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HomeMy WebLinkAbout0100 WEST STREET - Health 1.00 West Street A=139-066 Osterville } q � A r i y 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (� 100 West Street �� ^M Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor_do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 reran City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification G 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 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: \i ® Passes ❑ Conditionally Passes ❑ Fails ❑ N"Furtherluation by the Local Approving Authority 6/11/2008 Inspector's Signature Date a The system inspector shall submit a co of this inspection report to the Approving. uthori ?Boan Y P PY P P Pp g tY ( of Health or DEP)within 30 days of completing this inspection. If the system is a sh red system orrn has a design flow of 10,000 gpd or greater, the inspector and the system owner sha submiR�ie report to the appropriate regional office of the DEP. The original should be sent to th system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments ^M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: L ® 1 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: The septic system is in porper working order at the present time. 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 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 . every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: ' S 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 a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. 100 West St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts " W Title 5 Official Inspection Form . o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be. attached to this form. 3. Other: 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 %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. 100 West St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts t W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): t Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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. 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments ,M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for . Osteryille Ma. 02655 6/11/2008 , every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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: ❑ ® 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(5)] 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2006:70,000 9. ( Y 9 (gpd)) 2007:77,000 Sump pump? ❑ Yes ® No Last date of occupancy: 6/11/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 1 100 West St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 I ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town, State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Tank pumped 5/23/2008 Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy-of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New Leach Pit installed 8/27/1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No 100 West St.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 26"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gallon Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 0 71, Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of leakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 100 West St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM10 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has 2 outlet laterals.Distribution is not equal.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000 gl. LP ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Old leaching pit was full.New leaching pit water level was 56"to invert pipe with no stain line above. 100 West St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 100 West St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel View Custom Map Abutters Map Size ® Zoom Out er JI j M J j !fl In + _ + as + +a a + a a + a � + + + 1-5 a = t �1 a Y = rat aae I M A ti t; t ' 4 a a _ - 0 20 Feet = Set Scale 111•= 20 I Aerial Photos ( MAP DISCLAIMER a (`nnvrinht )MF_9MR Troun of Qn—&shlc KAA all rinhte raenn,, httn://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=139066&map... 6/11/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 100 West Street Property Address Richard Grey Owner Owner's Name information is required for Osterville Ma. 02655 6/11/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 10' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranged of groundwater elevations. 100 West St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of 13,-cirnst.-,ible , f, E i\ Regulatory Services BARNSTABLE, ; Thomas F. Geiler, Director �prF039. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS r DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and.interpretations contained within this report. In addition, by receiving this report the . Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would .be listed on the "Disposal Works Construction Permit".. If you should have any questions regarding this. report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTICMisclaimer Private Septic Inspections.DOC TOWN OF BARNSTABLE LOCATION �)o�--�57. SEWAGE # 0 '38 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Ocl� �r( �r/a,g J SEPTIC TANK CAPACITY "QOQ LEACHING FACILITY:(type) 7,V --6X8 . (size) GOy NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes Now% �ACk O No u s� (� o------------- Ll�► TAIA Lf o tD Prr .3 1 ©0-0 one PIT l `� �( i No.....7Z.:: Fps... .. THE COMMONWEALTH OF MASSACHUSETTS 3 q v V BOAR® OF HEALTH TOWN OF BARNSTABLE ApplirFation for UhipwiFal lVorkii Tonstrnrtinn 1hrnti# Application is hereby made for a Permit to Construct ( ) or Repair (/) an Individual Sewage Disposal System at: � ..�o._ .._....__. ' ---------- K�U)/s......................:-....-....._ Lo ation-Address or • 1 Owner dres V— a ✓r -----------.._......-------... _s . .� �4a4c1. _R..!` °!'= � - •................ � Installer Address d e of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms!_...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures ---------------------------------------------- d ------------------------------------•---------------------------------•--•--••-- 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. 1----------------minutes per inch Depth of Test Pit--------- _---------- Depth to ground water_____________:.______-_- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ P4 --------•-----------------------•--•--_.....•-•-•----•--•-••---..._..................---•------_............................................................. 0 Description of Soil........................................................................................................................................................................ W U x -----•-•---- -- -------- --- --- ----------- ---- - --------------- ------ ----- - ------------ Na re of Re airs or Altera ions—Answer when a licable______ �._ �__.:�___. . U P PP R --------- -----�0 d---fA•-- .� 1141�`L7 -1�----------Z4... . ... ---- °vim -•------------- --------------•-------------.._..---------------------------........--•---...._. 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 been issued by the board of health. Signed - - ... l ..............4----. ------ 7 Application Approved By "------- c.�-.. y..S..:-.--... ---- 'aZ � �� .."--------------------------.. Dale. Application Disapproved for the following reasons- ........................----------------------------------------------------------------------------------"--------------------------- ------ - - ----- -------"..---------------------------- - -------------------------------------- --------------------------------"""----- Da[e Permit No. ----"----------. .�>. ..---- Issued -- = .................................................... Da[e .................................. o THE COMMONWEALTH OF MASSACHUSETTS : 3 BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for 14sposal Works •\\C us;Tnr#inn ramit Application is hereby made for a Permit to Construct (, ) or Repair (�j�) an Individual Sewage Disposal System at: � � • / --/.Q .__......_ .. .s ..._._.....r?m_?s Livls-.------•---------------- ---------- --------------------------..-.--------' Location-Address .. or t o. /Oc>-- r{�"s ------------------------ Owner CI A ress v T_..... Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria al Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter__.___._-____ Depth................ Disposal Trench—No. .................... Width.........._.__.___.. Total Length Total leaching area.........---__.__...s . ft. P g g q 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•-_-_-_______-__--___--- G4 Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ 9 •------------•-------------------------------------------••......-•-----------•••-•------•.............---•••-••--••--•------......-•-•------.......--...... ODescription of Soil..................................................................................----------•----------------------.....---..............------------------------.----- U --•----------•----•---------------•-----•-----------•-----------•--------------------------._... ------------------.............:...................................... �4 -----••----•----------------•-......-----------------------------------------------•---.........-------------- -----------...----------••------------•--•-......._.._..j Nature of Repairs or Alterations—Answer when applicable _.�� �___"..../lJ d.d....i ,4. ....1�� U P PP r 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 been issued by the board of health. Signed . ./' ? �l J.:... -. Application Approved BY ......... -.. .-Z�- Application Disapproved for the following reasons: -------------------------------------------------------------------------------------------------- -- - -------------- ------------ -------------- --_---_ ......................-- Date PermitNo. — ..��.G..--- Issued ---------------------------------------------------- - -- Date Y� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C6ertifirate of Complianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b (� e,4.. ----------------------------------------------------------------------------------------------------------- ---------------------------------------------- Installer at --------------�- -6..---........t�f/.�� ----- --- ...... . . �s�Q 1.--------..................----..............---------- ............................................ has been installed in accordance with he provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......eo-....3.36.......... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................. .... .. ..--$. '.. /�............... .. Inspector ....--------.............-- - ---------------------------------------..-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..... C 6 FEE..... . ........ 15ispos l Works Twnnstrnrtinn "Prrntit Permission is hereby granted............. -K.......1 - ?�d c .... ..._.................._..._..........._................_..__ to Construct ( ) or Repair ( �'an Individual Sewage Disposal System atNo................... OC 1,�_�_ e J -=3 T n /..'-'-'----•........................ Street as shown on the application for Disposal Works Construction Permit No.. .��:J.!!. Dated.......................................... .......................................t- ....... ..................................... .............•••................. U Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS 707 FE No.. E.....�`5...:�...... THE COMMONWEALTH OF MASSACHUSETTS ti BOARD OF HEALTH OF............. x ApplirFation -for Diii o.iaal Works Towitrurtioaa Vrrmit Application is hereby made for a Permit to Construct (k or Repair ( ) an Individual Sewage Disposal a System at a c� --......--1 / -------•-----------------------------•----- ...---•--------------------.H--------•------------•• ------------------- V ion-Aj0 ress j� r Lot No. .(�)s[ { --`'•-• ---e ----- ---- ---------"`�.. •. 'ddress.. Installer Address vJ U Type of Building Size Lot.___- c_-t-----.Sq. feet Dwelling—No. of Bedrooms__-----------------------------------_-_-.Expansion Attic ( ) Garbage.Grinder ( a pi Other—Type of Building ----------------I- o. of rsons------------ _._ howers ( ) ='Cafeteria ( ) dOther fixtures of Z------- ----------�- < Fes--------------- ------ =" ------------------ V W Design Flow..................................... gallons per person-per day. Total daily flow....................................;:_.:.__gallons. USeptic Tank—Liquid capacity_A�_gallons Length................ Width_....---------- Diameter---------------- Depth_._.--._---_--- x Disposal Trench—No.-------------------- Width--- --------_._ . Total Length-------------------- Total l-eaching area-------- --------.--sq. rea--_-._--..._.___-.:_sq. ft. � Seepage e Pit No-------J-_______-_-_ Diameter..-XP--_- Depth below inlet=-------- --_- Total leachingarea----- _ -----------si�.ft. z Other Distribution box ( ) Dosing Y Percolation Test Results Performed b ,+��_.___: 2_A-6?A---------------------_ Date............. ® a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_.-_--__---.-..--._:_ fs Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.-.------.---__-_-__- �+ --- ----•-- - r �y------- ---y O Description of Soil-- � � C:rGr�y ..__.: � - - 1 'U ----------�-- ' -"-----.�'.. / .. ��� c. ' j —Answer when applicable._-_- ----_. _- --------- ------------------�1! U Nature of Repairs or Alterations -- . _---- -----------___---.-__.....______-- . IU Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b e bo o�Itl --Signed G' 1 � Date Application Approved By_-_-_____ � ._._____ _. __ :f/ Date Application Disapproved for the following reasons:...........................................----.........-•----------------....----------•----•--•---•---------••- -----•--••----------------------------------------------------------------------------------------------- Date PermitNo.......................................................... Issued...................... -----------------------------•-" Date .............................. THE COMMONWEALTH OF MASSACHUSETTS 4y}r a BOARU"01T HEA TH -D?,� ..... . F...................... r�� ... ? l rtt#iu fnr t"aiittl Works Towitrurtion : rrnift Apphcahora` is hereb made for, a Permit to Construct (Al or Repair .( ) an Individual Sewage Disposal System a '{ � , : __------•---_-----_ ----_--------__-•_••_- _----__- canon-Address or I o �S/f� �_.�Own ._.•- ...............9 -------- ... Installer Address QType of Building Size Lot_______ _ _ __._Sq. feet U Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder (� Other—Type of wilding __--_`-__-__ ____ N . of e sons-___________/_ __--_____ _-- owers 1 ) — Cafeteria ( ) P4 Other fixtures ------------- Q2_- ------� _._._°�-_.N�..�__p�-�_-�e�.. ......... W Design Flow----------------------------------------->-_gallons per person per day. Total daily flow___________________-___________-_-___,____-_gallons. 94 Septic Tank-1 i,,q_uid capacitv.w _gallons Lengt(i................ Width................ Diameter-_______-.-___. Depth___-_-___-__... x Disposal Trench= o, ________a _._____71 e Wid li_________ ______ _ __ Total Length__________________ Total leaching area.-.----------------- ft. Seepage Pit No_____ ___________ Diameter_.tv_ Depth below inle ___________________ Total leaching area--_____-___.__---sq. ft. Z Other Distribution box ( ) Dosing ( a Percolation Test Results Performed by_____- _ !�' _ _�_ i _________ __________ Date_ _______________-_____ 0-1 �P _________. - it No. 1________________minutes peer inch epth of Test Pit_...._.___-..._____. Depth to ground water-_--___.-_ - (S, Test Pit No. 2................ per inch. Depth of Test Pit____________________ Depth to ground water_.__-_.- ----- ------ -- •--• Description of Soil = � M �✓ '� �Ly r x .. f . K - W4 •.., , UNature of Repairs or Alterations—Answer when applicable._...___ _______ _ ______ --- -. _-_. -_. . _.. = --- ---- ------•-=------------------ ;. .. 'Agreement,t. '+ The undersignedgrees to-install the .afor`gdescribed Individual Sewage Disposal System in accordance with the provisions`of Articl \I of the State Sanitary"Code- The undersigned further agrees n to place the system in operation until,a-Certificate of Compliance has been,is ued by h board o e th ; �f C/ 1 igned.. ........ ....-••-------••-••--_-•--- -- ----- ----------- ---• Date Application Approved BY '"' l iy/ "�' ..- '7----.�7--------- � Date I' APPlicatiori..Disapproved f o; tlae;f ollowing:.reasons ------- ------- --------------------------•--- ----- - - --------------•----------------- . ` ______________________________________ i _____ __ _ ____-. ____ __ _______-_________-________________________-._________________-___-__________________ >x Date t Permit No. � Issued.- ...................................... Date e T..H r'C MONWEAL--TH OF MASSACHUSETTS OARD OF HEALTH W Tlertif ratr of Tompliaurr THIS IS ZC. T , Th e Individual Sewage Disposal System constructed (� Repaired' ( ) by.........' - ---- .v� . -- �[ - - 7�! ; I er - `�. has been installed in accordance with the provisions of A4c I of The State Sanitary Code as described in the application'for Disposal Works Construction Permit No:. 7r .... __..._._ dated..-' _ '7 THE ISSUANCE OF THIS,, C4ERTIFICATE SHALL NOT BE 'CONSTRUE© A5 A GUARANTEE THAT THE SYSTW,.:WILL FUNCTION SATISFACTORY. DATE ::. •-•--- Inspector= ya : ......---------------------- ......... - --------------- THE­COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i:. ........... .... . ... ..OF......... .. ...........-•---..........._... -------- .,,...... FEE_--f Binvolia >� trurti> at rrtttit , , �I Permission. is.,hereby granted--'______________ __ _ _.. z to Constr t/� rJ;pair ( di idual Se age i po 1 SystJe�p'j.�/ at No..--,. -s • Street ----- -- -- - ---- --------- J as shown on the application for Disposal.Works Construction Permit o.________ `ated_.. .............. f Boar Hea _. DATE..... ". -._ a of Itn FORM 1255 Hoe Bs & WARREN. INC..�PUBL'6S14ERS - i - -6 r 'r. � .. _• E a A� '' �r 1 ` )1 1 / TOWN OF BARNSTABLE LOCATION ., SEWAGE # (?0 -386 VILLAGE ASSESSOR'S MAP & LOT 3 14 INSTALLER'S NAME & PHONE NO. 0C1r14�6rAe-,4, SEPTIC TANK CAPACITY /r000 LEACHING FACILITY:(type) 7 / (sue) ®OCR 60,11. NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� j3ACk o F.. J46(.i 611 w3 '34` � � C� y 4 5' �le�l 3 ((- -37 ' 6ii LOCATION SEWAGE PERMIT NO. VI L LAG E L2s- I N LLER'S NAME & ADDRESS. c /3,qLZ 94 e RIP , BUILDER OR OWNER 0AlE ,. -PERMIT ISSUED DATE C.O-MPLIANCE. ISSUED W a . !,3. •i t 5c1i• //- � � Roes_ Air M) } iOT ° # R C / E LE V. ' TQry !gib . . IS AVAIL$ x Jul/aJ/wtUit/! 3 ul/^DIIVG S E770, C� �EQU�,�E.ME.I/T� �C A 'L,,.. F"2�N T Si DE, T2C ' ,t �! 0Z 50J�l�'O FP0 5D SE'P T/C 5 Y5'Tl�M COA/S T2 UC T,/ON E S14A 4-4 CONFO1zA4 TO MA 55 • Ue-S/G AJ PL 0 GV GAL! hA Y 'r ENVJQO�a/MGn/T [,. Co�E TiTL,E:�T . _ C/ 4 E A CAI J2,A TE ��� M/A� / ' /VCN , 7"PP OF yE,�1LTiy T��6G/L,47`/c'dN ;. a"g ,= OTTOM MAN�,(QE.E. GCS✓Ej2 TO Er}�7-E^12> 7'0 /MPC2✓/OU5 coVE12 a n TO P2E✓EA/7" �/h/,--S. R WIJ A4/A/'. / OFAT/it/6 f f &4 GO✓r s ,� 5 / f 57"O.vE. �I.11105� D/ST. , , � '? 3:43 Q R1 . 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