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Home My WebLink About0210 SEAPUIT RIVER ROAD - Health 210 Seapuit River Road, Osterville A,= i u r 8 6 1 No.-------------------- Fee-------_--- --- BOARD OF HEALTH TOWN OF BARNSTABLE Application,forWell Congtruction Permit Application is hereby ma for a.permit to onstruct ( ), Alter ( ), or Repair ( )an individual Well at: ocation — Address Assessors Map and Parcel ---------------------------------------------- pO�wner -Address -- — "�'` ——— ------— —— ---- —--------------------------- — ------ ---------------- Installer — Driller Address Type of Building Dwelling -- ------------------------------------------ Other - Type of Building —------------------ No. of Persons------------------------------- -- Type of Well �-Az - --------------- Capacity----------------------- - -------- ------ Purpose of Well - - I " -- --- --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. �q Signed_'� �` at —__ -- --------------------- --- — -- - - - - --- - 1 date ----- ——-- —------- —— 1 —O Application Approved By— -------- ------------ date Application Disapproved for the following reasons:------------------------------------------------------- ---------- -- --- --- - - - -------- -------------------- — , date Permit No. Issued---------------------------------------- — --- - date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) bY- - <<- ------------------------------------------------------------------------ - Installer at -— ------ has been installed in a cordance with the provisions of the Town of Barnstable Board of Health Private Well Protection --II --tl Regulation as described in the application for Well Construction Permit No.��V�°�7----3 --Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. *96J--------- --- -- Inspector--- - ---------------------------------------------------------- DATE -------------- No.-------------------- Fee----------- -------- BOARD OF HEALTH TOWN OF BARNSTABLE - -� ApplicationArVell Congtructionpermit Application is hereby mad for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: A-Eication — Address Assessors Map and Parcel �Owner Address _ ----------------- -------------------------------------------------------------------- Installer — Driller Address Type of Building I Dwelling -v -- ----------------------------------------- Other - Type of Building-------------------------- No. of Persons----------------------------________ i Type of Well Purpose of Well---_�--K!'�, ' '-'--------- l Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Earnstable:Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed -Z' -�'�''=� --- - - l 7 r -- ------ 's I ab Application Approved By - --------------- ----- -------- ---- date 1 Application Disapproved for the following reasons:------------ ----- ------- ' ------------------------------------------------— ---- date ot - - -____-3- - Permit No. -- -- - -------- Issued-------------------------------------------------------------- date ------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance I THIS IS TO CERTIFY, That Individual Well Constructed ( ), Altered ( ), or Repaired ( ) bY-� �� -G - —------ --- - - Installer ' at has been installed in a cordance with the provisions of the Town of Barnstable Board of Health Private Well Protection O Regulation. as described in the application for Well Construction Permit No.W '3--Dated-V---10,G_7 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. /� _ DATE- --r -- -� - - --- - -- Inspector------------------------------------------------------------------------- I1 ___a._aasaoa'—---------.------ -----------------seam---------------------;—ate--sue —mama--.------------ `f`fI I BOARD OF HEALTH TOWN OF BARNSTABLE ' Ivell Con5truction3permit M �S No. ---------------- Fee--------------- Permission is hereby granted - ---------------------------------------------------------------------------- to Construct ( 4-,'Alter ( R� ) an dividual Well at: No. -C� -E Jr) .-."do -— --- ---------------------------------------------------------------------------------------------------- Street as shown on the application for a Well Construction Permit No�lC� Q- 1 - - --- ---- -- - - Dated -�_4_91 ----------- - ------------- --- -- - -------- ---- ------------------- ...... �( I Board of Health DATE— -- ---- -- -- -- -- — -- SQpfyIftf wN Of BARNSTABLE LOCATION r1VV �C. SEWAGE # _ VrLAGE 03—)etv%16., &Yr �i NAf. SSESSOR'S MAP & LOT O70Z001 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) <9- (S X 6/ P 7 (size) -.0 00 NO. OF BEDROOMS G BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet Fumished by B A� i Q y3 a �. ao 46 3 3 S ys acl TOWTJ OF BARNSTABLE :.00%f 'ION (�V�� R� SEWAGE # aOOS 3Yo1 VItL' AGE O Sr"V.II. (0� t r S4eASSESS9R'S MAP & LOT— INS TALLER'S NAME&PHONE NO. - ^-, FDA` 0e dv\ um o SEPTIC-TANK CAPACITY Sdy LEACHING FACILITY: (type) bt.` X�'' 1 ids (size) NO. OF BEDROOMS BUILDER OR OWNER lRAMSQ^- tom- Qcs�C CPA' PERMITDATE: COMPLIANCE DATE: Separation_Distance Between the: _Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by J •- t1 y3 _zc . 413 i5`(a3 3 ac0y s No. ;?_0a-5- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for MigogaY.bpgtem Congtruction Vermit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System �10 Individual Components Location Address or Lot No. a t Q S tv (W t r �s, Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0 5I tr, x. `C�5h e dt6of 0-00 _oat S �(A �OMSe�i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil, Nature of Repairs or Alterations(Answer when applicable) r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this Board of Health. Signed Date / Application Approved by RL Date -7 Vvl— Application Disapproved for the following reasons a -- Permit No�2C--- ----------s Date Issued---" o Y .w, No. 3 7 �. Fee THE COMMONWEALTH OF MASSACHUSETTS '`Entered in computer: k Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS S 2ppricatibn for Mizpogal *r6temfCon6truction iOermit Application for a Permit to Construct( , )Repair(grade( )Abandon( ) El Complete System El Individual Components j Location Address or Lot No. a 5U f 1 J!f Owner's Name,Address and Tel.No. Assessor's Map/Parcel S(--IA 8(A IT-o m So j Installer's Name,Address,and Tel.No. /7a r Designer's Name,Address and Tel.No. For — 3(oy- $ j / G a i�o•, (3u,v „S �� Type of Building: ✓' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of'Septic Tank Type of S.A.S. Description of Soil, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of ffitle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date -7 60/0 Application Approved by K '� Date 7/2 Af- ` Application Disapproved for the following reasons Perms:No. p lLS- 3�? Date Issued o 7,� THE COMMONWEALTH OF MASSACHUSETTS _ Q�K rt Ai J BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(,I-U_`pgr aded( ) Abandoned( )by at 910 Seou;f` (t y t/ I?� d e has been construe ip accordance with the provisions of Title 5 and the fo Disposal System Construction Permit No. qu-5-3 t(Z dated Po o r Installer _on Ig n vS J i rr1 0/ Designer The issuance of this permit s,nll not be cdnstrued as a guarantee that the systemawill function as designed. Date 1 Inspector-,. No. 3`/� t� Fee THE COMMONWEALTH OF MASSACHUSETTS ►J� PDX ryA/r PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS i5ogaY bp5tetn on5tructionern�it Permission is hereby granted to Construct( )Repair( Upgrade( )IAband n System located at 010 Se t�, rt v R� O S fI w,l ( � S�t1 44r 01_5 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her.duty to comply with Title 5 and the following local provisions or special conditions. r- Provided:Constr7LUA tion must be completed within three years of the date of this p t. Date: Approved by � i D DATE: 2/21 /97 PROPERTY ADDRESS: 210 Seapuit 'Rivet Road Osterville ,Mass . Oyster Harbors On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . -1 -1 500- gallon septic tank. '2 .1 -Distribution box. 3 . 2-1000 gallon precast leaching pits . Based on my Insz?ectlon, I certify the following conditions: 1 . "This is a title five septiccsystem.' ( 78 Code ) .2 . �TYie septic system is in proper working order at the present time. 3. `Sec "'t-a`rik mu st be�`pum- pti d."—` 4. Distirbution box is shattered and must be replaced. 5 . Sprinkler lines should be moved. They run over tank cover and 1 pit cover. SIGNATURE: Name: J. P .Hacomber Jr., i ---------------- Company: J. P_Macomber &— Son-_Inc . , Address: __Centeorville LMass__02.632 Phone:___548_7_7.5_333a--___-- t THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. 7-4 Tanks-Ceupools-Leachflelds pN. 3I/ . Pumped 4 Installed ® r � Town Sewer Connections ��' P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 B U Commonwealth of Massachusetts • Executive Office of Environmental Affairs Department of ` Environmental Protection WUllam F.Weld Trudy Cone Oorunoe ArW Paul Cellucc! FILE# 1 1 37-438 Davld B.Struha e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION property Address 210 S e a p u i t River Road O s t e r v i l l eAddress of owner: P. H.H. Relocation Date of Inspection: 2/21 /9 7 of different) 2221 Camden Court Name of Inspector. Joseph P.Macomber Jr. Oakbrook Ill. Company Name,Address and Telephone Number. 60 5 21 -1 2 81 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: �_ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signat l�4GfKz Date: 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: 11 SY9 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. BI SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) j�Q The septic tank is metal, cracked,strudurally unsound, shows substantial infiltration or enfiltration,.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 11/03/95) I One Winter Street a Boston,Massachusetts 02106 a FAX(617) 556-1049 a Telephone(617)M-5500 ��Primed on Rayckd Pepeu FILE# 1137-438 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION(oontlnued) Prop.rtyAddre.s: 210 Seapuit River Road Osterville ,Mass . Owaen P.H.H. Relocations Date of In P"Uon: 2/21 /97 B)SYSTEM CONDITIONALLY PASSES(ooatinued) Sewage backup or breakout or 40 static water level observed in the distribution box is due to broken or ob4ructed pipe(s) or dua to a brokm settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaood obstruction is removed distribution box is levelled or replaced A0 The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will peas inspection if(with approval of the Board of Hsalth): broken pipes)are replaced obstruction is removed C) FURTHER EVALUATION 18 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the systam is failing to protect the public b.ahb safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 60 feet of a surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE) DETERRUM THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. 4�Z The system hu a septic tank and soil absorption system and is within 100 feet to a surface water supply or ueutary to a surface water supply. J20 The system has a septic tank and&oil absorption system and is within a Zone I of a public water supply well a The system has a septic tank and&oil absorption system and is within 60 feet of a private water supply weu. 42 The system hu a septic tank and soil absorption system and 1s Is"than 100 feet but 60 feet or more from a privau waur supply well,unless a well water analysis for coliform bacteria and volatile organic oompounds indicates that tba wall is b." from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leas than 6 ppm J) OTHER (revised 11/03/95) 2 C3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION(continued) Property Address: 210 Seapuit River Road Osterville ,Mass . Owner. P.H.H. Relocations Date of Inspection: 2/21 /97 D) SYSTEM FAIL&: e 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. •�Q Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. AM Discharge or ponding of efIIuent 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 lean than IJ2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped �d Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or truutary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a akgnkficant threat to public health and safety and the environment because one or more of the following conditions cdst: 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 &tf 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) 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 6.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address 210 Seapuit River Road Osterville ,Mass . owner. P. H.H. Relocations Date of Inspection: 2/21 /9 7 e Check if the following have been done. JPumping information was requested of the owner,occupant,and Board of Health. �oae of the system oomponagts have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Lame voh="of water have not been introduoed into the system meetly or as part of this iaspocci= f—As built plans have been obtained and examined. Note if they are not available with N/A. 2Ths facility or dwelling was inspected for signs of sawage back-up. 2 system does not receive non-sanitary or industrial waste flow site was inspected for signs of breakout. rystam compoasats,ludin`g the Soil Absorption System, have been located on the site. ZThe septic tank auaholss were uncovered,opened, and the interior of the septic tank was inspected for conditioa of befn or taw,material of construction, dimensions, depth of liquid, depth of sludge,depth of scum Z7-u size sad location of the Soil Absorption System on the site has bate determined based on apprazimatod by non-intrusive methods. �' or Zras facility owner(and oocupaats, if different from owner)were provided with information on the proper maintenaaa of sub. Surface Disposal System. (revised 11/03/95) 4 � ! j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION PropertyAddresar 210 Seapuit River Road Osterville ,Mass . Owner. P.H.H. Relocations Date of Inspeotiou: 2/21 /97 FLOW CONDITIONS RESIDENTIAL Design flow: '. 1d pllonj 10&VeA01V Number of bedrooms:Number of current residants:Q h6agL):i vAcA4/1 Garbage grinder(yes or no):. Laundry connected to system(yes or no): A's, Seasonal use(yes or no):A L Water meter if a Last data of occupancy:_ COMMERCIAL/I ND U S TR IAL• Type of establishment: Design Dow: AJIL gallons/day Grease trap present: (yea or uo)A& Industrial Waste Holding Tank present: (yes or no)A& Non-sanitary waste discharged to the Title 5 system: (yes or no)�� Water meter readings, if available: AIW Last date of occupancy: OTHER: (Describe) Last date of occupancy: AIA GENERAL INFORMATION PUMPING RECORpS and#purce qf information: J� System pumped as part of inspection: (yea or no) Cj Ryes, volume pumped: Reason for pumping. TYPE OF YSTEM Septic tank/distribution b=/soU absorption system N 6 Single ceaapool Overflow ceupool Privy ,00 Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APTgROXaJMArE AGE of components, date installed(if)mown) and source of information: '� 9 Sewage odors detected when arriving at the site: (yes or no) �v(! (revised 11/03/95) 5 I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 210 Seapuit River Road Osterville ,Mass . Owner: P.H.H. Relocations Date of Inspection:2/21 /97 SEPTIC TANK:L.IDP�r/��C/d�V /�.tr/�• e (locate on site plan) Depth below grade�Q, material of construction: concrete _metal _FRP _other(explain) Dimensions: M. $' Sludge depth:_, Distance from top of sludge to bottom of outlet tee or baffle:,,„_ Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bosom of scum to bottom of outlet tee or baffle._v Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural 'My, evidence of leakage, etc.) mum — ,Sg"t�.i n �tapk ; G ct.riirt.iiral I entiln�• o• e•vi e ce of leakage . GREASE TRAP. �4 (locate on site plan) Depth below grade:;V& material of constriir%ionroJzoncrete _metal _FRP —other(explain) r A>4 _ Dimensions Scum thickness. Distance from top vt scum to top of outlet tee or baffle:flJd Distance from bosom nl .crnm t^ bonom of outlet tee or t5hle-. A i Comments: (recommendation for pumping, condii—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integnty, evidence of leakage, el� )_,�_, e: Grease trap is not present. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontlnued) pr„pO1.yA,d,i.,w; 210 Seapuit River Road Osterville ,Mass . owner. P.H.H. Relocations Date of Inspection: 2/21 /9 7 TIGHT OR HOLDING TANK:dkwf'-- (locale on site PUZ) e Depth below Vida: MssarW of oonstruetb vLoonartr_metal_FRP_otha(aplaia) l Dimensions: 44 •-• Capacity AM mllons Dears flow ns/day Alarm le"L• CO-4m : (condition of inlet tee, condition of alarm and float switch", etc.) Tight orholdimz tank: Not present. DISTRIBUTION BOxZ (locou on site plan) //JJ 1 Depth of liquid level above outlet inver :—&L—Aek j$ (b/)l�i /n a6r be Comments: (note if lrvsl and distribution L equal, evidence of solids carryover,evidaaco of laakap iato or out of bout,ata) D=Box is not level: Has evidence of solids carry over :Has signs o leakage out of the box. Box is badly cracked. Crushed during bac 'i=ing nf thje syst,Pm when it. was installed _ Box must bP re 1ayed . PUMP CRAMBER._d,.;Vt. (locau oa sits plan) Pumps in working ordar:(yes or no) Cammeats: (note oondkton of pump chamber,condition of pumps sad appurtetsaaoss, ste.) Pump Uhamber is no presen (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C a c SYSTEM INFORMATION(oontinued) Property Add"" 210 Seapuit River Road Osterville ,Mass . Owner, P.H.H. Relocations Date of Inspection: 2/21 /9 7 son,ABSORPTION 6Yg= (WA 6t—fbcd q ,o 4'ec 5 r' X;,c 6`)t&' (locate on sits plaa,if possib ;scavation not tequin4 but my be apprcaimatd by aan•latruaive methods) It not detsrminad to be present,a:pl Type: 1wehias piss,aumbe oZ 1whis chambers,number. 0 Isubin p1leries,ate= 1.achim trenches,numbs lsagth lsaehim batch,number,dimenalons: (� overflow cesspool,number, Commeas,: (note condition of soil, sips of hydraulic Ullurs, level of poadin&condition of vegstatioa,etc.) Soii con 1 ions : See page 97t-No signs of hydraulic failure or pon ing: _A11 yP.gt-tgti on is normal. CESSPOOLS:�f/e Qocue on die plan) 1lambet and ooali�uratioa: Depth-top of liquid to inlet invert: Depth of solids layer. AM Depth of grim lyer ii>rQ Dimaar3oas of cesspool: .►�� W gu iaL of constructim. ? Indication of pvundwatar N114 inflow(cesspool must be pumped u part of iaspedioa) 6f) (�o n__c!r�nn� a arc nut. 71 YPQPn t, "' Comments:(note condition of soil,4u of hydraulic failure,level of pondia4,condition of vegetation,etc.) essiDoo s are not presen PRIVY: d e , Gocau on die Plan) Materials of oonsuNbcdou. �/�/� Dimensions:_ d d Depth of soli r ate: (aces condition of soil suss of lydmulic failure, level of pondirZ condition of vegetation,itc.) Pr; vg ; G nnt, present, (revised 11/03/95). g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two -permangnt references landmarks or benchmarks locate all wells within 100 ' Centerville Osterville Marstons Mills Water Company 428-6691 d N p i ►✓ DEPTH TO GROUNDWATER "12 ! + depth to groundwater rpthod of determination orapproximation: Se,e pa ;. .and 9B" ram: 1 I . 1t Coo cogp.V 06 uf ,r ALA• t " '� '. � � •' � �� T �.B jON .n t ' � X�E�. • v' • • fS IoN 994.N ''." ,9 �'p• oo �: • ''r'` ' 57 614 09 Solt. 111 . •. � �• �yam a � . ' ' ,� ' � '.', ' ' '1 i It -Fv row G 5 t� noo A" No60 ',V, .`�' V.), F If Oa. P 4� !A fl ewlv) l � SEWAGE PERMIT NO. L O /'T 10 VILLAGE / INSTAL ER'S NAME i ADDRESS 6 U I L D EIt OR OWNER DATE PERMIT ISSUED , DATE COMPLIANCE ISSUED Oki • q yy� O J' ' �•rn.nr•..-n,7�,�-a.wr�w•naswTn.+r.nr.rrw+�nr�n+t.w..s.ren,u ns�n�w,+ TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I `� �:-•7rt,1••.-: .-1•.ix-..:rnn+►+n•+fln rwR+rearan'nTa'a—:,.•9vRr�m.wr`r+1RRAf/er�,R7 �n .•.-vr'- r--�. _..A -TYPE OR PRINT CI.EARLY- PI?OPERTY INSPECTED STREET ADDRESS 210 Seapuit River Road Osterville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # lot # 11 /, OWNER' s NAME P.H.H. ael!ocations PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr.. COMPANY NAME J.P.Macomber & 8" ii Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State tip COMPANY TELEPHONE (508 1 775 3338 FAX ( 508 790 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed' and 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 one : '1XXX, U-S.ystem PASSED--- The inspection which I have conducted has not 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 which I have con lcted 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 . e Inspector Signature Date2/25/97 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEAL1'll. + If the inspection FAILED, the owner or"'operator ehall u d within one year of the date of the inspection, unless allowed ort required he m otherwise as provided in 3.10 CMR 16 . 305 , i partd .doc 9 w V THE COMMONWEALTH OF MASSACHIJSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION DE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 210 Seanuit River Road Osterville,MA 02655 Owner's Name: Sandra Thomson Owner's Address: Date of Inspection: July 20, 2005 Name of Inspector: (Please Print) Jaynes M. Ford Company Name: James M. Ford rQ 'Mailing Address: P.O.Box 49 Osterville..MA 02655-0049 — � Telephone Number: (508) 862-9400 " � CERTIFICATION STATEMENT CIO M I certify that I have personally inspected the sewage disposal system at this address and that the in ormation 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: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: Julv 20, 2005 The system inspector shall sub t 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 1.0,000 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 Comments ****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 i conditions of use. Title t 5 Inspection Form 6/15/2000 P page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 210 Seanuit River Road Osterville, MA Owner: Sandra Thomson Date of Inspection: July 20, 2005 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. 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. 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.. ND explain: 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 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 t Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 210 Seapuit River Road Osterville, MA Owner: Sandra Thomson . Date of Inspection: July 20, 2005 C. Further Evaluation is Required by the Board of Health: 1 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 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 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 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 coliforin 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. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 210 Seanuit River Road Osterville. MA Owner: Sandra Thomson Date of Inspection: July 20, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ 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 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 'h day flow ✓ 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. ✓ 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.] No (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. E. Large System: To be considered a large system the system must serve a facility with a design flow 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 210 Seanuit River Road Osterville, AM Owner: Sandra Thomson Date of Inspection: July 20, 2005 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? ✓ 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 back up? ✓ 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 210 Seapuit River Road Osterville. MA Owner: Sandra Thomson Date of Inspection: July 20. 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 6 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No . Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): spd Basis of design flow(seats/persons/sqft,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 Pumping Records Source of information: None on file-System pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of.all components,date installed(if known)and source of information: Installed in approximately 1982 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 210 Seapuit River Road Osterville, MA Owner: Sandra Thomson Date of Inspection: July 20, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 Qal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): No outlet tee was present. The liquid level was even with the outlet Pipe There did not appear to be anv signs ofleakar;e The tank was bumped after the inspection for maintenance A new outlet sanitary tee was installed i GREASE TRAP: None (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: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 210 Seapuit River Road Osterville. MA Owner: Sandra Thomson Date of Inspection: July 20, 2005 TIGHT or HOLDING TANK: None (tank must be pumped 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 present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- Carmments (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.): The D-box was caved in and filled with dirt. A new D=box was installed(Permit#2005-342) PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alanns in working order(yes or no) Continents(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 i Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 210 Seapuit River Road Osterville, MA Owner: Sandra Thomson Date of Inspection: July 20, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal.) 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.): One pit(#1)was dry. The cover was 15"below grade The other pit 02)was also dry The cover was 15"below Jzrade There did not appear to be any signs of failure in either pit The bottom of the pits to grade was 8 5' CESSPOOLS: None (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 or no): Commnents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 a Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 210 Seanuit River Road Osterville, MA Owner: Sandra Thomson Date of Inspection: July 20, 2005 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'rO�S' I�OOr A . Q i i► Y3 _ a ao 143 3 3 y 3� yq y S yS 29 10 , Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 210 Seapuit River Road Osterville, MA Owner: Sandra Thotnson Date of Inspection: July 20, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topogargphic and water contours maps, the maps were showing gpproximately 20'+1-to ground water_ at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will junction properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 V�2 t i L;OCAT10 � SEWAGE PERMIT 110• VILLAGE ot- INSTA L,LER'S NAME i ADDRESS ' c Al n + i U I L D E R OR OWNER DA T E PERMIT DATE COMPLIANCE ISSUED 1 ` e J rh r � a THE COMMONWEALTH,OF MASSACHUSETTS � BOAR® OF' HEALTH IUD ...................OF........ .,...LA L � ApplirFation for Bi"us al Work.5 TOUstrnrtion Frrmit Application is hereby made for a Permit to Construct (6�) or Repair (' ) an Individual Sewage Disposal System at: - -- ----114---_.......•--------------------- Location•Address or Lot No. ----------------------- .L A..................Lv. ----------- ----------------------------------------------.------. -----•--------........._.... oo Ow A^ Address a ................................ Aw. .................. ............. fa4!G 1J 9.............. .. ............. Installer Address j Type of Building Size Lot..........................:.Sq. feet U Dwelling—No. of Bedrooms..............._.......................Expansion Attic ( ) Garbage Grinder ( aOther—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) Other fixtures Design Flow ...�15...................gallons per person per,day. Total daily flow._.............._5 ...............gallons. WSeptic Tank—Liquid capacity ._gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ___4............. Width..... Total Length..............q._.__ Total leaching area....................sq. ft. Seepage Pit No......... --__-- Diameter.......1C?_...... Depth below inlet....... 2....... Total leaching area...5t sq. ft. Z Other Distribution box Dosin tank ( ) k.'J�_07 '—' Percolation Test Results Performed bytes.` - .e.-•-•-• _...'Pr-. Date....... -I •_----. Test Pit No. 1.....in......minutes per inch Depth of Test Pit---------I _... Depth to ground water........ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ------------------------------------------- -•----.--•--..--.-------------•-------•...._...•--..............--------.------..........--•-----•--- Description of Soil .. - v .................................................... 1 �........................ ..------------------......--------------.-------------------•----------•-----•------..... 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 iITI111, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n is ued by th bo of h Signed. .•.............. .... .-----•-•--•-•---- � J � ...... Date Application Approved BY .�.�.A ------------��' L Date Application Disapproved for the following reasons:-------•-------------------------•--•----------------.......................................................... ...........•---••••••-•••••---••.._..•-••••••--•••••••--••-••-•---•••••-•--•--•-••----•-••-••-••••-•••-----....--••---•••••••••--••••--•---•-•-•--•-----------••---••-•-••-••-••-----------•--••--•-•-•- Date PermitNo......................................................... Issued........-.............................................. Date r=r ` Fps, No. --•-- ............_....._..... THE COMMONWEALTH OF MASSACHUSETTS BOARD rQF HEALTH ....T J_...................OF......... .................................... Appliration for Di-spniial Works Tomitrnrtiun Prrmit Application is hereby made for a Permit to Construct (1/i or Repair ( } an Individual Sewage Disposal System at: � ��u i�' l'VIZ._ .• � "........ ��# ................__................... ........., • ..._.. ................................ Location-Address or Lot No. •--•••-•-•-•-•-••-••----..!��'�-V!T.... ........................ •----•-•..............•-•---•------........------.....------•---------......--••-•----•-.......... � Ow Address,_ �l.....5 et/. E L... ... Installer Address JType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.................�-'._.__.___.____._______Expansion Attic ( ) Garbage Grinder ( aOther—Ty-pe of Building ............................ No. of persons..........................t._ Showers ( :) — Cafeteria ( ) Other fixture ..............._ DesignFlow...................a15...._.. ...._ gallons per person per day. Total daily flow................._..&c.•.;:_ _ W --- - •;�, ---g P P P Y• Y �--------•-----gallons. R; Septic Tank—Liquid capacity.. gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. ..__A,._......... Width....... ....... Total Length............... Total leaching area....................sq. ft. Seepage Pit No..__.__.- ---__. Diameter--------� _..... Depth below inlet........ Total leaching area.....-�...2-sq. ft. Z Other Distribution box ( /� Dosing tank ( ) aPercolation Test Result Z �_Performed b ._& -. ' ;....... �._..L-t Date........ Test Pit No. I................minutes per inch Depth of Test Pit.......... --- Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•"--------------------------•--••--"----•-••---"-"--•---------•"----...................---•-•-•--......................................................... DDescription of Soil :.:. ----•------�------"-•-------------•----------------------•----------------..-------------------.... -------- 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 TIL L is 5 of the State Sanitary Code—The undersigned furt ai�r agrees not to place the system in operation until.a Certificate of Compliance has be n s ed b-ged 'y e a 1 t - .... ... . Application Approved BY.....---................................................. ------ Date Application Disapproved for the following reasons:-----•-----"---------------------"--"---------"----- ........................................................... --••-----•--------"-------....."--•-•"-------•----•"--"------------"-------------•---•----...----"-"-"---I----•••----•----••-•--•----•---•--•-•--•-•-------•------------•-•••----•---••......•---••.••••. Date '""" PermitNo.......................................................- Issued-....................................................... Date Y r THE COMMONWEALTH OF.MASSACHUSETTS : -� BOARD OF HEALTH "r .............Tn �wi. .........OF........... .T _ At wrtif iratr of Toutplianrr THIS" CE�YeAhat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) at----_-------------------------------•-------.---•--------------------------•--------------------------- has been installed in accordance with the provisions of TIT W 15.4ie State Sanitary Code�s described in the application for Disposal Works Construction Permit No---------------------------------........ dated-...._..__, '_--____-______-_--__--_•_---.---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU ®, S A GUARANTEE THAT THE, SYSTEM WU F NCTION SATISFACTORY. DATE..... ..... = .... Inspector...... ------------------------- --------•---------------------------•"-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ......0F........P.0I-Sr i INC..............................................................( 9; No......................... FEE........................ Dispao W rk� q* rtilan rani# Permission is>: eby granted---.......................................................;•-----••••--------------------•• .. ................-- to Construct air In vcge D' a�lSys�, t . , Street as shown on the application for Disposal Works ConstructiongVn;-t .... 1' Dated.......................................... ..........................------•-----"-------"--"----------------....------........•-•••-.....__..... Board of Health DATE............................................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS c,,tL4C,LE FAMIL.-%e • 5tMEDR40A -1 . 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