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0055 PINELEIGH PATH - Health
55 Pineleigh Path Osterville / A= 071 —001 -003 n Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 55 Pinelei h Path Property Address �• Carla Cabot Owner Owner's Name - information is MA 02655 July 18 2012 required for re OStervllle y q State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist-,at the end of the form. r Important: A. General Information . When filling out forms on the computer,use 1, Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return l key. Septic Inspection Services Co. Company Name Q 189 Cammett Road Company Address Marstons.Mills MA' 02648 mam City/Town State Zip Code 508-428-1779 Sl 12855 ; Telephone Number; License Number , b A B. Certification t. 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 c: was performed based on my training and experience in the proper function and maintenance of on site e`bewage disposal systems. I am a DEP approved system.inspector pursuant to Section 15.340 of t`' :.Title 5(310 CMR 16.000). The system: Cam. Passes ❑ Conditionally Passes' ❑ Fails , ��. w i ❑ :Needs Further Evaluation by.the Local Approving Authority E July 18 2012 Job# 12-109 In ector's 'g ture , Date The system inspector shall submit 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. ****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 al.IsPection Form.Subsurface Sewage Disposal System-Page 1 of 17 t5ins-11110 k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 55 Pinelei h Path Property Address ` Carla Cabot Owner Owner's Na me information is Osterville MA 02655 July 18 2012 required for City(rown State Zip Code Date of Inspection ` every page. B. Certification (cost.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: - ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR-15.304 exist. Any failure criteria not evaluated are indicated below. r j Comments: - - Recommend pumping tank in next 12-18 months, leaching pit showed no signs of saturation or surcharge. .r B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass_ t Check the box for"yes", "no" or"not determined" (Y,.N, ND) for the,following,statements. If"not determined," please explain. a The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the. Board of Health. - *A metal septic tank will;pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.' El Y ❑ N ❑ ND (Explain below): „ Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 2 of 17 t5ins-11110 ' Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A 55 Pinelei h Path Property Address Carla Cabot Owner Owner's Name information is Osterville ate MA 02655 ;July 18 2012 required for I St Zip Code Date of Inspection every page. City/Town ' B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ;] IND (Explain below): ❑ obstruction is removed ❑ Y,. ' ❑ N ❑ ND (Explain below):, ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 'ND (Explain below):' I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ` ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed& ❑ Y •❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. , f. 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, S safety and the environment: t - ❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 3 of 17 F t5ins•11/10 Commonwealth of Massachusetts It M' Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Pinelei h Path Property Address Carla Cabot Owner Owner's Name information is Osterville MA 02655 July 18 2012 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) - { 2. System will fail unless the Board of Health (andPublic Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Failure Criteria A plicable to All Systems: D) System F p . You must indicate "Yes"-or"No" to each of the following for all inspections: t Yes No Backup of sewage into facility or system component due to overloaded.or ❑ ® ` clogged SAS or cesspool w 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_day flow ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 15ins-11/10 I , Commonwealth of Massachusetts . Title 5 Official Inspection Form . :. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pinelei h,Path ' Property Address n Carla Cabot - Owner Owner's Name ion is A '�02655 , Jul i18 2012 informal M Y r OSterVllle ode Date of Inspection required fired for Zi C to 9 � � Sta P every page. City/Town B. Certification (cont.) ' Yes No ❑ ® Required pumping more than 4 times in the last year NOT due'to clogged or obstructed pipe(s). Number of times pumped: ' ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or , tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy,is within a Zone 1 of a public well. El ® Anyportion of a cesspool or privy is within 50 feet of a private water supply well. F JJ t El ® - 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 fecal coliform bacteria indicates absent and the presence r of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, ' provided that no other failure criteria are triggered. A copy of,the analysis and chain of custody must be attached to this form.] ❑ ®''^ The system is a cesspool serving ajfacility with'a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board'of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve'a facility with.a. design flow of 10,000 gpd to 15,000 gpd. A • t • For large systems, you must indicate either.yes".or."no'`to each of the following, in addition to the questions in Section D. Yes. No ' ❑ 'the'system is within 400 feet of a surface drinking water supply ❑ tthe system is within 200 feet of a tributary tofia,surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered-"yes"to-any question in,Section E the system is considered a significant threat, or answered"yes in Section D above the large system has 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 l5ins-11110 , c Commonwealth of Massachusetts a Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. 55 Pinelei h Path F Property Address Carla Cabot ' Owner Owner's Name information is Osterville MA 02655 July 18, 2012 required for every page. Cityfrown . State Zip Code Date of Inspection ,C. Checklist Check if the following have been done.-You must indicate"yes"or.,no as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? . El ® Have large volumes of water been introduced_ to tl a system recently o�as part of this inspection? ER El 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, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material.of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different,from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ; ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(5)]: D. System Information Residential Flow Conditions: 3 3 , Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based on 31,0 CMR 15.203 (for.example: 110 gpd x#of bedrooms): j t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 55 Pinelei h Path Property Address ` Carla Cabot r Owner Owner's Name information is Osterville MA 02655 July.18 2012 required for Cityrrown State Zip Code Date of Inspection every page. D. System Information Description: r 0 Number of current residents: Does residence have a garbage grinder? El Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ®. Yes ❑ No Water meter readings, if available (last 2 years Fusage (gpd)): Detail: ., t ❑ Yes � ,No Sump pump? Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions:. Type of Establishment:_ .' Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of.design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? :`b i ❑ Yes El No r Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Water meter readings, if available: Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 t5ins-11/10 r A. • Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Pinelei h Path Property Address Carla Cabot Owner Owner's Name information is Osterville MA 02655 July 18 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: R Date Other(describe below): General Information Pumping Records: ,' Unknown Source of information: Was system pumped as part,of the inspection? -❑ Yes ® No If yes, volume pumped: ` gallons , How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑, Shared system (yes or no) (if yes, attach previous inspection records, if any). ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system.owner) and a'copy of latest inspection of the I/A system by system operator under contract r ❑ Tight tank. Attach a copy of the DEP approval. µ❑ Other(describe)` Lt5ms, •11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 55 Pinelei h Path Property Address ; Carla Cabot Owner Owner's Name information is Osterville MA 02655 'July 18 2012 - required for State Zip Code ' Date of Inspection every page. Citylrown D. System Information (cont.) Approximate age of all components, date installed (if..known) and source of information: Compliance date: 3/4/92 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ' ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,,evidence,of leakage, etc.): . • Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal . ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes El No , . 8 5' long x 5.2'wide-.'1000 gal. Dimensions: 3„ Sludge depth: t5ins•1 tlt0 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 9 of 17 ' r � o Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Pinelei h Path a ~ Property Address Carla Cabot " Owner Owner's Name .' information is Osterville F MA 02655 July 18 2012 required for every page. Cityrrown State` Zip Code Date of Inspection D. System Information (cost.) f Septic Tank(cont.) - T ' 27" Distance from top of sludge to bottom of outlet tee or,baffle .. 3" Scum thickness ' .61 Distance from top of scum to top of outlet tee or baffle 10 Distance from bottom of scum to bottom of outlet tee or baffle Measured f How were dimensions determined? , Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert; evidence of leakage,.etc.): Liquid level was found at bottom of outlet invert and tees were intact. Recommend pumping every three years. . ,-.. • , ' 1. , Grease Trap (locate on site plan): Depth below grade:". feet x 6 Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑,polyethylene E] other(explain): A Dimensions: *' - Scum thickness Distance fromatop of scum to top'of outlet tee or baffle z Distance from bottom of scum to bottom of outlet tee or baffle _ Date of last pumping: Date t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pineleigh Path Property Address Carla Cabot Owner Owner's Name information is Osterville MA 02655 July 18, 2012 required for every page. Cityrrown State. Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: r Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No. .Date of last pumping: Date Comments (condition of alarm and float switches, etc:): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes -❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessmerits F 55 Pineleigh Path Property Address Carla Cabot Owner Owner's Name information is wired for required Osterville MA 02655 July 18 2012 every n ion v page. Citylrown State Zip Code Date of Inspection ect D..System Information (cont.) Distribution Box (if present.must be opened) (locate on site plan): 01. Depth of liquid level above outlet invert 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.): No solids or high stains. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: o ❑ Yes ❑ No Comments (note condition of pump chamber., condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,,explain why: l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 y, Commonwealth of Massachusetts Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pineleigh Path Property Address " Carla Cabot Owner Owner's Name information is required for Osterville MA• 02655 -July 18, 2012 Y every page. Cit frown State Zip Code Date of Inspection D. System Information (cont.) Type: • , One 6x6 pit. ® leaching pits number: ` ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching-trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of " vegetation, etc.): , Stone and soils surrounding pit were probed with no signs of saturation found. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer - Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 55 Pineleigh Path Property Address Carla Cabot ` Owner Owner's Name information is required for Osterville MA 02655 July 18, 2012 every page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) Comments (note condition'of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions j Depth of solids F Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation', etc.): a l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments •'" 55 Pineleigh Path Property Address t Carla Cabot Owner Owner's Name --------. --------j------ -- . ----- ". information is Osterville MA 02655 July 18, 2012 required for - --------- ----------- - every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately f 40 ` 25 t 52 _ • 4 5 Commonwealth of Massachusetts s Title 5 Official Inspection Fora{ Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments,, M 55 Pineleigh Path Property Address Carla Cabot # " Owner Owner's Name information is Osterville MA 02655 July 18 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cony) Site Exam: , ® Check Slope ® Surface water ® Check cellar Y ® Shallow wells t 20+ Estimated depth to high ground water:. ,, feet , Please indicate all methods used to determine the high ground water elevation: . ❑ Obtained from.system design plans on record 1 If checked,date of design 'Ian'reviewed: Date ® Observed site (abutting property/observation hole within 150 feet-of SAS) ❑ Checked with local Board of Health-explain: ' ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: - You must describe how you established the high ground water elevation: Low areas of adjacent properties and surface water are considerably lower than SAS. Y A Before filing this Inspection Report, please see Report Completeness Checklist on next page. sposal System•Page 16 of 17 t5ins•11/10 .Title 5 Official Inspection Form:Subsurface Sewage Di Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. w 55 Pineleigh Path Property Address Carla Cabot Owner Owner's Name information is Cisteryille MA 02655 July 18 2012 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 3 ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to,high groundwater ® Sketch of Sewage Disposal Systerri either drawn on page 15 or attached in-separate file S , r t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r f NO....qj_::.W C��A Fims....,� THE COMMONWEALTH OF MASSACHUSETTS t. a R 0 V E D BOAR® OF HEALTH 07/ Oel- O®'3 �_on i -v on Co` IL, arnst_b-� n a �. .O F..... Aw+M• Signed Alip trat f i r ispillial IF rk r ri P Ittt on is hereby made for a Permit to Construct e air an Individual Sewage Application y ( p ( ) 5 ge Disposal Nub stem at ................__ . ... ,.................-- Locat' � ^ No. .� � � -.---------•.------- ................... ..� ............. ..._ ..---_.. -•-- Owne Address W Installer Address Type of Building Size Lot... '_.-__�_____�___- sq.-4ee� U Dwelling—No. of Bedrooms______________ _____ -_-__Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ..---------•-------------------- . W Design Flow...................56----------------gallons per person per day. Total daily flow......................_:M.0......gallons. WSeptic Tank—Liquid*capacitylopugallons Length................ Width......... .__._ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length...........________ Total leaching area....................sq. ft. Seepage Pit No._______-.�-------- ameter-------JO_..... Depth below inlet........ _____.__ Total leaching area.....�,l 6-7-sq. ft. Z Other Distribution box ( VT Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_._-_-_-___-_________--. (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-------•-------------------------------------------------------------•-..---------------------•----......................................................... 0 Description of Soil.........................................................................................................................---............................................ x V .............................................---------------------•--••---•-------------------------•----------------------------------•-------------------------------..._...•--•••-•-------•--------- W ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--••---- UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environment Code—The dersigned further agrees not to place the syst ation until a rtificate of Com i ce s been is d the board of hea - Signe ., 2 ZP.r . ' /_ - Ap ation Approved y J�r' � �/ Application Disapproved for the following reaso ----------------------------------------------------------------------- ................ .... ............................. --- --- ----. ---------- ..-...... ... -.. Permit No. ..... ../ t Issued - �---I----..Da[....... ........................... Da[ ... It �.� No_._: .. ._.. Fx$.. THE COMMONWEALTH OF MASSACHUSETTS c BOARD OF HEALTH Appfira#ion for Disasttl forkWepaA( r ' n rrnti# Application is hereby made for a Permit to Construct ( Qtr( ) an Individual Sewage Disposal 00 System at: .;.� .... . .... ..... ........... ... II J LocatC.61 s or Lot No. : GT�� r.... •--. ._ ...---•.............. .........•-•-------------= ------.....-•-------•--••-•-•---•--•-----........................_._ <_— Address a --•-•....•••-••••-•...............•--...._..----------••---.....•-----..._........................ ...__._......._..__........_..._..._..............•-•--•. -----... Installer Address i s. d Type of Building Size Lot___ :_ ..`..... U Dwelling—No. of Bedrooms.............______..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Pl Other fixtures--............................................................................... W ' Design Flow.......W ............ �3........i__,. ,.gallons per person per day. Total daily flow...................... �� ......gallons. WSeptic Tank—Liquid capacity��60" allons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...........I-___-__ --------ID Depth below inlet....... ........ Total leaching area__._._�-�;_7_sq. ft.. Z Other Distribution box ( ;•�) Dosing tank ( ) - ` Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit------------_....... Depth to ground water........................ f3 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ P4 --------------------------------------------•-•...... ......_......-•--•-------•-••------•-........--•---...-------•-----..._..__.._._...._ -------•••-- 0 Description of Soil.................................................................T...................................................................................................... x �., •-••-----------•-------•--•---------------•----•------•---•--•--•._._..._...-•-----•...........-•---•------------•-•••-•---••---•••-•-.-•----------•--•-•----•••••------------------------------------•- W ------------------------------------------------------------------------------------------------=------- -----------------=---------------------------------------------------------•---•......-••------ UNature of Repairs or Alterations—Answer when applicable..........................._................................................................... ----------------------------•------....-•--•----------------------•-----------------•-------------------•----•-----------------------------------------•---------------------•----------••••-......----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the systtgn-) i o f tio/n" until a rtificate of Compliance has been issued by the board of health. J C% Signed J/ r e� ................... ;..... ! J �l'f �--------�.. .- to A ration A roved /=' f o •"��-'' t/rr`�-✓'-� �C. Dare Application Disapproved for the following ream ............................................................................. Permit No. ..... ............. ..............I .. ...-- ----- ------- s Issued ....-.-.. ... ..... -- 9 - / - ---------- -------Date------ THE COMMONWEALTH OF MASSACHUSETTS f E BOARD OF HEALTH ..................... ---- OF ............. -» -". - x'L� (., J.---------- Cgeztifirate of C omplianre upcoo THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................. ...._.. - -------------- --- ,.... w Installer � �� f at -------�'.--- l..f Y:......-Ll ., :�..I- .........C/ has been.installed in accordance with the provisions of TITLE f he t t:AS vironmental Code as described in the application for Disposal Works Construction Permit No. ... -.-' .. `` .. dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRU A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE `" c�ot.......... Inspector ---------------------- , .. THE COMMONWEALTH OF MASSACHUSETTS / BOARD Of HEALTH ........... ........v).. ........OF................5P t" 4.1 ....................... -/ No...... ( FEz Uiapaoal Workii Tnnotrndion antic Permissionis hereby granted---------------------••--------- -------•--------••----------.....---•--05----•-•--------_..._...__.......--------------.............. to Constr tje if an Indiv rage D s at No.... -- !_ Street ---- l - J -------- r as shown on the application for Disposal Works Construction Permit No____ ____________ ated.... _ ...... ---...-•---------•-----•---•-•-•-------•---------------------------------••----•------•-•-----......---- Board of Health DATE................................................................................. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ---P>U Iz�� l o 'Ex6TI Qc. WEE— PC'ZWoo LLJ Of R04ARD t BAX�TER ,I kc,d4a^e CaApo)1��'rs A I coo GAL 5c -13 . ULsT2��svn�,J "�-•ox � • - . L6A6� Prr/z, STm F- S IC U P6 AREA GE,eT/1'/EO �LCT �,Ll,tf 7',47 7"�1� �r��1 �J[� ,CaG 4T/C��/ L/ Sh�OWitY yE.2E0.C/Cpis'1F�L YS Gf//T/� D STEZ.f I�I�,G��_:...•� , SCSI L.G— � �_ =�0 . p�17_� 1�-�r:• %�:�'f i=f �' �EQf//,eE�1EiC/TS,.Off' ?".�,�� 7`oWit/4F �.L�� .2E.c'� ��/.�u!,c'I�j (� ;.�t• Ax4c) / C- 4O47;EG� LO j S JJ Lr�i7'h�/.t/ - . Mz SATE:JUNK l7 19 4,4 XTE.0 E�V, /RUC. AEG/S7'E,eEp L.Qic/p SU.e/iYa� /NST.eU�/�it/T,•S'U.2YEY� 7-yE. �• O��s'FTS SyaLt/y Sf-��ULD as�'E,e•,�icL�a �l,4ss. %SEQ 7"-2O i 133 , r TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE -37eR T/A/ 6/ZS ASSESSOR'S MAP & LOT O'J l'mil-c-I INSTALLER'S NAME & PHONE NO. DA/02 e5 . SEPTIC TANK CAPACITY 11660 1 LEACHING FACILITYAtype) I-eACH11✓6 1017 (size) x Olome NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: — tJ — ? :a- VARIANCE GRANTED: Yes No i i 1 S� 1 Z ' ^ C> V t`` �V 1{ f� Y TOWN OF BARNSTABLE S� � + q LOCATIONe��,.,� SEWAGE # 1 1 �Q,�, � ��©�I/�VILLAGE � ASSESSOR'S MAP & LOT ODMtl INSTALLER'S NAME & PHONE NO. �-- -r SEPTIC TANK CAPACITY /& le s�Q LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �. k(l 0 \� � � GArzaG /aDorT'iorJ• c�Ni C � 20'— M/N !' I �. NILii