HomeMy WebLinkAbout1430 SOUTH COUNTY ROAD - Health 1430 South. County Road
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COMMONWEALTH OPMASSACHUSETTS
r EXECUTIVE OFFICE yOF ENVIRONMENTAL AFFAIRS
a �C PROTECTION
DEPARTMENT OF ENVIRONMENTAL
r
TITLE 5
OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION ` G
Property Address: V6-;0 C�' ! �C% U d V l— O D
Owner's Name: M a
Owner's Address: C
Ae
Date of Inspection: 0(y !
t ZZ -
Name of Inspector: please print)
Company Name. (471 tZL �u`�. �— t
Mailing Address: G `0 A ^T
O Sid"
co
in
Telephone Number: • `7Ja _� 6
CERTIFICATION STATEMENT cn -
1 certify that I have personally inspected the sewage disposal system at this address and that the i`formation report d
below is true, accurate and complete as of the time of the inspection.The inspection was perform d based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a
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,
ails
Inspector's Signature: Date: 5E?/ /fp�OG
The system,inspector shall submit a copy of this"inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector acid 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 Comriments 19C? �5 C9c?°1'rl ��✓rleG � � � �'� 5 �%°. /"`c1�/�
• l
**** e f inspection.and under the conditions of use at that
the-time o
This report only describes conditions at
P Y ..
time.This.inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page,1
Page 2 of 1.1 ..
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS s.•
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Pr C a
operty Address:
Owner;
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found an in
formation nformation which indicates that an of the failure criteria described ',, Y r dm310CMR
15.303 or in 0 31 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 exfiltratiori.or.tank failure is imminent.System will Bass 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.pipes)are replaced
obstruction is removed
ND explain:
Page .) of 1 l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART A
CERTI ICATION(continued)'
Property Address � (
h
Owner: 17 r ,Ch
Date of Inspection: (j
C. Further.Evaluation is Required by the Board.of Health: "
Conditions exist which require further evaluation by the Board of Health in'order to determine if the system
is failing to protect public health, safety or the environment.
1... System will pass unless Board of.Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect'public health,safety and the environment:
Cesspool or privy is within 50 feet of`a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
.2. System will fail unless the Board of Health (and Public Water Supplier, if any).determines that the
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
surface water supply or tributary to a surface water.supply.
_ The system-has aseptic tank and SAS and the SAS is within.a Zone I 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 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.
3. Other: ; •
3
Page 4 of I I
OFFICIAL INSPECTION FORM ".NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION:FORM
PART A. .
CERTIFICATION(continued)
Property Address: Y &, z
Owner: q'f 7� �1tZ A,
Date of Inspection:en l a.f� ��PGa�.�eQ 9"=50 y
D. System Failure Criteria applicable to
all systems:
You must indicate"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 %s day flow
Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped y
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
l 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 5 private water supply well.
!1 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 colifornt 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 ppin, provided that no other failure criteria
are triggered..A copy of the analysis.mustbe attached to this form.]
(Yes/No)The system fails. I have determined that one or more of.the above failure criteria.exist as
described in 310 CMR 15.303,therefore the system fails.The.system:owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a.facility:with a design flow.of 10,000 gpd to 15,000
gpd
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—I WPA)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 shall upgrade the system in accordance with 310 CMR
15.304. 'The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART B
HECKLIST
Property Address:
Owner:
Date of lnspection:
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 ?
ave 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 thfe 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 ,.
t7 j Existing information. For example,'a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at.issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5 .
Page 6 of I I.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEMINFORMATION
Property Address: C �..0 �, 6�j X •P/,� � C'►-�%'
Owner:
/_-4 9 , fl 4
Date of Inspection:
F W CONDITIONS
RESIDENTIAL
Number of bedrooms(design):__y .Number of bedrooms(actual):
DESIGN flow based on 310 CMR1 5.203 (for example: 11.0 gpd x#of bedrooms): 7 es/o
Number of current residents:
Does residence have a garbage grinder(yes or no): c`'
Is laundry,on a separate sewage system(yes or no)/ .[if yes separate inspection required]
Laundry system inspected(y s.or no): (J
Seasonal use:(yes or no)M. /
Water meter readings, if av 9lable(last 2 years usage(gpd)):Awl
Sump pump(yes or no):/ i,,
Last date of occupancy:
COMMERCIAL/INDUSTRIAIIV
Type of establishment:
Design,flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the mspectib (yes or no):_
If yes, volume pumped: -- gallons--How Was quantity pumped determined? .
Reason for pumping:
TYP F SYSTEM
eptic tank,distribution box, soil absorption system
Single cesspool
_Overflow cesspool
Privy
—Shared system(yes or no)(if yes,'auach 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 the DEP approval
—Other(describe):
proximate a e of all cotnponent ,date inst lled(if own) and 0' rce of information: _
0
Were sewage odors.detected when arriving at the site(Yes or
) —
Page 7 of 1 1
OFFICIAL INSPECTION•FORM-NOT FOR`VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
SYSTEM.I FORMATION(continued)
Property Address: MW .�901e-A
Owner - �
Date of Inspection: `' � �' 0
BUILDING SEWER locate on site elan
( P )
Depth below grade: '
Materials of construction:_cast-iron _40 PVC other(explain):
Distance from private water supply well or suction line: A
Comments(on condition of joints, venting, evidence of leakage,"etc.):
SEPTIC TANK —(toc ate on site plan)
Depth below grade:
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: �C" .a
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 bottom of scum to bottom of outlet tee or baffle: L
How were dimensions determined:
Comments(on pumping recommend tions, i et and out et tee or baffle condition, structural integrity„liquid levels
as related to outlet invert, e i ence of leakage,
5 r
GREASE TRAP (locate on site plan)T
Depth below grade:_ AA
Material of construction:_concrete_metal 'fiberglass_.__polyethylene_other .
(explain):
Dimensions:
Scum thickness: r
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:.
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid.levels
as related to outlet invert,evidence of leakage,etc.):
V
Page 8 of I 1 .
OFFICIAL.INSPECTION FORM-NOT FOR YOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:��
Owner:
Date of Inspection: 02.�'�.T
TIGHT or HOLDING TANK(tank must be pumped at time of uispection)(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:Z(ifresent must be opened)(locate on site plan)
Depth of liquid level above outlet invej1t`:z2tn
Comments(note if box is level.and distribution to outletsual, any evidence of solids carryover,any evidence of
ea kage into c out of box e ):
PUMP CHAMBER (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.):
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT:FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
_ . PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection (p
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan"he'avation not required)
If SAS not located explain why:
Type _....
leaching pits,number: '
eaching 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.):
F � 1
Af
CESSPOOLS: (cesspool.must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth`—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: x
Materials of construction:
Indication of.groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydra lic failure,level of potiding, condition of vegetation,etc.):
PRIVY: (locate on site plan) F
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):. ,
9
Page 10 of 1.1
OFFICIAL INSPECTION 10RM—NOT FORXOLUNTA' RY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'C
SYSTEM.INFORMATION(continued)
Property Address: `
Owner:
Date of Inspection:
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 thebuilding.
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Page 11 of 1 1
OFFICIAL INSPECTION PORTLY-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: Gi2C
Date7.
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water Ze .feet
Please indicate(check)all methods used to determine.the high ground water elevation:
Obtained from system design plans on record-1f checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
.Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain: '
You must describe how you established the high ground water elevation:
5 1Jam
e �
}
1.1
4 _
Permit Number:
:
k.
Date
;
y.. Completed by.: '' /
HIGH GROUND-WATER LEVEL COMPUTATION
„ Site Location: �/�oy Lot No.
Owner: r: �s Address:
` .
Contractor: 1'' Dom, Address: ��
Notes: -`�Cl��j r.7�1
se.
STEP ..1 Measure depth to water table '
:. to nearest 1/10 ft. ...........:........: . .. Date ;�CU� . 10
month/day/Year
STEP 2 using.Water-Level Range Zone
and:lhdex:Well Map locate
: site`and determine:. %
OARPropr.iate index well,:..............:
OWater-level,range zone
STEP 3 Using monthly report "Current
Water Res ources.Conditions" "
determine current depth to
water level for index well .......................... Ve !
month/Year
STEP 4 Using Table o:f.Water level Adjustments j
for index well:.(STEP 2A),current depth
to water level for index well (STEP 3),
andwater level zone (STEP 2B)
determine water-level adjustment .....................:...
STEP 5 Estimate depth to high water
by subtracting the water
level'adjustment(STEP'4)
from measured depth to water
'level:at si.te:(STEP 1') ......
... !7�J
Figure 13.—Reproducible computation form.
15
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OFFICIAL INSFECTION FORM-NOT FOR VOLUNTARY A l rr�
SUBSURFAGE:SEWAGE DISPOSAL SYSTEM lC E 1VED
_ PART A .
CERTIFICATION AUG,5', 2002 :
Prop"Ad�; Y�g,,County Rd � � ;r . TOWN OF BARNSTABLE
Odety�l MA HEALTH DEPT.
Owner's Name:min Sullivan
Date of Inspection:6 W02 _
iMAP
lz
Name of Inspector:Eric Lenardson PARCEL
Company Name:Statewide Environmental Services,inc.'
Mai ing Address:2750 Itarkney Hal Rd. Coventry,RI 02810 - { LOT
Telephone Number:(401)392-6906
CERTIM CATION STATEMENT[`
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is true,accurate and complete as of the time of the
inspection. The inspection was performed based on my training and experience in the
proper function and mainttnartce of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15JO of Tide 5(310 CMR 15 Wg0
The system:
x Passes ,
Conditionaiiy Passes
Needs Further Evaluation by.the Local'Approving Authority
Fails
Inspector's Signature: of e,;� Date:6.%102
The system inspector shall submit a copy ofthis 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 18,E gpd or greater,the inspector and the system owner shall submit the report to the
dateregkmW office of flit DEP.The original should be sent to the system owner and copies wart to
the buyer,if applicable,and the approving authority.
Notes and Comments
*:::Tlris mart only des r conditions at the time of inspection and under the coaditious of use at
that time,This ins does not address how the system wit perforce in the future under the same
or differt t conditions of=L
.. a y. .
.a
PART A
CERTIFICATION(continued)
Property Address: 1430 S.County Rd
OstemW MA 02M
Owner's Name:Kevin Sullivan
Date of Imo:64M
Inspection Summary: Cheek A^CA or E/ALWAYS complete all of Section D
A. System Pames:
a i have not found any information which indicates that any ofthe failure criteria described iw310
CMR 15.303 or in 310 CM 15.304 exist.Any f dune 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.ff"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,"bits substantial infiltration or exfiitration or tank lbihue is imminent.System will
pass inspection if the existing tank is replaced with a dying 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?A 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 obsftucWd pipe(s)or due to a lavken,settled or uneven lion 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 reghced
ND explain:
The system required pumping more than 4 times a year due to.broken or obstructed pipe(s).The
system wrM pass inspection if(with approval of the Board ofBoth): broken
pipe(s)are replaced
obstruction is removed
ND explain
OFFICIAL INSPECTION FORM•NOT FOR VOLUNTARY ASSESSMENTS.
SUtLSUIRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTMCATJODN(corfinued)
Property Address: 1430 S.County Rd
Osteuvdle,MA 026SS
Owner's Name:Kevin SuHivaQ
Date of Inspection:6/26/0
C. Further Evaluation is Required by the Board of health:
Conditions exist which require fiather evaluation by the Board of Heahh in order to determine if the
system is failing to protect public health:,safety or the environment.
L SysteIR will pawn unless Board of Health determines in accordance with 310 CIMR 15 1)(b)
that the system is not functioning in a manner which will protect public health,safety and the
eevhreament:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wedand or a salt marsh
2. Systeu;Will fain unless the Board of Health(and Public Water Supplier,if any)determines
thatthe
system is tiunctioning 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 tanit and SAS and the SAS is within a Zone 1 ofa public water
supply-
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
w-ell
_ 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 welt water aumlysisy 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 ofamumoma 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.
- 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DMOSAL SYSTEM MSPECTTON FORM
PART A
CERTIFICATION(continued)
Property Address: 1430 S.County Rd
Ostervik MA 02W5 ,
Owner's Name: Kevin Sullivan
Hate of Mspw .ion:6/26/02
D System Failure Criteria applicable to all systems:
You am indicate-ye or"no"to cads of the following for j inspections
Yes No
} Backup of sewage into facility or system component due to overloaded or dogged SAS or
._ x Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or dogged SAS or cesspool
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than'V2 day
flow
x_ Required pumping more than 4 times in the last year&_Q_T due to clogged or obstructed pipe(s).
Number of times pumped
x Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
suufaoe water supply.
x Any portion o f a cesspool or privy is within a Zone 1 of a public well.
__ x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x 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 passm if the well
water analysis,pu formed at at DEP certified laboratory,for celiform bacterb and
volatile organic compounds indicates that the well is free from pollution from that facility
and Me priesencg e9f ammonia nitrogen and nitrate nitrogen in equal to or ims than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis most be
attached to this foraq
No(Yes/NO)The system_q .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 wr'11 be necessary to correct the failure.
L Large-Systems: s
To be considered a large system the system most serve a facility with a design flow of 10,000 gpd to
13,000 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 wit)iin 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
flre systems is located in a nitrogen sensitive area(Interim Wdlhead Protection Area,—IWPA)or a
mapped Zone H of a public water supply well
ff you have answered"yes"to any question in Section E the system is considered a significant tluaat,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 lamed 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
QFFIC1tAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSAWAM
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CHECKLIST
Property Address: 1430 S County Rd
Ostetville,MA 026SS
Owner's Name:Kevin Seliivan
Date of Inspection 6/26/02
Check if the following have been done.You meat indicate"yes"or"no"as to each of the followiw.
ire - .r- ��r�rr.�ri�.rr. 7
Yes- No
x_ ____ Pumping iatbrmation was provided by the owner,occupant,or Board of Health
x Were any of the system oamponents pumped out m the previous two weeks?
x 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 pact of thus inspec�tion
JIL Were as built plans of the system obtained and examined?(If they were not available nm as
x Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
x Were all system components,excluding the SAS,located on site?
c Were the septic tank manholes uncovered,opened,and the interior of the tank inspecW for the
condition of the baffles or tees,material of oonstcuctioa,dimensions,depth of liquid,depth of sludge and
depth of scum?
x _ Was the facility owner(aced omupants if difli xent f m.owner)provided with information on
the proper maintenaux of subsurface sewage disposal systems
Vie sine and loesdon of the SeD Absorption Sys(SAS)on the site has been ermined
based on
Yes no
x Existing information.For example,a plan at the Board of Health.
Reined in the field Of any of the failure criteria mbW to Part C is at issue approximation
of distance is unacceptable)[310 CATS 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTION FORM
PART C
SYSTEM PWORMIATION
Pmaperty Address: 1430 S,County Rd
Osterville,MA 02655
Owner's Name:Kevin Sullivan
Date of Inspection:6126102
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4 Number of bedrooms(actual):4
DESIGN flow based on 310 CUR 13-203(for example: 110 gpd x#of bedrooms):440
Number of current residents:4
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):n!a
Seasonal use:(yes or no):no
Water meter rseadinA if available(last 2 years usage(gpd))
Sump pump(yes or no):no
Last date ofoc upancy: cement
COMMERCIALANDUSTRIAL
Type ofestablishment:
Design flow(based on 310 CMR 15.203): and
Basis ofdesign flow(seats/petsonsiN etc.):
Grease trap present(yes or no):_
bx+dsbW waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readier,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Recoids
Source of information:
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
x Septic tank,distribution box,soil absorption system
___.Single cesspool
Overflow cesspool
Privy
Shard system(yes or no)(if yes,attach previous inspection records,if any)
lnnovative/A>ternative technology.Attach a copy of the current operation and maintenance contract(to
be obtained from system owner) _
rgk tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of aM components,date installed(if known)and source of in>rmation:5/21/97 asbuilt
Were swage odors detected when arriving at the site(yes or no):no
OFFICIAL EW PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 1430 S.County Rd
Oslerville,MA 02655
Owner's Name: Kevin SuWan
Date of Inspection:6/26/02
BUH,DING SEWER(locate on site plan) .
Depth below Wade:22"
Materials of construction: ,_cast iron x 40 PVC other(explain).
Distance fiom private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.): Tight joints,no evidence of leakage
SEPTIC TANK: (locate on site plan)
Depth below grade: 16"
Material of consttucxion xconcrete metal fibagiass_,_polyethylene
other(explain)
U tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(Attach a
copy of certificate)
Dimensions: 1500 gallons
Sludge depth: 2"
Distances from trap of sludge to bottom of outlet tee or baffle:39'
Scum thickness:2"
Distance from top of scum to top of outlet tee or bade:3»
Distance from bottom of scum to bottom of outlet tee or baffle: IT'
How were dimensions detamumd: In the field
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invest,evidence of leakage,etc.x tnletloutiet are in good condition and
functioning properly. Septic tank shows no evidence of leakage and appears structurally sound.
GREASE TRAP-.(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass--jwlyethylene otter
(explain):
Dimensions:
Scum thickness:
Distance from top of scam to top of outlet tee or baffle.
Distance from bottom of scum to bottom of outlet tee or baffle:
Date oflast pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity;
liquid levels as related to outlet invert,evidence of leakage,etc.):
7
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1430 S.County Rd
Ostermlle,MA 024M
Owner's Name:Kevin Sullivan
Date of Inspection:6/26/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass__potyethylene other(owlain):
Dimensions
Capacity: sallons
Design Flow 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:_a (ifpresent must be opened)(loc ate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if box is level and dinrilim-on to outlets equal,any evidence of solids carryover,any
evidence of leakage into m out of bob etc.):D-lmx is level,and distribution of flow equal. No evidence of
solid carryover or leakage into or out of D-box.
PUMP CHAMBEW (locate on site plan)
Pumps in working order(yes or no): '
Atom in work*order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,
8 ,
OFFICIAL L4SPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION(continued)
Property Address: 1430 S.County Id
Ostemik MA OUSS
Owner's Name: Kevin Sullivan °
Date of Irssipeeoa:6126M
SM ABSORPTION SYSTEM(SAS): (locate on site plan,eaeavation not required)
N SAS not located explain why:
Type
leaching pits,number:_
x leaching chambers,number:S 2 x 4 x 7
leaching galleries,number-
leaching hencims,number, :
leaching fields,number,dimensions:
overflow cesspool,number.
innovative/ahernative system Typelhame of technology:
Cor�nents(note con&=of soli,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.): No signs of ponding or hydraulic failure. System on the surface is fiuictioning properly.
After examining tank,D-box and nmuinding area the system appears to be functioning properly,'
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and cocoa:
Depth—top of liquid to inlet invert:
Depth of solids layer-
Depth of scum lays
Dimensions of cesspool
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.r .
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of sail,signs of hydraulic failure,level of ponding,coition of vegetation,
etc.):
9
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(co ued)
Property Address: 1430 S.County Rd
Ostewi lo,MA 02655
Owner's Name: Kevin SulEivan
Dote of InVW ion:6/26/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Pmvide a sketch of the sevvW disposal system including ties to at bast two pertinent refem=
or benchmarks.Locate all wells within 1(0 feet.Lode why water supply enters the
TO"I OF DARN3TABt
LOCATION G e'�' Z IWO
SEWAGE#
• • VlI.L!►CiB ��o� •
r---T ASSESSOR'S MAP dt EAT '
INSTA1.LM'S NAM&PHONE NO. C�t � ...
SEPTIC TANK CAPACITYQ
NO.OP BEDROOMS 7 •
EUU.DE R OR OWNER
PEUMDAM J - v
a ��+ 7 �...COiNPLEANCE DATE.-
ftalm—fion �• .? — . .
1?istancn d�a:.
Minimum Adjusted Groundwater Table and Bohm of Leaehlag Facility
Private WSW Supply Well and Leeclang FscalltY Of any was exist f`
vn site Of wiW2=feet of lwxhW
- wnOf 3ooW few nd 'f f nay wedm&axist
E�Shed hy. 8 ►) :r� t
t3 .. .
.�,
w w
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I14PORMATION(continued)
Property Address: 1430 S.County Rd
Vie,MA 02655
Owner's Name:Kevin Sullivan
Date of Inspection:6/26/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 8 feet
Please indicate(check)all methods used to determine the high ground water elevation:
x Obtained from system design plans on record-ff checked,date of design plan reviewed:95'
Observed site(abutting property/observation tole within 150 feet of SAS)
Checked with local Board of calth4cplain:
Checked with local excavators,installers-(attach documentation)
Accessed t7SGS database-explain:
You most describe how you established the high ground water elevation:Plus.on Rec'd
21
TOWN OF ARNSTABLF�,
LOCATION L$'� � �� SEWAGC��Q E,# 2 ,
VILLAGE � `� �V` l P ASSESSOR'S MAP & LOT XP0-�/`00
INSTALLER'S NAME&PHONE NO. �OC� ��► l4yr�a `- °r'y ��t
SEPTIC TANK CAPACITY � �Q
LEACHING FACELl TY: (type)) (size)
NO.OF BEDROOMS T
BUILDER OR OWNER
PERMITDATE: J - IO COMPLIANCE DATE: 15
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
.;Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
9
{
' `• oQ,� � /
No. Fee V
" - THE COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[pplication for Mig oot *p$tem Cow5truction 3permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Locaty Add n
Owner's Name,Addr d Tel No
6�� 4,! �. , Aix— .
k-0;4�z
Installer's N e,Address,and Tel.No. Designer's Name,Addre n�No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder WV)
Other Type of Building_0� d1.0yaC_ No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 1 06 gallons per day. Calculated daily flow gallons.
Plan Date :NS3CV7 Number of sheets Revision Date
Title 6,0! 2- L ck _G F 1
Description of Soil � ��� kX 6ln
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 Title 5 of the Environmenta Code and not to place the system in operation until a Certifi-
cate of Compliance has bee y t ' Board Qf Health.
Signed Date/
A2
Application Approved by " / 015-7
Application Disapproved for the following reasons
Permit No. IY Date Issued
. ..r . 1 il- a:s. •E„ - ... �„ /`t ,.,;_ `w �r''`�//-.. //^u1 �t s _ .t � :` _�— f _ .•_ _ �_� 'i
.00R
1 - 5 7 14 lJ Fee ' 6Q l /
No. I V
` THE COMMONWEALTH OF MASSACHUSETTS �
" PUBLIC HEALTH'DIVISION - TOWN OF BARNSTABLE"'MASSACHUSETTS
~ 2pplication for Migpaal *pgtem COngtruction 3permit
Application is hereby made for a Permit to Construct O or Repair( )an On-site Sewage Disposal System at:
Locat' n Address or Lot o. Owner's Name,Add res and Tel N "
Installer's Name,Address,and Tel.No.1 Designer's Name,Addre,�4nd Tel.No.
f..
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder o)
r Other Type of Buildin No. of Persons '1 Showers( ) Cafeteria( )
I� ._Other Fixtures p
Design Flow gallons per day. Calculated daily flow yY o gallons.
Plan Dater Number of sheets Revision Date ,
Title G,fI? L C.C- 7n69 --)
Description of Soil
4
• 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 Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bee y t ' Board gf Health.
';.
Signed Date7/
k 2
Application Approved by / /( 57
Application Disapproved for the following reasons
y4
Permit No. Date Issued
041
Cop? 04 2en Vt S 9� LTHE COMMONWEALTH OF MASSACHUSETTS —
0 gC Sv�t44-*Uk2m HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
40
Certificate of Compliance "
THIS IS TO ERTIFY,th t the On-site ewage Dis osal ystem installed( �or repaired/teplace`d( )on
by for hzlla GCQt
as has constructed in accordance
with the provisions of Title 5 and the for Disposal.System Construction Permit No. dated --�jq"�
Use of this system is conditioned on compliance with the provisions set forth below:
No. / Fee f O J
THE COMMONWEALTH OF MASSACHUSETTS
t
PUBLIC HEALTH DIVISION - BARNSTABL"�E MAS_SA'CHUSETTS -
lwigogar *pgten� _ oaxgtr rmit
Permission is hereby granted to 'c
to c nstruct(repair( )an On-site Sewage System#located at
s r'
and as described in the above Application for Disposal Sy tem nstruction Permit.The applicant recognises his/her duty to
comply with Title 5 and the following local provisions or s a 'onditions.
i
All construction must be co pleted wo years of the a e below. o
Date: y Approved by
MAY-27-1997 08:26 FROM TO 7750155 P.01
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�1i1R(1 � ALLYN
1
t i '
f '
TOWN OF BARNST ABLE
LOCATION L a� saute SEWAGE #
VILLAGE_ ASSESSOR'S MAP & LOT 00/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) `� ` �� (size)
NO.OF BEDROOMS
BUILDER OR OWNER�P,4k
PERMITDATE: ' /0 _COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Welland 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.
N
0
TOWN OF BARNSTABLE ¢
LOCATION 1/40 S. C OQA�� 1�pp e SEWAGE # 9y' /6 o-
VII.LAGE O-Mervl Ik ASSESSOR'S MAP & LOT /c 0Q 00/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY dGl�
LEACHING FACILITY: (type) (-,-r (size) 000
NO.OF BEDROOMS 3
BUILDER OR OWNER f Ay] LIA'1.��
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 T/1 sPtyfl-y� -Z FD/d
A 6
c
i
Q
Iv lU
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'e 1
!.._w Fss.......��,�.v...�
THE COMMONWEALTH_ OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphratilan for Di-tipw3al lUvr1w Tomitrnrtinn Prrmit
Application is hereby made for a Permit to Construct ( L4 or Repair ( ) an Individual Sewage Disposal
Systemt ---------------------------
l:
/j LOcat' Xddres Lot No
,_.� ... _\r. ......... .... . •.. ... .-----••-----•............................
0
O ' Address
a --- Tl/1� -CI
Installer Address
� 5 .Type of Building � Size Lot___ 3 _____4,6 s_ q. feet
�-, Dwelling—No. of Bedrooms.____________ -------------------------Expansion Attic (A Q) Garbage Grinder ( )
Other—Type O� «C
a yp of Buildin g _____�_ '�....� No. of persons____________________________ Showers ( ) — Cafeteria ( )
d Other fixtures ------------------------------ •----
W Design Flow.................Cj6-------------------gallons per IM per day. Total daily flow ---------_-_--gallons.
WSeptic Tank—Liquid capacity/Odn._galIons Length---------------- Width---------------- Diameter-----.---------- Depth----------------
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
►" Percolation Test Results Performed by.......................................................................... Date........................
Test Pit No. 1__�------minutes per inch Depth of Test Pit----- S9_......... Depth to ground water...NQti .....
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
RS ® .........................................................
0 Description of Soil........... 1i. .--------------------------- --------------------------------------------...----•------..
x
U -•••-•-••-••--•---••--••--•------•---•-•-••-------------------•----------•--••--••••-----------•--••----•••-•-------•-•-----••-•----•------•....••-------------••--•-------•-•--•-••......--••••------•.
w
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
- ----------------------•-•-•-............----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The j1pdersigned fj&Kher agrees not to place the
system in operation until a Certificate of Compliance s een issWte (Jfealth.
ed ---- ------------- .�G�...... --------------------- ....... .Xe
...............
ce
f Application Approved By _..........L -------------------- f 9 y-
Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------ ...... --------------.......------------------
.................--------------------'--------..........-------------.......... Dare
Permit No. --------- L� U
.......... .. ................ Issued ...........!.. ..� .1 .-.(.
Dace
Nov .Lt_._ ..!_._t ,^ Fss.....
�^ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
► (,ITOWNOF BARNSTABLE
i ApVfiratiott for Bi-npwml Workii Tonotrurtion ramit
Application is hereby made for a Permit to Construct (d/)' or Repair ( ) an Individual Sewage Disposal
System at
,.
Lcation-:\ddress /7 ..
o N or1 Lot o.
Ow e/r � -•-'")n,� �����-^�-C Address
✓� Installer Address r ��
UType of Building Size Lot_..._......'.................Sq. feet
Dwelling—No. of Bedrooms--------------��.._.___....__.______.__._Expansion Attic (�) Garbage Grinder ( )
Other—Type of Building GG�W4 ice( /YJC No. of ersons____________________________ Showers
YP g = P ( ) — Cafeteria ( )
QOther fixtures �.�/<----------••-•---------------------------- ---------------•---•----•---••-•--•----•--•----••----------.-
W Design Flow.................dl�...............____gallons per person per day. Total daily flow--_-__ 330 ................
WSeptic Tank—Liquid capacity ZW__gallons Length................ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by---------- -------------------•--••......------•--i..---••-... --••_. Date........................................
Test Pit No. 1..:�!�-----minutes per inch Depth of Test Pit----�Q._....___. Depth to ground water.._ �✓U ......
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------------------- ---------------------------------------------------------•-•-•--••----........••---••------•------•-••......--..._.......--•-
DDescription of Soil :.'j�/ -- - ---------------••-•-----------------.....------------•---------------------------------------•-•--•---•--------...-----
x
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•--------------------------------------------------------------•---•••••-••-••-•---•--------------------••---•----------•••-•--------•-••---------------•--......---•------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—Theu ndersigned f •-1her agrees not to place the
system in operation until a Certificate of Compliance hrbeen issued y the boa f health.
Signed '. Jf!.C..:..........:.:.�_..... . �.x�.- - -----
1 ce
Application Approved By ......... ................................................................. v Y�---
......................................................................... ........ Dale
Application Disapproved for the following rea.ronr- -------------------.................._--------....---...........-----......................_........._.....
--------------------------------------------------- ------------------------
Date
Permit No. ....... .y.......... _.2...... ...... Issued ................
.. ..�.. ....�� y ................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Complinure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( V"') or Repaired ( )
by TAT... .f.S'Ct�� ......- - -
Insrallcr
----
at
..... ......... ...................
has been installed in accordance with the provisions of TITLE of The State Environmental Code a desgibed in
the application for Disposal Works Construction Permit No. .... --------------------- dated - . /_2 .----- --
.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �.
DATE...........,�� '6 .._„�` . '.'i...._. �� --- --- ------- Inspector
� " ... � ��.�..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ TOWN OF BARNSTABLE
No.......j.... ...�.�C� 2 FEE....l` .0.V...
Elwpoiiat Works Tonotrurtion "rrmit
Permission is hereby granted.....� __. --..��.�5�L..-.__............. . .. .
to Construct ( � or Repair ( ) an Individual Sewage Disposal System
at No...L��_T. `•--Il ... _/l_7 ....... Street
Y----- 1� r .`��'��".!?.U�C L
. Street /� � L
as shown on the application for Disposal Works Construction Permit No._-/--L�_l_..\__________ Dated__________ ________________.._.._........
.................... �.ti.__)------------------.--•_-- t-- ...
`. p, Board of,Health
DATE -_�. ..-._.1.�---------------------------------
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aJ1. C-t L kX"J1"��•, assIONA L E��`
TOWN OF BARNSTABLE /�
LOCATION La's �a��� Coin�- oa�l SEWAGE # Z�g
VILLAGE �St� � 1`'���C�� /�c5f
ASSESSORS MAP & LOT-
INSTALLER'S NAME & PHONE NO. Of`tSGca`' -77I IOg0
SEPTIC TANK CAPACITY 000 1Iq 1(06S
LEACHING FACILITY:(type) ����" `' '� (size)
NO. OF BEDROOMS J PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER '60L�5 ;, , �Ui`�r�, CG' .77/- O%qL/
DATE PERMIT ISSUED: ,
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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