HomeMy WebLinkAbout0184 ROBBINS STREET - Health 184 ROBBINS STREET, OSTERVILLE
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COMMONWEALTH OF MASSACHUSETTS �
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRSfyer
DEPARTMENT OF ENVIRONMENTAL PRATE TIONA(/G -p }'
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TO `C 3 1998
��Ty�E jABCf �?)'
WILLIAM F.WELD oil' TRUDY,COXE
Governor QSecretary
ARGEO PAUL CELLUCCI DAVID'B. STRUHS
Lt. Governor Commissioner
`� Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
11-\ \ PART A
(CERTIFICATION
Property Address: +�} i�l� i.3s ��. 0,5A>_ ✓V (.e Address of Owner:
Date of Inspection: j li3 y (If different) q��t, e_. C, �
Name of Inspector:
FFt�y.rt/ i
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: r `� L_ e'rt tfu► l y:
Mailing Address:
Telephone Number: SCE ,—y"t1 tZ�
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:
APasses
• _ Conditionally Passes
Needs Further Evaluation By t Local Approving Authority
Fails
Inspector's Signature: Date: 7 23 !
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection.
If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the
appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D: .
A SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any
failure criteria not evaluated are indicated below.
COMMENTS:
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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection, or the
septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 04/25/97) Page I of 10
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• • Pnnt"h on Rlrvrl.d Parer
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection
if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
i
Cl 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONTNG IN A
. MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRON/tfacility
:
The system has a septic soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface w ly.
_ The system has a septicd soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septicd soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septicd soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unlell water analysis for colifotm bacteria and volatile organic compounds indicates that the well is
free from pollution frocility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determnce (approAmation not valid).
3) OTHER
(revised O4125/97) Page 2 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution boa 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 112 day flov;.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Anv portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Anv portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
And portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate.either "Yes" or "No" as to each of the following:
.The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and saiety, and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04111117) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 60' P.SJbtN
Owner: t
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
•. _ The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from ow-nen were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of.10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: �hkk%
Date of Impectiom,7173i
1 FLOW CONDITIONS
RESIDENTI ,p
Design flow: U p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current restdents:_r
Garbage grinder (yes or no): lit
Laundry connected to syste (yes or no): t�
Seasonal use (yes or no):1
Water meter readings, if available (last two (2) year usage (gpd): d�(�
Sump Pump (yes or no):_ %
Last date of occupancy: ;jtL(
COMNI ERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:ygallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GE FERAL INTOR IATION
PUMPING RECORDS and source f information:
i A
System pumped as part of inspection: (yes or no)--
If yes, volume pumped: Gallons
Reason for pumping:
TF 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)1-=�/
(revised 04/25197) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
o_ SYSTEM INFORMATION (continued)
Property ddress•
Owner: r,(�
Date of Inspection:
BUILD
ING SEWER:
(Locate on site plan)
Depth below grade:—ks�
Material of construction: _cast iron _40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
'SEPT
IC TANK:
(locate on site plan)
�i
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal.r�list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth:_ N
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: 00 Zti
Distance from top of scum to top of outlet tee or baffle:_ �,
Distance from bottom of scum to bottom of outlet t or baffle:_
How dimensions were determined:
Comments:
(recommendation for pumping, condition of i let and outlet tees or baffles, depth of liquid level in relation to oud t i vert, s ructural integ 'ty,
evidence of leakage, etc.) 4.30+ w Q iS CT
+ G
GREASE TRAP:—&-0
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity.
evidence of leakage, etc.)
(revised 04125/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: V�5 y �,,'sn pieiCT i
Owner:
Date of Inspection: 7
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes. _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
)ISTRIBUTION BOX: S
(locate on site plan)
Depth of liquid level above outlet invert: w�Ov '� .11i�,1e.��
Comments:
(note if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:A�P
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
i
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: iz3�4
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible: excavatiorvnot required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields. number, dimensions:
overflow cesspool. number:
Alternative system:
Name of Technology:
Comments:
(no a condition of soil. signs of hydraulic failure, level of ponding, con ' ioq of v t' etc.) V
�'s1his, O
f
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:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:)W'`S
Owner: jK I".
Date of Inspection: . Z3 t5
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
OS �
3 z ;
Ja �01C&
(revised 04/25197) Page 9 of to
1.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
{ SYSTEM INFORMATION (continued)
[1
Property4c1dressAIS' 14-M KS
Owner: 7t
Date of Inspection:,�z3`��
Depth to Groundwater -`124eet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you.established the High Groundwater Elevation. Must be completed)
(revised 04/25/97) Page 10 of 10
TOWN OF BARNSTABLE
LOCATxON �'b`1 N C S ( SEWAGE #
VII.LAVE 4 `euW10�. — ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.,
SEPTIC TANK CAPACITY 1 A
LEACHING FACILITY: (type) a (side) (_Oc=
NO.OF BEDROOMS
BUILDER OR OWNER SA-\\;aK
P 'DATE: 7 17 d� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and ` Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1"�� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist (
within 300 feet of leaching facility) Feet
rurnis►ed by � aE.�
�g`�-S� �q 1� _��
L`e y h� e b5 ' � r
ba -�9 -_
v $ �
���t� �9� �� � � �T
l 2
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S
h�l �
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t�Yl?'u"/ N�OGARNSTABLE .
LOCAMON S - Zm7i 0(t kf f --��SEWAGE # -
VILLAGE^ -� ASSESSOR'S MAP & LOT,��
INSTALLERS NAME & PHONE NO. .j Z:77"6q j 1
SEPTIC TANK CAPACITY I( Y-d 4,4-L,
LEACHING FACILITY:(type) ,I>e�- (size) •(-,
NO. OF BEDROOMS PRIVATE WELL PUBLIb;W TER
BUILDER OR OWNER��11'-�� c,G �t[
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No�
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(,�V T E COMMONWEALTH OF MASSACHUSETTS
O� rrr/JJJ�O BOAR® OF HEALTH
TOWN OF BARNSTABLE
, pphration for Diripimal Wi orkii Tontrnrtinn jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
........................
i �O/3!3 f�✓_. S ,��,2 r/, -----------------(o S-----••-----......_..._......._..........._......
T� Location-Address
................. !�'_ !✓._. f -E ,7s � s_ �a� - ��'� ........
-----------------------•---.......
Owner Address
W
Installer Address
U Type of Building Size Lot..AQ..<.2 ZZ.._..Sq. feet
., Dwelling—No. of Bedrooms........_.........-_--.---..----_.. ...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons----------------------------- Showers ( ) — Cafeteria ( )
WDesign Flow.Other fixtures...--ss .._gallons per person per day. Total daily flow.-.........................................gallons.
WSeptic Tank—Liquid capacity/�da.galIons Length-.1.4.4.. Widths 4?.... Diameter...... ....... Depth.S. .....
x Disposal Trench—No. .................... Width.................... Total Length....--.............. Total leaching area....................sq. ft.
3 Seepage Pit No....------Z....... Diameter......//.......... Depth below inlet...._4.......... Total leaching area... .19..(......sq. ft.
Z Other Distribution box (V-f Dosing tank ( )
Percolation Test Results Performed by... o w.c7..«'^..................................... Date..11 �Z `9�
04 Test Pit No. lL�`f S..Z.minutes per inch Depth of Test Pit.-- Z�-.------ Depth to ground water...:". ..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.....--.....--...... Depth to ground water........................
Q.'
----------------------------------------------------------•------------------•-••-----------------.....:.
0 Description of Soil.... ��__5........- 4/g..--5��)•--------------------------------------------------
W
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 Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Co is ce has ued by the board of health.
Signe .a..................... .........6.Wsl
' Application Approved By ........ ........ ... .. ....... ............ . . .. . .................. ................�....................
Application Disapproved for the following reason . ........ ............................ . ...................................:................................. .
............................ ........................ ...... .........................
___ /.............Dace..................
Permit No. qc.......-8�. ------------- Issued ..........
. .....
�.. .-.p E..1�:J ---...................
t:A'^h+^.rWJ°"'!t.3/`��%«._,�..}:�-::,n.w-.�•w:e._...--.i�..�..���-.:-r^:r�'�.0�-t...}r.:..dR;$�^�.R�i'h'T �.aF�^,."{'wT,'!^f� .�.J:,�.'.'�.•�i:-�.:miG;�"n51µ.i � .w'.e"�`i"a1�,��w�w���^+t.«tirM
Fizz....� ..
a THE COMMONWEALTH OF MASSACHUSETTS
O BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripnial lVork.6 Tomitrurtivit Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
p p G`
.............. C/ EVZ/_3/3!!!�..2C•._' S[!.Zt�/LLc_ .-•-•----------------------------•----•-=-•-�S----•---••------•-..............--^---.........
t.... Location-Address ff
..............s.t l mil. t ._.. .................................... ; ,....... •-••••..........-----•.
owner Address
W
{ Installer Address
UType of Building Size Lot.../v,.7.Z,,.r.....Sq. feet
Dwelling— No. of Bedrooms__________________¢______________-_. ----Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------------------------------------------------------------
W Design Flow................................:55- ._.gallons per person per day. Total daily flow._4 2:2......._.......................gallons.
WSeptic Tank—Liquid capacity/_<Ro.galIons Lengtli__/C2_G1_.. Width_.S-.�---- Diameter...--._------- Depth-_S&..__.
x Disposal Trench-- No. .................... Width.................... 'Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..........7....... Diameter------//........... Depth below inlet........ ......... Total leaching area... l/......sq. ft.
Z Other Distribution box (V Dosing tank. ( )
~" Percolation Test Results Performed by .�i�j.._! !�•< -..-•---••••-•--.•................ Date-,/./`ZL_-9
`a Test Pit No. 14 -.55_&_minutes per inch Depth of Test Pit---/.2n....._... Depth to ground water...__.:--:..___..
L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----••-----•-•-----------------------••--•--•--•--••---••-•••--•--•-•--•---•---••-•-........._...•••.........................................................
O Description of Soil.... . ... ........./se 1'
x ... :a v��..._.........._.....
-----------------------------------•-------------------------•--•••----.•••...••-•••--•
W
...••------------------------------------------------------------------„---------------------------- ---------------------------------------------•••-••-••••--••----•••--•--••---.....-•-.............
V 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 Co 'plia.ce has be n is ued by the board of health.
a
1 Signe ... ............I- ..................... .....
/ 0-....... .....................i G Dace �........
Application Approved BY 4�.... ............ / / .-.--y/ .<(f ------------------ ........................................
��
• Dace
Application Disapproved for the following rea.ronf0................................................................................ .
............ ...................................... .................. .. ........:.................. :........................ .......................�............ yx............�....................
I j� a e
Permit No. `7..-.........: b/.. Issued - ...........................
(� ._--
'4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Qxr if rate of Tomplianre /
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by ........................ ........ .. .. .....................------------....... -------------...--------------.----------./..:`.................................................
.
JA
'/t .'.Z.:'<_�iR........0-
has been inlalled n accordance with the provisions of TITLE of The State Environmental Code as described in
. -�the application for Disposal Works Construction Permit No. _............._..._..........._ / dated .............. ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE._ ..�'..... ......� F .... ..._....:........... �----- ...Inspector .._.a1w
----------------------------------,--------------------------- ---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`1 } TOWN OF BARNSTABLE
No..::.!��.:.�... (T''J" FEE.. ............
Permission is hereby granted--------------------- ----------------------------------------------------------•-----------------•-.----.-----•----
at No....-._ ct ) or Repair ( ) an Individual ewag�Disposal System
to Construct c^� f
r v I y" �. .1 J v V Y Street p
as shown on the application for Disposal Works Construction Peerrrr-ryfif;No.1 ... --.. D�aatt'sec`dT- ->......................................
.........=._.._..,......
�y ^• s.'_..u././7_.nr�....-- ................
Board ofHealth
DATE......... ------ ..............................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
APPROVED �I -'
!4 ..OF................
earnstable Conservatimospestt '........... . • .................•--......
i .� luati&fjgohipasal Work.6 Towitrurtion Permit
on is hereby mat ior a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: ��- S ) I1 q
/ --Lo tion•Address �^ or Lot No.
ypv►� 1 l ?55. -� ..p.�Z' +.C��E.I ........................«.
- --- •- ^ _
/6 00 Cr Zvy �Zj Owner : <<Tower 1'✓ c,l� Address - -•
V_t'ray -t-�,-, {.{ ------------------------------------------------------
--_----T— Installer U y, �� Address
Type of Building Size Lot... ......Sq. feet
U Dwelling—No. of Bedrooms.............................__. .....Expansion Attic ( ) Garbage Grinder ( )►-�
'14 Other—Type T e of Building No. of persons.............:.............. Showers —
W YP g ...-----•---------------•--- P ( ) Cafeteria ( )
04 Other fixtures -•-••-•••---------•------•--------•.........................••---•• -
W Design Flow..................l.l_-�?..................gallons per person per day. Total daily flow............. ................gallons.
WSeptic Tank—Liquid capacity l 0-0gallons Length... �. ��.. Width:..`��..in� Diameter:............... Depth.:�.! '%.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.......I............. Diameter........1.0....... Depth below inlet............... Total leaching area..;ges:Zsq. ft.
Z Other Distribution box (� ) Dosing tank ( )
'-' Percolation Test Results Performed by. '.M`-E!!-!`"��..�Ds�-�.L� .. Cac Date.......!!_.! -.�1�........
a
Test Pit No. 1....`-....-""..minutes per inch Depth of Test Pit........}. `E'.. Depth to ground water.......r}-
Lt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•••-•-•--••• •. ........... ........................•--....-•-......-
---••••. ....... ...•.
O Description of Soil_-........o.:. ..._....!..... ..5�. .- .'j.......- " - .l`E`k..`.....n"'.7 ...' �
....................•-••-- -••---.....-----........-----------•-••-••---••-••----•-----.......--•...--•-.....-•------•--------.-••••-••••-•-••-•---...-•••-•••-••-•------•-••-•••.........-••.....•.....
V 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.TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,, en issued b the board of health.
Signed. e � ' •.......................... ......�a 1.�. .��.�....
�! rDate
Application Approved By•. ......,��'.. - ••--. •. ----------•--• ...
Date
Application Disapproved for the following reasons:........................•--•--.__.-.....
...................................................................
...........................................................................•--------•---...................•-•---•..................-••••••-•••-••--•-•-•••-•••--•..............-••••••................�
Date
Permit No.....--- �F�� jp..................... Issued./ .. .... ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
\ BOARD OF HEALTH
............vc.Q ).................OF........ ! -rvS`��1�t�l.L. .............................
Trrtifiratr of Tamplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired ( )
by_........ .,C.0''t .. . �r'S ......................... •----•---•....................•----......-----................................•.
Inst---
/ 0 6� � Installer
at........LP7 .....6...5........................ ..--- �-----•-•--•----.••..a.tiC- -----•------------...•--•..........................................---...
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-_/9-;�?- ..c._..�j5�....... dated.__...- ,n ^.X.2,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........` !^ . .................OF......: ...............................
Fes-�-�•�-----=�-•.,�
Disposal Workii (ffonntrwt#i n Permit
Permission is hereby granted.-•-- �C t 4•................ (LJC. d-••------•-•--•----•--••-•--•-•-•-----••---•---•--................
to Construct (>O) or Repair ( ) an Individual Sewage Disposal Sys
n
at No..........-P. .�..... ...........M.4S 131.N.5..........S 1�...'..........................................................................................................
.
Street
as shown on the application for Disposal Works Construction Permit No .-._��c_....'�.DDated...Z—,—.2 r. ......
----•-.......:•-••--•-•--••••--•....--•-•••••--•----••--•----•..........._•-••--.........-•-•••••••...._
Board of Health
DATE...............................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............Tol414t-.-k..........OF................ ...................................................
aAppftrattlou for Disposal Work.6 Tgoiitrudion "ermit
Application.is hereby made for a Permit to Construct (q) o.r Repair an Individual Sewage Disposal
System at: -t--V I
0-T
............................ ..............................................
Location-Address or Lot No.
.....................
-------tCeQ ...........
------- ----j------------------- .................................
/27.9c) Fc,lo,t"M (Q4 OwnerITO-WeV- W7C,11 ........ Address
A........ .....................
Installer Address
Type of Building Size Lot... ......Sq. feet
Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ................................................*---------*------*--------------------------------.............*--------
..........
Design Flow.................. ..................gallons per person per day. Total dailyflow.............. 4:1...............gallons.
Septic Tank—Liquid capacity.!-O.O.L)gallons Length... '_- Width:.. Diameter................ Depth.�'.f."..
Disposal Trench—No. .................... Width.................... Total Length......._..-........ Total leaching area....................sq. f t.
Seepage-Pit'No.......1............. Diameter........ij?....... Depth below inlet........ Total leaching area.l�.�tsq. ft.
Z Other Distribution box Dosing tank
Percolation Test'Results ?ei-formed by............................... .......... Date___....!_ ..........
.... . . 6u)
Test Pit NO. I................minutesperinch Depth of Test Pit......_.1.4.4�... Depth to grotind water.......
Test Pit No. 2................minutes per inch Depth of Test Pit.............._.._.. Depth to ground water.............-..........
...........................................................................................................................................................
0 Description of Soil_.... P.- ................................................................
....................................................... .. ........ F-a4
U ........................................................................................................................................................................................................
.......................................................................................................................................................................................................
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 T I T LZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha!§\-been issued by the board of health.
. .................................. ......
...........
Application Approved By....4 ... ..............
--------------- ...
Date
Application Disapproved for the following reasons:.................................. .....................................................................
.........................................................................................................................................................................................................
Date
Permit No. .0..........
....... .... ........... Issuedz�./7.....................................
Date
------ ------------------ -----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............M.Z .................OF......... ................... ......
Tatifirate of Toutplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by
......... ........
......................................................................................................................................
Installer 1, .
at...........................6..s.................................................................... .........................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......19. ....... dated.......THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......
.......................................................................... Inspector....................................................................................
..........
THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF HEALTH
.................OF....... ... .. ................................
No. ........ FEEZ��:/�
1 ] OV0141,10orks Tonstrudion VerrAft
Permission is hereby granted..... .............e(J,-J Sl_�2 ac-'776)
..........................................................................................................
to Construct ()0) or Repair Li an Individual Sewage Disposal Systemat No..........L.-.0=---6.Sr................................ ...................................o5�1.............................................................................
Street
as shown on the application for Disposal Works Construction Permit
.......................... ............................................................................
Board of Health
DATE................................................ .............................
P D > {}\J
. JASM•�yM, V T- •T�,.
7630
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