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HomeMy WebLinkAbout0208 OST.-W.BARN. RD - Health 208 ®sti per - A.ff D Barn, R 121-027 Ostervil(e , a i '.. a ... • .. - �, .. � c.. � ' 1 A PROVED •� Bar 2v":'u'-'rvation Commission �/ Fps.... ............._ THE COMMONWEALTH OF MASSACHUSETTS S OAR® OF HEALTH Signed Date TOWN OF BARNSTABLE Appliratiou for Uiipuual Workii Tuuutrurtion tirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• ` --•-----•----••• --•---------• --_----- Loc lion-Address uR or. Lot No. ....... _ .._. W --------------------------- --------------------------------------•----.... ...... - .-.-.............-------- . • q�� Owner Add s W - •�'--' •-•-- ---------------------------• -------------........._ �0�.. ! � Y 1•. . \ SCSYI-•--.�_..._ ` .: ... �.. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons---•________________•______- Showers — Cafeteria (a, Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic 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.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I................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........................ 0+ ---•--------••-•••••••••-••.................•••••••----••----•----------..................................................................................... ODescription of Soil........................................................................................................................................................................ x U ..................-..................................................•-•-•--•-•--•-•--------------••-----•-••---•----•------•---•-•---------•--••••....... ............................................ W x ------------------------------------- ----------------- ------------------------------------------------ • . --- --------------- - -- -- - ------------ - --- U Nature of Repairs or Alterations—Answer hen a plicabl ._ � _ . ._. _____________________ ...................... �C T--------------- ----------.....--------------•--•-- 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 Complia ce s en is the board of health. Signed .... ..... ...... ..--- �� /. Application Approved B ... .............���..�....---...---- --..®-............. --- -- --............ . . ...................... ........... ..`�J�--- PP PP Y te Application Disapproved for the following reason - ---------------------------------------------------------------------------- .. .... ---------------------------- . ........ .................. ............:. ........ ........................... .................................. -----------------------.. .... Permit No. 9./-- _ Issued >�.. i ' -.........._..... FEz.... .... Z THE COMMONWEALTH OF MASSACHUSETTS a3 �ey'\%OARD OF HEALTH " TOWN OF BARNSTABLE Appliration for Biiipuital Works Towitrurtinrt Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (y) an Individual Sewage Disposal System at• ' n\¢ Loc tion•Address or Lot No. :�J *,2:..... .. .. .................... - • �I�� ..............`.....---- �- Ownez P_'_' Addr ss� Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..................6...................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of ersons............................ Showers � YP g ------•-------------•------• P ( )--- Cafeteria.( ) Otherfixtures ------------------------------------------------•----.-••--------- w Design Flow............................................gallons per person per day. Total daily flow...........:................................gallons. WSeptic 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.................... Total leaching area..................sq. ft. Z Other Distribution box (Y.. ) 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.:....................:. ......................................................... •-•---------:------..---...------ .-------------•----..---•-•-•••--------- --------- 0 Description of Soil------------------------•-------.........------•----------------...------------------------.------------------------------......-----------------------._....-•-•.•---- x w _ 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce s en iss-t\c-b} the board of health. Signed .--...... ---- ---------- ...------------ ---------------- --.—-- Application Approved By ..- Z�� B i.................... . ... . ....... .. le Application Disapproved for the following reason - -----------------------'t----- .................................... /.. / ------------------------------------------------------------------------------ -----------------1.� 3 ---------------------------------- Permit No. 9�. ------ - Issued .-- Dare t_77e------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V er tiff ate of Camplian e IS TO I Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( � f by .- -------------------------------------------------------------- .----...... . -_.... ----------------------------- -- -------- � 1 _ at - ------------- Q-` -...... .. W-t=�6:.�a,--- -...... - -----........C��..- �.1.. has been installed in accordance with the provisions of TITLE 5 of The t e nvironmental Co s es n the application for Disposal Works Construction Permit No. ---q--/� .... ................. dated --------- -. - --- ..-.. : .... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CON TRU D AS A GUARA TEE H T E SYSTEM WILL FUNCTION SATISFACTORY. 1 - 1 ./ DATE................................ - - = -; Inspector .... - . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE `' No...... .......... .... FEE. -•••................ ��k qPermission is hereby granted-- ---- -•------- --------------- ......-----........-•-•--------------------......................-----•..••- to Construct ( ) or Repair (,f an Individual SewageDisposal tem �(� ' \` at No.•�O- ? -- ---���j'' `��' L � L� '�� i � �stre'C-__ _�-S_V6 V-�.5� ...- ..:...._ as shown on the application for Disposal Works Construction Permit No.. �Dated...._7-1=.� '7 ._1....................•----...•--...-• --- - --•...T.� .--.... .Bard of Health DATE................ -- �-v--- ---•--I-----•--•-----------------... FORM 36508 HOBBS Q WARREN,INC..PUBLISHERS TOWN OF BARNSTABLE LOCATIOQ©r� 05C% k- �S. A EWAGE # q l VILLAGE ASSESSOR'S MAP & LOT INSTALLER.'S NAME & PHONE NO!FA SEPTIC TANK'CAPACITY /Q0Q LEACHING FACILITY:(type) 2Lt (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER W DATE PERMIT ISSUED: f DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No y'Ff �� � �� ��� . .. ���� �, ��: � i �a — -- — �u � �� � � � � _ 6 � �" �� �� �` �� �� � � � � _ �� � -�� � . f z r t I TOWN OF BARtNSTABLE LOCATION of O�T /LJ �C-, b5kL j EWAGE#_a6J 1-,T�2 VILLAGE ASSESSOR'S MAP&PARCEL \;;Lk da;7 INSTALLER'S NAME&PHONE NO. J�y �' - n `�.��I` SEPTIC TANK CAPACITY 0,kk aUV 0 6 LEACHING FACILITY:(type) CS"L yt� (size) (e�C6 LJ S NO.OF BEDROOMS C'u, � 1�4X (SI\\�^� OWNER s PERMIT DATE: 9 �rl 1 � I COMPLIANCE DATE: Ci I(' Separation Distance Between the: Maximum-Adjusted Groundwater Table to the 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 -;r 40_ 25 41 �oFt"E roy,� Town of Barnstable Health Inspector Office Hours Regulatory Services 8:00-9:30 . 9 MASS. Thomas F.Geiler,Director 1:00-2:00 i659. �0 Only A,Eo �a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: Address: ( ��T l�� ,�J�,�f7IJJ' ��/�/ Map Parcel Qo2: 0tz7 Name: 1�il Phone: ,5DF- hIo2.J - jc",5-23 2. How many bedrooms exist on your property now? a /}� I�TDUSZ°�/ l/7 Gt�OG�ZZJ�df�T` 2a. Please include a copy of your floor plans. 3. Is the dwelling connected to public sewer? YES or If the dwelling is connected to public sewer, skip questions 4-9 below. 4. Location of dwelling is 7NSID r OUTSIDE a Zone of Contribution to public supply wells? S. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER. . 6. Is a disposal works construction permit on file? YES 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 1V0 8. .Is there an engineered septic system plan on file at the Health Division? YES or N0 9. Has the septic syste .been ins ected b a DEP �ertified inspector within the last two years? YES or NO /9Z /eGISe_�GvGIS laG . .-am ex/— -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTORIAGENT ONLY The Public Health Division ha o objection to !S bedrooms at this property. Signed: Date: Z IF Inspector(Print): y �1 J TOWN OF BARNSTArBLE LOCATION ogc) O ►�+?EWAGE # qj VILLAGE ASSESSOR'S .MAP 6z LOT INSTALLER'S NAME PHONE NO � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (' (size) L NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER. C� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L/< ■■ ■■■■■■■■■■■■■■■■■■■ � mmom ■01 r r�R■ ■Irr■■■■ ■■■■■■■■r■■■le � � ►, ■rrr�r ■■ENE rNNE■■■■■■■r■rir , . _ fir ■■ r■r■ ■ ■■■ ■■■■■■■0 MEN ■■■■■■r% , ■■%�■■.., , ■■■r ■N Eel. ._ • ■ ■■■■■Ir■■■ ■■■ ■ ■ ■■■■■�■■■ ■ ■■■ ■■ ■ ■■ ■ ■■ ■■■ ■ ■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■ ■ ■■ ■■I■■r■ ■ ■ ■■ ■■■ ■■ ME ■■■■ ■ ■■ ■■r■■■r�■��■■ �, ■�■ ■� , W..... ■ ■■1"INS . .r .1■ A 1■ Now 4, . MIN W._ n all INS I WWI u mum- INSr■� ■ ■ ■■ ■ ■ ■ ■■■r■r ■ ■■ his ■� �■ � ■■ Commonweanh of Massachusetts Executive Office of Environmental Affairs 3 Department of EIR13 Environmental Protection William F.weld FEB 2 a 19�7 Gormot . Trudy Cox* OFBr�n,r s.ua.ry,EOEA N6AlTHDEPi David B. Sttuhs r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �4 �l MAP# 1 PART A F PAR# 097 ©sTrow-4- Wes 7--CERTifICATION aoS osT w-Sdvv R� 3RkN F�PAN��iN Property Address: OS'7` Address of Owner: Date of Inspection: -/Y'—f17 (if different) Name of Inspector: J-A1,7£S -D .S EAIfs Company Name, Address and Telephone Number: A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and _ maintenance of on-site sewage disposal systems. The system: fit/oT£ --�iYiS /5 4 /ti,5,0Z c1/oti Passes N o ('Vdlf A;71L o A- cif f c r S YSZrlvr- _ Conditionally Passes -,_ Needs Further Evaluation By the Local Approving Authority _ Fails �q- r�• Inspmtoes Signature: d' Date: 111A -02�- S The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspectoott. If the system is a shared system or has a design-flow of 10,000 gpd or greater,the isupector and the system owner shall submit the report to the appropriate regional ofilce of the Department of Environmental Protection. The or4i al 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: Al 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. El SYSTEM CONDITIONALLY PASSES: ' One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y.N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,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 ponforming septic tank as approved by the Board of Health. (t'evised 11/03/95) I OM VAnW Strout • Boston,Massachusetts 02108 0 FAX(617)556-1049 9 T•lephon•(617)292-SSW . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: Owner. Date of Inspeotlon: B)SYSTEM CONDITIONALLY PASSES(continued) , — Sewage backup or breakout or high static water level observed in the distribution box is a to broken or obstructed pipe(*) or due to a broken,settled or uneven distribution box. The system will pass inspection (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 obstructed pipe(s). The system will pas* inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF if Tit: Conditions exist which require further evaluation by the Board 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 ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC TH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a su ce water Cesspool or privy is within 50 feet of a ering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BO OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM 1S NCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - The system has a septic d 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 and soil absorption system and is within a Zone I of a public water supply well. The system has a septi tank and soil absorption system and is within 50 feet of a private water supply well. The system has a se p c tank and soil absorption system and is less than 100 feet but 50 feet or more tom a private water supply Well,unless well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is free from pollution Bro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or'•less than 5 ppm. 3) OTHER e (revised 11/0 /95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: DI SYSTEM FAILS: I have determined that the system violates one'or more of the following failure criteria as defined in 3 CMR 15.303, The basis for this determination is identified below. The Board of Health should be contacted to determine what failure. be necessary to correct the _. Backup of sewage into facility or system component due to an overloaded or clo AS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface wale due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an erloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available v ume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT d e to clogged or obstructed pipe(#). Number of times pumped Any portion of the Soil Absorption System,cesspool or rivy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 f of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a ne I of a public well. Any portion of a cesspool or privy is wit 60 feet of a private water supply well. Any portion of a cesspool or privy is 1 than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. I the wgll has been analyzed to be acceptable, attach copy of.well water analysis for coliform bacteria,volatile organic mpounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to tar systems in addition to the-criteria above: The,system serves a facility 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 a ament because one or more of the following conditions exist: the system is thin 400 feet of a surface drinking water supply { the system within 200 feet of a tributary to a surface drinking water supply I the is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water pply well) The owner or operator f any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 6.00 and 6.00. Please consult the local regional office of the Department for farther information. (revised 11/ /95) 3 f SUBS URFACE E SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addreaec Owner. Date of Inspection Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. h None of the system components have been pumped for at least two weeks and the system has been receiving vltlg 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. V 'I'h 7'The e faciLty or dwelling was inspected for signs of sewage back-up. system does not receive non-sanitary or industrial waste flow kThe site was inspected for signs of breakout ' system components,f/(eluding 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 material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. _The rise and location of the Soil Absorption System on the site has been determined based on existing information or �a praaimated by non-intrusive methods. V The facility owner(and occupants, if different from owner)were` rovided with information on the P proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL; Design flow:__Vjlons Number of bedrooms: 3 Number of current residents: Garbage grinder(yes or no): NO Laundry connected to system(yes or no); 7£S Seasonal use(yes or no): Nd Water meter readings,if available: /V A Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_,gallons/day Grease trap present:(yes or no)_ Industrial Waste Bolding 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,volume pumped: O o 0gallons Reason for pumping. _ V S 01n fie, R£g yfsT-b --^91A,/4,vc r 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) P£,Pier iT APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site:(yes or no) N 0 (revised 11103195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: SEPTIC TANK ✓ , (locate on site plan) Depth below grader Material of construction: ✓Concrete_metal_FRP—other(explain) Dimensions: O O d FW R E C S T sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3� Scum thickness: / Distance from top of scum to top of outlet tee or baffle: /0 Distance from bottom of scum to bottom of outlet tee or baffle: !s Comments: (recommendation for pumping,con�tion of inlet and outlet tees or beffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) _1f/AI T /.vo�p�/iv( £V£,G j,✓4 gT j_ ovT 1-t% L FS v ,l/ P c o vT T FT rollrlx / £Low F ,✓ t T FOULA io ' ,gF�ow GiPA?J£ GREASE TRAP._ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: &um thiclmess: Distance Som top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or bafes,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage.etc.) (revised il/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - J PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: ¢allons Design flow:_ gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX._✓ (locate on site plan) Depth of liquid level shove outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) ':D 10 O X IS C1-Z 9N , oy® Sod i�S, 0Nf £ Ix,, .v£ 1,v£ p vT . PUMP CHAMBER:_ (locate on site plan) Pumps in working orden(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: 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: leaching pits,number: leaching clambers,number_ leaching galleries.number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number Comments:(note condition of*oil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) P,r CA £ Cq >— C a V £ G.ir a F e i,v P r c,L r�•v /7" 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 construction Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:(Dote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments:(note condition of s4 signs of hydraulic failure,level of ponding, condition of vegetation,etc.) (revised 11/03/95) _ 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addreea: Owner. Date of Inspeotion: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at lead two permanent references landmarks or benchmarks locate all wells within 100' !� EAR� _ 0 0 DEPTH TO GROUNDWATER Depth to�water: feet method of determination or approximation: #4AV3 v �£S% /�sL / A1- 7 £.Lobo 6A4.DZ c T' IY-v '�/ lBFLow moo/ oM of �i`7` (revised 11/03/95) 9 TOWN OF BARNSTABLE 'Y UNDERGROUND FUEL AND CHEMICAL STORAGE.SYSTEMS. 7D 7 q1VA go i. ASSESSORS MAP NO. PARCEL NO. 00 ADDRESS; O'y'S)lzic (VA f VILLAGE. OS TLC�wr 11 NAME:.... ._._ 40Sep4-C--- CONTACT PERSON&P-L 21EAE1eL"+-So J DJ(-: PHONE NUMBER LOCATION OF TANKS:. _ CAPACITY: TYPE OF- FUEL AGE: TY_PE:_ LEAK-, --- _ �OR CHEMICAL: DETECTION SYSTEM' lie ­4 -Zz C9 log a DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. I