HomeMy WebLinkAbout0023 SWIFT AVENUE - Health WIFT AVENUE, OSTERVILLE
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UPC 12143
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HASTINGS.MN
Commonwealth of Massachusetts
Executive Office of Envirommental Affairs
Dept. of Environmental Protection
Jolui
One winter Street,Boston,Ma. 02108 Septic
D.B.Y. Titlee V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD , (508)564-6813
Governor t 1
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART A
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CERTIFICATION S�P E/(/
2
Property Address: 27 SWIFT AV.OSTERVILLE MAP 165 PAR 033 LOT 01 Address of Owner: ' Td �P �998
Date of Inspection: 919198 (If different) h�(TH49NSTA8
Name of Inspector: JOHN GRACI MRS.KJOLLER �FPT �f
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
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:
z
X Passes This Inspection Is based on criteria de finedIn Title V
Conditional) Passes code 310 CMR 16.303.My findings are of how the system is
_ y .performing atthe time of the inspection.My inspection does
_ Needs urt er Evaluation By the Local Approving Authority not Impyanywarrantyor guarantee of the longevity ofthe
Fells septic system and any of Its components useful life.
Inspector's Signature: Date: 9117198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] 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.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection,or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 ,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 27 SN11FT AV.OSTERVILLE MAP 165 PAR 033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:9/9199
— Sewage backup or.breakout or high.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval'of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 the public health, 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 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid)
3)Other
D) SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add re55: 27 SWIFT AV.OSTERVILLE MAP 105 PAR 033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:919198
D]SYSTEM FAILS(continued)
Yes No
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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
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 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
co►iform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following.-
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA) or a mapped Zone 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 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(rev19ed 04r27)97)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 27 SWIFT AV.OSTERVILLE MAP 165 PAR033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:9/9198
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ _ Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
x _ As built plans have been obtained and examined. Note if they are not available with N/A.
x _ The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum..
x _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
(revised 007197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 27 SWIFT AV.OSTERVILLE MAP 155 PAR 033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:919r9s
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 3
Garbage grinder(yes or no): Yes
Laundry connected to system(yes or no): Yes '
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
n1a
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nra
OTHER:(Describe) Iva
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rda
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nla
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
NEW SYSTEM WAS INSTALLED IN 1996 BY ROBINSON
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127)97)
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 SWIFT AV.OSTERVILLE MAP 165 PAR 033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:919198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 4"
Material of construction:x con create metal FRP_Polyethylene—other(explain)
If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L10'6'•H5'7"W5'6"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness:z"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 16"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEAR
GREASE TRAP:
(locate on site plan)
Depth below grade: nra
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:Wa
Distance from lop of scum to top of outlet tee or baffle:nra
Distance from bottom of scum to bottom of outlet tee or baffle: ola
Date of last pumping;,ra
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
No
BUILDING SEWER:
(Locate on site plan)
Depth below grade: v
Material of construction:_cast iron x 40 PVC other(explain)
Distance from private water supply well or suction line7OWN
Diameter: Na_
Carnments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 SN11FT AV.OSTERVILLE MAP 785 PAR 033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:919198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nra
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nra
Capacity: rVa gallons
Design flow: Ha gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nra
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
nra
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_ye:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
nra
(reyleed o4127l97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 27 SWIFT AV.OSTERVILLE MAP 165 PAR 033 LOT 01
Owner: MRS.KJOLLER
Date of Inspection:919igg
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits, number: rda
leaching chambers,number:We
leaching galleries,number: We
leaching trenches, number,length: rda
leaching fields, number, dimensions:ONE 4'x2'X60'LEACHFIELD
overflow cesspool,number:rda
Alternate system: rife Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH FIELD IS FUNCT70NING PROPERLY. i
CESSPOOLS:_
(locate on site plan)
Number and configuration: We
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rda
Depth of scum layer: Wa
Dimensions of cesspool: rda
Materials of construction: rda
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: rda Dimensions: rda
Depth of solids: rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
rVa
(revised 04l27)97)
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
27 SWIFT AV.OSTERVILLE MAP 165 PAR 033 LOT 01
MRS.KJOLLER
919198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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b FJ6P,
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36
(revised04)27197) Page ! of 10 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r
27 SWIFT AV.OSTERVILLE MAP 165 PAR 033 LOT 01
MRS.KJOLLER
919198
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
_X_ Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
(revised04)27197) page 10 of 10
i
&w HOBBS3 WARREN TM THE COMMONWEALTH OF MASSACHUSETTS
FORM 30 C
BOARD OF HE A TH
CITY/TOW r
W
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a � � DEPA MENT �
41M Syey`•s `568• `//�(1
-?_3 � p O^� TELEPHONE
Address--;r=7- /{{►. � `✓ Occupant_
Floor Apartme t No. No.of Occupants
'i No. of Habitable Rooms No.Sleeping Rooms
No.dwelling or rooming units No.�Storie_eNg •
Name and address of gw er
AG f4 . �,, Cji Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage 1
Infestation Rats or other: V ,t,w7
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows: 1
Roof
Gutters, Drains: V
Walls: p
Foundation:
Chimney: l
BASEMENT Gen.Sanitation:
Dampness: C_�-
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
..TYPE: Stacks, Flues,Vents: f
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
—Pantry
Den
—Living Room
Bedroom 1 ,
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Sjaqks, Flues,Vents,Safeties:
Kitchen Facilities in 0TV
S ove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors: UV V
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REP IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PE RJ III .
INSPECTOR f
DATE \Ij TITLE CC
— 7 0 TIME�'' • �,7 w�p�N"�j
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns,shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
66
30 .00
THE COMMONWEALTH OF MASSACHUSETTS ZYH xic..............................
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-l-ipwi al Wor1w Towitrurtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
-173- Swift Ave Osterville
- 7------------------------------------------------------------------------------ ....._
---------------------------------------------------
Location-Address or Lot No.
Carl Jenkins
......................_.......................................................................... ••-•-••--•-----••••-••----•-•-------•--•-•-----••••-----••--••-------•------•-----------•------••.
Owner Address
a W.E. Robinson Sept_icSery_ice P.O. Box 1089 Centerville
Installer Address
UType of Building 3 Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder (10)
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ----------------------- ------ - -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter..........--.... Depth................
x Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter----..--.-.----.---. Depth below inlet....---............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
14 Percolation Test Results Performed by----------_--------- .................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
Li, Test Pit-No. 2................minutes per inch Depth of Test Pit.--..-------..------ Depth to ground water........................
•--••- -
0 Description of Soil-------------------------•-•----•-------•-------------------------------------....--------------------------------------•----•----•----•-•--••......---•------------....
W
U •••••----•-•---••-.....•-••-••--••-•-••-•••----••---•-•--------••--•••••--•------•-•--•---•-•---------•-•--••-----------•-•••-----------•-••-••••••••---•--------•------•••-••-•--•---•-•......----•-•••
W
UNature of Repairs or Alterations—Answer when applicable....1.1-5.00___ga1---tank......d-box...&.........................
60 ' leachtrench
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as been 'g ed b,�'the board of h Ith.
Signed --------411&
Application.Approved By .. - --7„ ��e'---�----------
Application Disapproved for the following reasons:
.........................-------------------------------------------..--..__.-...--------------------------------------...--------------------------------------------------------------- ----------------------------------------
Permit No. ------7-�.............� ----
__. Issued ........................................... [e...
Dare
30.00
No.. � :.-,��.�.� Fss.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE-
Appliratiou for i� ttl3Ml`a. mrlt C��flt trurtt u ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
...Swift Ave. 0ster.vil1e
.......... . ....... ----•-----... --........
Carl Jenkins Location-Address or Lot No.
......................_.......................................................................... --•-•-•-••-••----•---••••••-----•--••-••------•--••-•••---••-••--•-•••-•--...........----.........
Owner Address
W W.E. Robinson Septic Service P.O. Box 1089 Centerville
Installer Address
PQ
UType of Building 3 Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------- ----Expansion Attic ( ) Garbage Grinder �10)
aOther—Type of Building ---------------------------- No. of persons------------------------- Showers ( ) — Cafeteria ( )
QI Other fixtures ----------------------------------=--------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity---------.-gallons Length................ Width........--.----. Diameter................ Depth----------------
x Disposal Trench—No. .................... Width-__.-.--..-_------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter...........--------- Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. I................minutes per inch Depth of Test Pit.....-------..-----. Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------_dfi
t� ` sand...........................................................................................................................................
Descriptionof Soil....•-••••••••••••••---••--•••-•••••••••••-•--••••••-•-•-•••••••••-•---•------••----------------•-----•••---•-•---••-•-••-•-•-•••...••--••-•••••......•-------------•---
x
U •-•--•••---•---•----•--•---••••••--•--••-•----•-•••---•-•••••••--••-•--•-•••••---•----•-----•---------•-••••-•-••-------•--•---•-----------•••-••••-----•------•••••••--•-••-•--•••--•••••......------•.
W
. ••-----------------------------------•-•.........--------------------------........-----------------------•------------------....------------------------------------------------------••---•-------
U Nature of Repairs or Alterations—Answer when applicable.....1-p.599__ gal tank ....d-box &
60 ' leachtrench
--------------------------------------------------------------------------------------•--------•------------------------------------------......----------------------------------------................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has b�e_�n�ed the board of he lth.
//Signed --------Z ---� ---- ------------ ......- 6 e .. ......
Application.Approved By .............art. --
L1 .................... .........................................--------------- Date
Application Disapproved for the following reasons: .....................................
---------------------------------------------------- -------------------------------------------------------------------------------------------- ----------------------------------------------- ----------------------------------------
DateNo. ...� ............. ' Issued ----------------------------------------------------
Permit .......
------�---':1—...............1' Date ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BAR����TTNSTABLE
�ertifirate of Tomptiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X )
by W.E. Robinson SepticService--_ --------------------
-------- - ------- ------ -------- ------ . ...
lwalle,
at ......27 Swift Ave Osterville_---------------_.--- - --- . -
- - - ---- !�----------------------------------------------------_----------------------------------------
has been installed in accordance with the provisions of TITLE 5c of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. `.....L.�...f.6 .... dated ........�.-_..j.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE d/ Inspector -- ! ---------------
f .._........... ^-
7
---------------_----,-_,---- - ---_-------_ --.a--_--,-_,__----_,_-,-_-_,---_.-•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE o.00
lRispntittl Workii Tomitrtrtuan rrutit
Permission is hereby granted --
W.E. Robinson Septic Service-. -------
_ ........
---------------- -------------------------- --- --- ..
to Const ;ct ( ) or Repair (x ) an Individual Sewage Disposal System
Il / Swift Ave Osterville
atNo.....................................................1 ••.............................................................................. ......................................................
Street Q
as shown on the application for Disposal Works Construction Per it No.��--_/6-an Dated.._.-_--7- �..-.✓.��....
.......................
..:�`--------------------- .............................................
DATE.....................7,�...1., ." — Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 2-2 j , concerning the
property located at 01- 1• ) 1/ meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED:SIGNEDA 4 ^- � DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
7 / 1
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TOWN OF BARNSTABLE
LO CATION0 34- u- Ike' SEWAGE # !10.,-V L(- R
V LLAGE S(,.) Ayc, ASSESSOR'S MAP&LOT/ '4�f3i.
INSTALLER'S NAME&PHONE NO. (0)C— Yob 7-)SA Z Z(,
SEPTIC TANK CAPACITY I S ot3
L �
LEACHING FACILITY: (type) (size) u x
NO.OF BEDROOMS 3
BUILDER OR OWNER e-ke P .
PERMITDATE: `?lQ--'1 LCOMPLIANCE DATE: '?� 5
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
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4M K .�
x"':--!X7 V®eanY ✓
r � TOWN
�O,F BBARNSTABLE
LOC7,i'PDX-4 SEWAGE # t' 43 2
VTLLAGE_ KQ ASSESSOR'S MAP& LOT r Lbf l
INSTALLER'S NAME&PHONE NO. i
SEPTIC TANK CAPACITY 1��o
LEACHING FACILITY: (type) 4;CO (size)
NO.OF BEDROOMS 2 '
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) 7 U. Feet
Furnished by o-4,
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