HomeMy WebLinkAbout0162 PINE LANE - Health 16o/162 PINE IN, OSTERVILLE -
A= 118-063
o
i
t
Y
{
} d
�� � c•: tea' r "�'�
DATE4/26/01
PROPERTY ADDRESS:160-& 162 Pine Lana___
Osterville,Mass
- ---------- -----
On the above date, I Inspected the 6eptlo system, at the above address,
This system conslsts of the following;
1 . 1 -1500 gall septic tank. r '
2 . 1 -Distribution box.
3 . 2-1000 gallon precast leaching ppits.
Based on my Inapectlon, I earthy th® �followlnv oondltlonv`
4 . This is a title five septic system. ( 78 Code )
5. The septic system is in proper working oder
?y at the present .time.
6.T'Pumped the -septic tank at time of inspection:
7. There is -a third leaching pit that is presently dry
and not hooked up to the system. JGIK'
SIGNATURE;./
N a m e :_,L a,-JUs s m k Lr-aj ------- r
Company:j07!2h_P _ Hacomber_b Son , Inc .
Address: Box-66-- ---------------
__Centerville Ha .'02632-0066
Phone:___ 508_775_3998__-
THIS CERTIFICATION o0es NOT CONSTITUTt1 A OVARANTY'oR WARRANTY
a
J6SEPH P. MACOMBER & SON, INC,
T+nks•Cssspools•L@ichfl#lds
Pump4d L Inst>1 0
Town Stwor Connootlons
P•0• Box 6775•J338e�I775.641 MA 22692.4066
• 4
• a.
_ _ t
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r 4
F
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 160 & 162 Pine Lane
Osterville,Mass,
Owner's Name: Jack Lebel
Owner's Address: Wh; tP Hall Pst-at-Pc;
uyann;s ,Mass 02601
Date of Inspection: 1/?6 /n I
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66
Centerville,Mass. 02632
Telephone Number: 508-775-333£l
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_y �/asses
-``' Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa' s ,+
Inspector's Signature: i� Date: 4/
The system inspector shall ait a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Conunents
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION,(continued)
Property Address: 160 & 162
Pine Lane Osterville,Mass.
Ownerjack Lebel
Date of Inspection: A/2 6/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A System Passes:
�.
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
Th r _ is a third lea hang that is not connected to the
nrPsPnt system System is dry- It would be benefiscial
if it were hooked up to the existing septic system.
B. System Conditionally Passes:
,VQ One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please-
explain.
4b The septic tank is metal and over 20 years old* or the septic tank('whether metal or not)pis structurally
unsound, exhibits substantial in or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
A10 Observation of sewage backup or break outor high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health): ,
broken pipe(s)are replaced
obstruction is removed '
ND explain:
2
•
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)'
Property Address: 160 & 162
Pine Lane Osterville,Mass.
Owner: Jack Lebel
Date of Inspection: 2/2 6/01
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
Svstem is functioning in a manner that protects the public health,safety and environment:
/M The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply. `
4b The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water.supply. .
d,&The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet 4r more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory,for,coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
l
3. Other:
d/n4je--
3
GI
` Page 4 of I I
i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 & 162 Pine Lane
s ervi e, ass.
Owner: Jack Le e
Date of Inspection: 26 01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
Clogged SAS or cesspool
Static liquid lev'ell,_in"the dis bution-box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in eesspeol is less than 6"below invert or available volume is less than 'h day flow
i/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped I.
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.(
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
s
E. Large Systems: a
To be considered a large system the system must serve a facility, with a design now of 10,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria'above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed, The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
F 4
I
aJ
Page > of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 162 & 160 Pine Lane
s ervi e, ass.
Owner: Jack Lebel
Date of Inspection: 26 01
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_XPumping information was provided by the owner, occupant, or Board of Health°
Y- Were any of the system components pumped out in the previous two weeks ?
_ Has the system received normal flows in the previous two week period? .
Have large volumes of water been introduced to the system recently or as part of this inspection'?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage backup
Was the site inspected for signs of break out ?
_ Were all system components,.reluding the SAS, located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR I5.302(3)(b))
5 •a R
Page 6 of I I M
� �• i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 160 & 162 Pine Lane
Ostervi e,Mass.
Owner: Jack Lebel
Date of Inspection: 0 2 6 01
FLOW CONDITIONS
RESIDENTIAL -
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms):yx��'i - vo(�``w:
Number of current residents: _
Does residence have a garbage grinder(yes or no): ti10
Is laundry on a separate sewage system (yes or no):,V0- [if yes separate inspection required]
Laundry system inspected (yes or no): .
Seasonal use: (yes or no): 20 .• j
Water meter readings, if available(last 2 years usage(gpd)): Z -��/� ` )cl��.ti'3tJ: �� n`/
Sump pump(yes or no): Aj0 4vro
Last date of occupancy: _�j � ,ri_ DcxalStlj 4tT i/6-2�f ^'
C0MMERCLAUINDUSTRIAL 7.2w
6T� e of establisbment: ,�/j�} A0
Design flow(based on 310 CMR 15.203): /,//9 gpd— �� h
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION r
Pumping Records J s
Source of information: /7fiS9 /,e
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: /5^OP gallons-- How was q anti. pumped determined?
Reason for pumping: �(�i►`[ t S:-)i d 4)1N`�'
TYPE OF SYSTEM
eptic tank, distribution box, soil absorption system ,
jf Single cesspool
Vb Overflow cesspool .
IbO Privy .
6 Shared system(yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
t,ained from system owner)Tight tank /,�l Attach a copy of the DEP approval
4 00ther(describe): �f}
Ap roximate aee of II components, date installed (if known)and source of information: -
D
Were sewage odors detected when arriving at the site(yes or no):
6 � _
r
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 160 & 162 Pine Lane '
Osterville,Mass.
Owner: Jack Lebel
Date of Inspection;4/2 6/01
BUILDING SEWER(locate on site plan)
Depth below grade: 4,
Materials of construction: cast iron0 PVCf other(explain): IVA
Distance from private water supply well or suction line: 1e07`'
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appear tight. No evidence of leakage.
System ' /�n� d throuh the roof, vent.
SEPTIC TANK: (locate on site plan)
Depth below grade: ✓7��
Material of construction:�oncrete A) metal/fir fiberglass polyethylene
/,other(explain) 1-4 4
If tan}: is metal list age: Is age confirmedPby a Certificate of Compliance(yes or no):/ (attach a copy of
certificate)
Dimensions: i/>�.' .✓ J�C� lU'���'. 7��/rIIC
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: (9
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to boa of outlet to or baffle:.
How were dimensions determined: >/Ai(1 _
Comments(on pumping recommendations, inlet and.outlet tee or baffle condition. structural integrity, liquid levels
Uas,related,to.outlet.invert,evidence of-leakage,etc.):
Pump the se6tic-every18'months ( Duplex ) Inlet & outlet tees
are in place:The-tank_is -structurally sound and shows no
evidence of leakage.Pumped tank at time of inspection.Heavy
scum and solids layers were present.
GREASE TRAP L&Iocate on site plan)
Depth below grade:-4—)
Material of construction: I)AconcreteiAmetalitAfiberglassd-lPolyethylene�r�other
(explain): )
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grpasp trap l g not nraccani-
h
7
M Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION(continued)
Property Address: 160 & 162 Pine Lane
Osterville,Mass.
Owner: Jack Lebel
Date of Inspection: A/2 6/01
TIGHT or HOLDING TANK:A2,A,.�(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: AM
Material of construction: concrete metal g,11Q_fiberglass A 4 polyethyleneg;�L_other(explain):
A/19
Dimensions: kl/1
Capacity: .4.),4 gallons
Design Flow: !/ gallons/day
Alarm present(yes or no): A
Alarm level: V,1 Alarm in working order(yes or no): W4
Date of last pumping: ,c/,f
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not nrPsPnf _
DISTRIBUTION-BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4121
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has twn a€--solids
carry nupr Nn evidence of leakage into ei out of the .%
PUMP CHAMBER: ,! .(locate oh site plan)
Pumps in working order(yes or no): I&A
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
Pump chamhar is nntpresent.
8
1
l
r.
.rZ •
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 160 & 162. Pine Lane
Osterville,Mass.
Owner: Jack Lebel '
Date of inspection: /26/01 '
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SASnot located explain why:
Tye
leaching pits, number: i� A
A(L leaching chambers, number: a
.dice leaching galleries,number: 0
leaching trenches,number, length:
leaching fields,number,dimensions:.n
_A10 overflow cesspool, number:
-A2�, innovative/alternative system Type/name of technology: y 2^el),/
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,_ '
etc.):
Loamy sand to hard pan to boney medium sand- No signs of
hydraulic failure or ponding_wastP wat-Pr in #1 it- ; c dry
#2 pit 26" below invert pipe. It is set up this way.Soils are
dry.Veget�ation is normal.
CESSPOOLS:,,Lv�(cesspool must be pumped as part of inspect ion)(]ocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: _ A),4
Depth of solids layer: nlf)
Depth of scum laver: A)/�
Dimensions of cesspool:
Materials of construction: `
Indication of groundwater inflow(yes or no):d ,
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present. ,
PRIVYLj�t (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: ,Zr
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy is not =racant r ,
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 160 & 162 Pine' Lane Osterville,Mass.
Owner: Jack Lebel
Date of Inspection: 12 r l n 1_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
t a�
THISA TO CF.R;
R .27I v \ by �L /
7�a two 3g 5s- at ./6o1GZ �Hr
;^ D has been installed in ac i
the application for D151
D� THE ISSUANCE (
SYSTEM WILL FUNCT
2�
�. DATE --
i
' r
1
10
f
Page 1 1 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 160 & 162 Pine Lane
Osterville,Mass.
Owner: Jack Lebel
Date of Inspection:A/2 6/01
SITE EXAM
Slope level
Surface water none
Check cellar dry
Shallow wells no
Estimated depth to ground water,/B feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system desi Tans on record - If checked,date of design plan reviewed:
Observed site abutting prope / bservation hole within 150 feet of SAS)
:21Necked with local Boar o Health-explain:
checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
TnGfa1 1PH ex Ct l nq septi n qy t-POLO_.129.195
Permit # 95-896
No water encnuntPred at- 1F '
. 1 F
11
I -
- -+�n•rr*--rT-"'n-mr•esenrrnn rt*T.marRT+1+1IrerrA+•+An nvrsv*s�9rrT•rtwT .T'rPt-rT-a-.:'- -. -_
r-rr Barnstable
'I'UHN UP WARD OF HEALTH
3UI1SUItFACF SFHA(;F DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION
•r•••T•••... -�.tIT.^�TTI.T.ran•n.TltTT.1'TTITY11'r•.'1-•in'T7�IR1•T-T�rR�R!'1R7 nm nleml.rlr-Trr+'r.-.�.rr,- r•- -. .,
-TYPL OR PRINT CI•EARLY-
PI?OPERTY INSPECTED
STREET ADDRESS 160&162 Pine Lane Oste>>rJville,Mass.
ASSESSORS MAP , DLOCK AND PARCEL 1 GL �
OWNER' s NAME Jack Lebel-
PART D - CERTIFICATION r
NAME OF INSPECTOR J.P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son In-e '
COMPANY ADDRESS Box 66 Centerville,Mass. 02632 .
Street Town or City State lip
COMPANY TELEPHONE ( 508 ) 775 3338 FAX ( 508 ) 790 -s1578
!t
N
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage. disposa7 system nt
this address and that the information reported is true , accurate , and
omplete as of the time of .inspection , ' The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check ne :
System PASSED
The inspection which I have conducted has no-t' found any information- "
which indicates that the system fails to adequately Protect public
health or Lhe environment as defined in 310 CMR 15 - 303 ,. Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED* .
The inspection whichrI have cony acted has found that the system fails to
Protect the public health and the environment in accordance with - Title
5 , 310 CMR 15 , 303 , and as specifically •noted 'on PART •C - - FAILURE
CRITERIA of this inspection form . .
.17
Inspector Signature Date
copy of this certification must be provided to the OWNER, the BUYEROne
Where applicable ) and the BOARD OF HEAL'1'll,
w If the inspection FAILED, the owner r or""o' oator shall up
grade pgrAde • the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 16 . 306 .
partd . doc
TOWN OF BARNSTABLE
LOCATION 160 /��c.e n�� 1,472 9 SEWAGE# ?fZ
VILLAGE SESSOR'S MAP&LOT&9-N—I
INSTALLER'S NAME&PHONE NO - �•
SEPTIC TANK CAPACITY %5�0
LEACHING FACILITY: (type) Z f[-,e (size) eIod 49
NO.OF BEDROOMS / f
OR OWNER � �.r��� /`'.G✓�� /
PERMTTDATE: `' �' g-+S� 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 facility) Feet
Furnished by
f
2
e 'VS
v`
o �
O
i
F
ASSESSORS MAPN(� /f,
PARCEL NO. ��
No..- _....... Fss................ ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Bi-nVa!3 l Work,i Toutitrnrtion ramit
Application is hereby made for a Permit to Coristruct ( ) or Repair (J__�-an Individual Sewage Disposal
System at:
r'
j
�� Location- dress o Lot N
_ _ O/iffi/Sa GL�C--C 6 //rf- s� ��:............
Owner Address
-------- -------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--- _tjr_" ....................Expansion Attic ( ) Garbage Grinder (N)
aOther—Type of Building ---------------------------- No. of persons----------------..-.------- Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow........._ .....-�K-------gallons per person per day. Total daily flow-..-... ., ..0 ....................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---..--..---_- Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit Now Diameter-----/a........ Depth below inlet-----P.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 13-0-4 ?�
S —4.7/
aPercolation Test Results Performed by------- ------------------------•----------------•-----•-----------•----.. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
t� ---- - ----------•-------------------------------------------- -------------
0 Description of Soil... ly---...- .�-U!a9 ........... sib,! }et-------------
U ----------------------------------•---------- ------------.....--•-----------------------•--•••------------......------------------------------.
-------------------------------------------•--------------------------------------••----- ..--------------------------------------------------•--
V Nature of Repairs or Alterations—,Answer when applicable G------_...�_/J4�iill... ®O® . L
%tj✓ -- -- --'.' -
Agreement. f bA-6". Z i-e-' 50V11G—
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 Compliant has been issue th oard o health.
M �- 2��
Sined ----- ---- ----------- -- ---------------------- --- - ------
i Dare
4
Application.Approved By ---------------------- ----- -- -------- - - 1n
--------- ----- - - - - -------- -- ---- -- ----------------- 3 Dare
Application Disapproved for the following reason.r- ---------------------------------------------------------------------------...........................................................
E
..........................................:.......... ......................................................................:.................................................................. ............................
Q � Dare
Permit No. 7-5. ? cl Issued 3 E� 49-
........... . ... ............
Dare
s
No...... ..-�........... � Fx$. � .............
+ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE i
pplirativit for Div--Vm3al Workii Towitritrfion Prrind
Application is hereby made for a Permit to Construct ( ) or Repair (L,,)-an Individual Sewage Disposal
System at: /
....h0 f .... ........... ........./tx� al......•.................................................•...........
�Locatiol /Vdress o Lot No.
G //iG
--� �7e-?fT2 �o
nddre
Installer Address
Type of Building Size Lot...........................S q. feet
Dwelling—No. of Bedrooms.......a.'�� ...................Expansion Attic (1-4) Garbage Grinder (1-4)
aOther—Type of Building ____________________________ No. of persons_-___.._-:-_-_..__---_.--._ Showers ( ) — Cafeteria ( )
Otherfixtures . -------------------------------------------------------------------------------"---------------------------------------------•---------------
W
Design Flow._...___..._i......'.... .- ._.<...__..gallons per person per day. Total daily flow------- Z.. ....................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?Ww._-./----- Diameter-_--./.Q....... Depth below inlet..... .......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) _ /3- 7�
= S -4-71
a Percolation Test Results Performed by:--.-•--.._:.:....::.............:.......... ............................. Date........................................
Test Pit No. 1----------------minutes per inch. Depth of Test Pit.--.._------_--_-___ Depth to ground water........................
GX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._..................
---•------- .
--------------------•...... ---
.....--------...--• -------------
D Description of Soil //�'s/DY ----- -------•---------------------------------------------•-•----
fW .._..--•. ..
U Nature of Repairs or Alterations Answer when applicable ��" ...�_ ! /.. /DOa �sy` .......
- --- -----
rJrrc/�l/✓ zz-n!'2=•L=--r/ •s/G-��-_f.f./_/�G- .L4-�ci f.
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 Compliant has been issue b th oard health.
Signed ..----- -------------- wl...
Application.Approved BY ..----------s� �)� `-"'" ---- --. ..... -----------------------------------------------------
Application /s''v h'
i
Disapproved for the following rearonr- ------------- ---------------------------------------------------------------------------------------------------------------------
- ----- --------- ------------ ---- -------------- ----------------- -
r � Dare
Permit No. --5----.----.----...y.�--------------------- Issued ..... ..3 ----�U
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certtftrate of C amplianre
THIS; TO CER32FY, That the Individual Sewage Disposal System constructed ( ) or Repaired
/ � -'---� -- �- L - - - ......... .........
by - __ _
--------
Install"
at .. 0/�� ��ir/G.—�i>l. - //��_-3---------------------------------------------------_---------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ... �'
PP P 9.��_..�'..______ - dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A, GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ��,�....
DATE... /...�-�. ---------- .`+� -------��... ------... Inspector- .. %°5 < ------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
5� TOWN OF BARNSTABLE
No............... FEE... ...............
�i��n�tt1 ur�� �uit��ri�r#uan �prmit
Permissionis hereby granted---------------------------------•----------------------------------------------------------------------------------------------•------------
to Construct ( ) or Repai (t.-)-a Indivi Sewage Disposal System
/do -f — G(/52 vlL �= l/ f---------------------•-----
Street
as shown on the application for Disposal Works Construction
Permit No� ________ Dated:_.._
- ...................�........_ - ---•--•-•--•-••----•••-•-•-••••.
DATE............. - Q-�-------------------------------------
Board of Health
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS