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HomeMy WebLinkAbout0201 ASA MEIGS ROAD - Health 201 Asa,MeigsRoad' Marstois Mills P - A.= 030 070 \� i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS > d DEPARTMENT OF ENVIRONMENTAL PROTECTION v� V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION O T O: Property Address: #201 Asa Meies Road PARCEL,LOT Marston Mills,MA Owner's Name: Heinz Sindt Owner's Address: 201 Asa Mews Road RECEIVE[) Marston Mills,MA Date of Inspection: 12/12/02 DEC 2 p 2002 Name of Inspector: (please print) Mr. Carmen E.Shay Company Name: Shav EnvironmentalDE PT. Services,Inc. TOWiv ;yDE i HEALTH PT.. Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT 1 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: XX Passes Conditionally Passes Needs Further Evaluation b the Local Approving Authori Y PP g '�v �. Fails CA iE > E. Inspector's Signature: Date: 12/12/02 S 0 FATIF�E a� The system inspector shall submit a copy of this inspection report to a Approving Authority(Board of DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1F�1 ` gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments No liquid in original leach pit and no evidence of back-up into d-box from SAS. ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #201 Asa Meies Road Marston Mills, MA Owner: Heinz Sindt Date of Inspection: 12/12/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles G Incnontinn P^— All si10nn 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #201 Asa Meies Road Marston Mills.MA Owner: Heinz Sindt Date of Inspection: 12/12/02 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 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: T41. 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #201 Asa Meigs Road Marston Mills,MA Owner: Heinz Sindt Date of Inspection: 12/12/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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—IWPA)or a mapped Zone 11 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. Title C i—.,ti— 17-- 411 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #201 Asa Meies Road Marston Mills,MA Owner: Heinz Sindt Date of Inspection: 12/12/02 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks ? XX _ Has the system received normal flows in the previous two week period ? XX Have large volumes of water been introduced to the system recently or as part of this inspection? XX _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up XX _ Was the site inspected for signs of break out? XX _ Were all system components,excluding the SAS, located on site? XX _ 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 ? XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems 9 The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no XX _ Existing information. For example, a plan at the Board of Health. XX _ 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)] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS Trio c i—.. t; " P- 411 5 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #201 Asa Meies Road Marston Mills,MA Owner: Heinz Sindt Date of Inspection: 12/12/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 330 Number of current residents: 2 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): Seasonal use: (yes or no): no Water meter readings, if available(last 2 years usage(gpd): Sump pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL 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: None on File Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1994-per Board of Health &Owner Records Were sewage odors detected when arriving at the site(yes or no): No Titles C lncn t;n 17- 411 ci)nnn 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #201 Asa Meies Road Marston Mills,MA Owner: Heinz Sindt Date of Inspection: 12/12/02 BUILDING SEWER(locate on site plan) Depth below grade:_16" Materials of construction: XX cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 9" Material of construction: XX 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: 5' deep x 5'wide by 8' lone (1,000 gallon) Sludge depth: 4. 75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: 2" Scum Laver Noted Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Structural integrity of tank was ok. No evidence of cracks,leaks,or water infiltration/exfiltration PVC Inlet tee present and in good condition. Outlet Tee installed at time of inspection. Liquid level equal with outlet invert Needs Pumping GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): T;t1. c Ino-6— P,.r.., Al �;nnnn 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: #201 Asa Meigs Road Marston Mills,MA Owner: Heinz Sindt Date of Inspection: 12/12/02 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_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: Present (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): 2—outlets—one to original leach pit and one to new trench installed in 1994. No evidence of backup or surcharging. Re-adjusted speed leveler so that some flow would be directed to leach pit 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, etch_ T:*iA Incnorr nn �,,, �ii ci�nnn 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #201 Asa Meies Road Marston Mills.MA Owner: Heinz Sindt Date of Inspection: 12/12/02 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX leaching pits, number: 1 —6' deep x 6' diam. leaching chambers, number: leaching galleries, number: XX leaching trenches, number, length: 1 Trench with 3-infiltrators 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.): No evidence of hydraulic failure, pondine damp soil or stressed vegetation. Excavated access cover of leachnppit and noted NO liquid in pit. New SAS Trench is 3.5 feet to top — no access port Riser present for pit. 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 or 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.): T41. 1; Incnar* ,., Pr.,, 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #201 Asa Mei2s Road Marston Mills.MA Owner: Heinz Sindt Date of Inspection: 12/12/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Swine Ties: A- Tank In—30.5' B- Tank In— 16' A—D-Box—39.5' B—D-Box—30' A—Leach Trench Cover—54' B—Leach Trench Cover—28' Exist. House B A Septic Tank Q (1500 Gal.) O D-Box lo O Water Line i Leach Trench Tula G l.+cnartinn Fnr.n lii ci�nnn Bennets Neck Drivel0 Page l l of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #201 Asa MeiEs Road Marston Mills.MA Owner: Heinz Sindt Date of Inspection: 12/12/02 SITE EXAM Slope Surface water - None Check cellar -Yes Shallow wells—None Estimated depth to ground water 35 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: XX 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) XX Accessed USGS database-explain: You must describe how you established the high ground water elevation: Checked with Ouadrangle of USGS Map-No evidence of any liquid in leach pit which is 9 feet to bottom from grade. Per Barnstable GIS: Elev. of Ground=102.5Feet Elev. Of Groundwater=55 Feet Elev. Of Bottom of Leach Pit=93.5Feet Therefore: 93.5—55 =38.50 feet separation between Bottom of Leach Pit and Groundwater. Groundwater Adjustment using Index Well SDW253: 8.8 feet Adjusted Groundwater Separation=55' + 8.8=63.8' feet (Refer to attached work sheet) Grade= Elev. 102.5 feet Leach Pit Bottom of Leach Pit=Elev. 93.5 feet 1,000 gallon Tank Adj. Groundwater=Elev. 63.8 Feet T;tlo G Incnart�nn �'nrm ail�r�nnn I 1 Permit Number: Date: I Completed by: HIGH GROUNDWATER LEVEL COMPUTATION I 1 l i Site Location'': ,�,, � RSiE ' Q\�S�d— M M1�\5 Lot No. Owner: i\\ckfl � S1 t'ik Address: `J At-ky, Contractor: 6!� f1l). Address: Cons Z• �� M���1• ^� Notes: O0L6uJ� �cr�utn d = to z S i I STEP 1 Measure depth to water table to nearest 1/10 h. t I.............................................................................. Date �a I month! +v/v +r i ' I STEP 2 Using Water-Level Range Zone I and Index Well Map locate site and determine: w OA Appropriate index well.................................................... SO © Water level range zone ..................................................... I I t STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... ' moot Y++r j STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water level zone (STEP 2B) t determine water-level adjustment .......................................................................................... I STEP 5 Estimate depth to high water by subtracting the water• i level adjustment (STEP 4) i from measured depth to water level at site (STEP 1) ................................................. ........................... 3' I i i i I I I I I Cape Cod Commission: USGS Well Data -November 2002 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information, please contact Hydrolo ist Gabrielle_Belfit at the Commission offices (508-362- 3828). November 2002 I.ISGS Site Departure from Number' Location Well No. Water Record Record Average" ` ' Level* High* Low* g (Links to LSGS Monthly Overall national water-level database) Barnstable 230 25.6 20.5 26.6 -l.l -1.9 413956070164301 Barnstable 24W 27.4 20.5 28.6 -2.2 -2.9 414154070165001_ Brewster BMW 21 13.4*** 6.9 13.6 -2.6 -3.2 414518070020301. Chatham CGW 138 25.4 20.9 26.6 -0.8 -1.4 414100070011101 Mashpee MIW 29 9.2 5.6 10.0 0.0 -0.6 �413525070291904 Sandwich ZDZ 47.8 45.9 48.2 -0.2 -0.5 414418070241601 Sandwich 2DW 54.6 45.8 55.1 -3.8 -4.5 414124070265901 Truro 1TSW 89 12.1 10.2 13.0 0.1 -0.1 420206070045901 Wellfleet W?W 12.2 7.3 12.8 -1.1 -1.7 415353069585401 http://www.capecodcommission.org/wells.htm 12/11/2002 TOWN OF BARNSTABLE LOCATION 41,54 Ai%/" SEWAGE # VILLAGE4 C,,0110,19 /NJ'�/5 ASSESSOR'S MAP & LOT03 p `70 INSTALLER'S NAME PHONE NO. Yf� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /h l.1 G,�f,� J� size) NO. OF BEDROOMS '? PRIVATE WELL OR 14 PUBLIC WATER ga/ "BUILDER OR OWNER DATE PERMIT ISSUED:` °7-- /g y . e x .DA:TE -COMP.LI'ANCE ISSUED: VARIANCE GRANTED: Yes No �/ i VVV ` 3 �i Z Dv0 �7L THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Aliptiration for Divi-pitial Wor1w Tutuitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: AAA /Zr .....p�C?.1..._./ .1` . ..---- r ._._..... ...- ---�----------------------•---------•-- ocatton-i\ddress or Lot No. , 'iyo�T wn Address W � Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms------------------------------ - - _Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' 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 ( ) 0-4 s Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------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........................ --------------------- ....................................................................................................................................... 0 Description of Soil........................................................................................................................................................................ x U -----------------------------------•------•-------------------------------------------------------------------------------------------------------•-------------------------...-------•----------. W ---------------- ------------------------------------------------------------- -------------- --- U Na ure f Re airs or Alterations—Answer he a licable. ._ - U P PP 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 Compli ce as been issued by the board of health. Signed ----- -n------I--------------- Date Application Approved By ----------- -� - .... ..__ _......._------------------------- Date Application Disapproved for the following rearons- --------------------------------------------------------------------------------------------------------------------------------- ---------- ------------------------------------------------------------------- ----------------- ------------------------------------------------------------------------- qQ Date PermitNo. ....: ...L. ....................... Issued ........................................................ Date R �3v C170 FRs....13.�2.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratilan for Di-tipm3al ldnrbi Towitrur#iun rrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..... 1....�1.�_/....... i .......Z. ..........AAA-------------------•----...t... ovation-Address or Lot No. fOwn i Address f Installer Address UType of Building Size Lot............................Sq. feet ,., Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder (- ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons 1:4 Septic Tank—Liquid capac>tv_-___--___-gallons Length---------------- Width................ Diameter-:----_-.--_--_ Depth___-- : W 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. I................minutes per inch Depth of Test Pit__---____-___--__-_ Depth to ground water...................... G1t Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ p4 ....••-•---•----------------••-•--•••------•-------------------••-•••-••......•-•---........•--_............................................................. 0 Description of Soil............................................................................... -----------------------------------------•------------------••-•••-•-------------- W U •-•••-•••-•-----••••---•-••--•---•-••••••-••-•-•-•--•--••-•-------••--•-----•----•--•----•--•-•-------•-•-•----•----•------•------------•--------------•-•-------•---•-•--••-----•-•----•--------------- W --------------• --------•-••-•--•---••-- UNature of Repairs or Alterations—Answer he applicable.. ... ... ...................... ..... .;t.l.`.l... ---------------------; _._._._....... -•-•A�� U•--- --•-•4.... . -•---------.................-•-• ............................... 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 Complian j as been issued by the board of health. Signed ...... ...........'....... ......A...k.............. Date Application Approved By ........... - ....... ......`f.4a...�...�4/ Dace Application Disapproved for the following rearonf- ----------- ----------------------------------------------------------------------------------------------------------------------- ......... ......... ...................... . ............ .._.................... . . ....... .............. . ................. ....................-------------------- e� Date Permit No. ----- ......................... Issued .............. . Date _______________ —_,—____, ._.—_._-_._,_—___._____� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ITErtifirate of CZnm li�tncE THI,�IS Lz� TIF , That the In ividual Sewage Disposal System constructed ( ) or Repaired by .... .. Ate?� fir c `'b--- - t- ---------------------------------- -------e ......................_ ......... . .. .......... .. .... Instaue has been installed in accordance with the provisions of TITLE 5gqo.f The State Environmental Code as described in the application for Disposal Works Construction Permit No. .._...1.-. ..^.. .�j_..2._. dated _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. per/ TE 1...... .._. ... •��...._. Inspector .. .. ...... . -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��pp gg TOWN OF BARNSTABLE :, No..`7.. ..L .l... FEE. n..�... �t��n�ttl nr�� �un��r�r#Uan Prmi� Permission is hereby granted----- -- ........................................................ to Construct ( ) or Repair ( n�`Individual Sewage Disposal System atNo........ •••--• l ..5 .......ttlt-- ..................-1,U - f---------------------------------------------------------------------------- G_ Q yr3�� as shown on the application for Disposal Works Construction Permit No.ff//___________ ___ Dated-_---__.- ._^_.�. ... _.... .......................................... = ------------------------------------------- ` o Board of Health DATE.................. J_C_5..�/-!�/•-••-----•••--•--------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS