .......................1--- .. .........................................................
Own r Address
..................................... ....... .........t7,
Installer
C.
Type of Building
�� Address
U Size Lot............................Sq. feet
Dwelling—No.-of Bedrooms..........3--------_--------------------Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons...._...____.._.._._.___.__. Showers Cafeteria
Other' fixt�es ............................................................................................................. ....................................
Design Flow............C7............................gallons per person per day. Total daily flow-------:7-3........- ----.................gallons.
Septic-Tank—Liquid capacityk gallons Length .... Width....(P....... Diameter._.....___............ Depth................
Disposal Trench—No..._._1............. Width.....&.......... Total Length---v .... Total leaching area....................sq. ft.
Seepage Pit No...____...._...._.__.. Diama- r.................... Depth below inlet..............._.... Total leaching area..................sq. f t.
Z Other Distribution box. Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.._.__._........__.. Depth to ground water....:.___._.._.......__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit._._........____.... Depth to ground water:....._._._.._......_...
fYi
. ............................................................................................................................................................
0 Description of Soil....................... .............................................................................................................................................
----------------*"**'*'*-----------------------------------------------------------------------------------*----------------------------------------*------**-----------------------*------
.............................................................................................................................4- ........................... ......................................
U Nature of Repairs or Alterations—Answer when applicable.:.___ -1.....t.......afkj(__�........ ..........
.......... .................
------------91.� -----sr_�..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'ME 5 of the State Sanitary.Code—The undersi ned further agrees not to place the system in
operation until a Certificate of Compliance_ba-s-been-i.s,s,ued-by the bo;,37 of health.
t.
g;ed.... .......... ------- ------- <
Date
Application Approved By........... � ....................... ...........&/149.6.......
-A _ .....Fiiale
Application Disapproved for fhe following reasons:.......................................................................................................a........
........................................... ...........................................................................................................................................................
Date
Permit No............. ea.----- Issued---------------------...................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......OF...... ....................................
Tertifiratr of Tomplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed�.'�..,,,/or Repaired
by................1��
..........
Installer
at
::!� .......?...•..........................................................................
............ ..............(::�
has been installed in accordance with the provisions of 'I'ITIL' 5 of The State Sanitary Code asidescribed 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.
7_/_1 Inspector..DATE......... .. ................. .......... .
. ............... ...........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF........ ......................
Disposal luorkii 1T1.Wngtrwt,:Wtt firrutit
Permission is hereby granted........ j
.. .........I.............4._>........................................................................
to Construct ( L_)-6—rRepair Individual" Disposal System
_.(C�i� f--—----------:�- ,,i I at No................ -=:qw,4a�---- ......kc;� ..............................
Street � �by .S;�
as shown on the application for Disposal Works Construction Permit No..______--_.-______ Dated...... _Z-------i.........*......
................ ............................
.......... Board of Health
DATE
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