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HomeMy WebLinkAbout0025 BLUEBERRY LANE - Health FBlueberry Lane 'Marstons Mills A= 102 105 rr TOWN OF BARNSTABLE LOCATION 2 5 91 ve be rr! L i.1 SEWAGE# -VILLAGE BARS'tbMS µ, 1 S ASSESSOR'S MAP&PARCEL / Oa 4S NAME&PHONE NO. SEPTIC TANK CAPACITY `bp O !S.,.kko N LEACHING FACILITY:(type) p .- (size) QA�Jw W Bbt l NO. OF BEDROOMS Z . OWNER (ArMC."PERMIT DATE: TE: 3'- S'-a 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 21 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 r' within 300 feet of leaching facility) Feet FURNISHED BY Blueberry Lane ' T C 25 Blueberry lane a Marstons Mills, MA 02646 a i Rear of House A B fI O 1000 Gallon ��[''' 1-2 B I-3 O 1 Septic Tank �A 2-28' 2-36' 2 3-39, 3-51' D-Box I O 3 6' (R=6') Leach Pit w/ estimate 3' stone Commonwealth of Massachusetts Title 5 Official Mspecti n Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or=on the-official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification 7a Important: When filling out 1. Property Information: forms on the computer,use 25 Blueberry Lane, Marstons Mills, MA 02648 only the tab key Property Address to move your Armand Bianco cursor-do not use the return Owner's Name key. 20 Epping St Owner's Address Weymouth MA 02189 Cityrrown State Zip Code Date.of Inspection: 03/15/07 Date 2. Inspector. Mike Hudson Name of Inspector Septic-wiz Environmental Services Company Name 31 Midway Dr Company Address Centerville MA 02632 City/Town. State Zip Code 508-367-5669 Telephone Number. l Certification Statement: - 1 ` 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. 1 am a DEP approved system inspector pursuant 6;Section'l5.340of Title 5(310 CMR 15.000).The system: 'jm f � ® Passes El Conditionally .Fai9s Conditionally Passes ❑ Need Further Eval tion by the Local Approving Authority { 03/26/07 Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector 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. ****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.- 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 �1 Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N A. Certification (cont.) 25 Blueberry Lane Property Address Marstons Mills Ma 02648 Cityrrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found 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: 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official lnspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 Citylrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection I B) System Conditionally Passes(cont.): lY ❑ 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: 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 25 Blueberry!Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official pnspecti®n Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cant.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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: 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 ®fficW Mspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State ZipCode Bianco 03/15/07 Owner's Name Date of Inspection 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 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. 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts v Title 5 Official lnspectlon Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection gift 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. 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form B. Checklist 25 Blueberry Lane Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection 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(3)(b)] 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official ��s�ecto®� �®�� Not for Voluntary Assessments Subsurface Sewage Disposal System. Form ' M C. System Information 25 Blueberry Lane Property.Address: Marstons Mills MA 02648 Cityrrown. State- Zip Code Bianco 03/15/07 Owner's Name Date of Inspection Residential-Flow Conditions: Number of bedrooms(design):. 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 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 years usage(gpd)): 2005-112 GPD 2006-134 GPD Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate 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): 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Water Pollution Control-no records Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons gallons How was quantity pumped determined? VIA Pumping Company Reason for pumping: excessive sledge and scum levels Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 19 years old, installed 1988 via as-built on file at Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Mspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form iG M C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): PVC pipe in good condition, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 17"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N?A years Is age confirmed by a,Certificate of Compliance? (attach a copy of ❑ Yes ® No certificate) Dimensions: 8'6"Lx4'10"Wx5'8"H - 1000 gallon Sludge depth: 34"(4'thickness) Distance from top of sludge to bottom of outlet tee or baffle 6"above bottom of outlet Scum thickness- 20" Distance from top of scum to top of outlet tee or baffle even w/top of outlet Distance-from-bottom of scum to bottom of outlet tee or baffle 6" How were dimensions determined? measured stick w/rag, stick w/ flapper, tape, floodlight 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping every 3 years, inlet and outlet tees in good condition, tank appears structurally sound, liquid levels normal, no evidence of leakage, due to non-conforming excessive sludge and scum at time of inspection system required pumping as part of inspection 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): 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection [dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 Citylrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection �rr Tight or Holding Tank(cont.) IV , 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.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even w/outlet 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.): D-box is level, 1 outlet w/effluent level normal, no solids or carryover, no evidence of leakage in or out of d-box, stain line indicates effluent was above outlet pipe at some point in time due to a clog or overloaded sas, pipe was clear from d-box to sas at time of inspection and levels were normal. 1t� Pump Chamber(locate on site plan): l� Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 ®fFicW inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection 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: (1)6'R-est. 3' stone around ❑ 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.): loamy to medium sand, liquid level 1.7' below inlet invert at time of inspection, stain line even w/ invert in indicates liquid levels in sas were at max capacity at some point in time, no ponding, damp soil or abnormally lush vegetation at time of inspection. 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection 1(y Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): !�V 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.): IU.' Privy (locate on site plan): �l Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Pnspecticn Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Bianco 03/15/07 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. IWBtueberr y Lane d 25 Blueberry lane 3 Marstons Mitts, MA 02648 > L A Rear of House A B O 1000 Gallon A 1-25' B .1-21' 1 Septic Tank 2-28' 12-36, 2 3-39' 3-51' D-Box O 3 6' (R=6') Leach Pit w/ estimate 3' stone 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N C. System Information (cont.) 25 Blueberry Lane Property Address Marstons Mills MA 02648 City/Town State Zip-Code Bianco 03/15/07 Owner's Name Date of Inspection Site Exam: Slope 4 ?, i Surface water 10u' 1-31� Check cellar cv-c'_�t 5 p — Shallow wells tj l N Estimated depth to ground water: o ` 4— 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: reviewed as-built ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS topographic and water resource maps You must describe how you established the high ground water elevation: Reviewed USGS topographic map and water resource map, google earth satelite map. Site elevation 72 ngvd, nearest open water elevation 43'. Distance to water table 29' below sas. 25 Blueberry Lane-T5 Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE LOCATION ��t1C�� 4 SEWAGE. # VILLAGEZ e . t�l.�' ASSESSOR'S MAP.& LOT 1 ' INSTALLER'S NAME & PHONE NO. 6QQ5; 16L© SEPTIC TANK CAPACITY /f)o0 ,-),,41 t ( � LEACHING FACILITY:(type)` 1"s size) e NO, OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 1949 AN14C S�' BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:_ VARIANCE GRANTED: Yes No b� 741 I �t4 --7 TOWN OF BARNSTABLE LOCATION V�cJC SEWAGEc _ VILLAGE/Y4t2/J1 IY1t`k ASSESSOR'S MAP AZ LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 1000 Qo4l LEACHING FACILITY:(type) 7- (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER_ /99•(Alg S sr BUILDER OR OWNER R/21VoXJD :31 4) DATE PERMIT ISSUED: — //— S DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes _�NO--�� f4 o us—e- d C I / NN" i ' � � Zm3go.21!........... THE COMMONWEALTH orMAsaAo*uscrrs ���~��� �� HEALTH ^� -��n� ��=° " " "��" ^�� " " " //J � �� �~~ ' / ~ ----'��F-� ..... ..... .................................. ' ' -l � �� �m � for ��^ ���°� Works ��� ���� 1hrutit \'- Application is hereby made for u Permit to Construct ( ) or Repair /�^� an Individual Sewage Disposal ^ ` �- o��� ' _=�^~_~~�~�-__' _-'----- ---_-'-'--'_---_-'-_'--_----'----------- ;In-Address or Lot No. Y �.................................. --------------'���n��u.YE............................................ m.~= Address .............. ----------------------' ........................ 9 )'.0.x^ja aH................................... Installer Address Type cfBuilding Size l.oL---------'----Sn' feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type /f Building ............................ No. ufy«r000x----------.- Showers ( ) -- Cafeteria ( ) P4Other fixtures ---.---.-----_---------------------'------..---------------------------- ' Design Flow.............................................Dulooa per person per day. Total daily flow............................................ . Septic Tank—Liquid capacity............gu}ooa Length................ Width................ Diameter---------------- Depth................ Disposal Trench--No. ---------' Width.................... Total I.co0tb'-.-----.-' Total bocbioQ area....................sq. 8. Seepage Pit No..................... Diaoetcr-----.--- I]cotb belm~ inlot---------- Totu area.--------'ml. ft. Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test Results Performed bv.......................................................................... Date........................................ Teat Pit No. l................nioutesperincb Depth of Test Pit.................... Depth to ground water........................ Test I`b No. 2................minutes per inch Depth of Test Pd..--------- Depth toground wuter.---------.. -, --..--.-'_-'__-_-'-__--'-__'----'_-----------'---------'--'----_-_-_ 0 Description c65oil- --------------'-------------------_---------------------------------_ ---```--------'---'----------------------------`---`-`--'---------'-----`--`-----`-'------` U Nature of Repairs or Alterations—Answe�wh li bl /79M---- -----'----------''---'-'---------- � Agreement:� � The undersigned agrees to install theuforedescribed Individual Sewage Disposal System in accordance with the provisions ofIlI1E 5of the State 5uoitucv Cod The undersigned further agrees not to place the system in operation until a Certificate ofEl b Signed—..... ---------~----- --.......... -�r-�a e '----- 8ppbcaboo Approved uy------ '- -------------------------------- --------------------- Application Disapproved for the following reasons:.............................................................................................................. _-_--_._---_�_����_��� ��� ______._---______ � oat" Permit No................-....... . • Fims............._............ . THE COMMONWEALTH OF MASSACHUSETTS BOA OF HEALTH G.�. ..............OF... .--'"r��U � ................................... Apphratiun for Disposal Works Tonotrurtion rrrutit Application is hereby made for a Permit to Construct ( ) or Repair K an Individual Sewage Disposal Sysle5aat: i atipn Address or Lot No. !� Owner /^, Address ........................ a ....._... - • 41-S.f f.. ............................................. . ........................... ...•-•- Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) �'4 Other—Type T e of Building ....... No. of persons............................ Showers yP g ..................•-- P ( ) — Cafeteria ( ) P4Other 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 ( ) I-•I Percolation Test Results Performed by.......................................................................... Date........................................ aTest 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........................ fYi �-• ----- .................. ------ ---------------------- D Description of Soi1... F'l .r ................. V .....--••-----•------•-----------------•-•...-•--••--•----------•-----•-•-•----•--------••••••-----..._...-•------------••-••---••--••--------. . ..---•--......-•----••-•------..............--.•---- W ................-............................................................................................ - .................... U Nature of Repairs or Alterations—Answer w en applicable....� .� i �-._._�� .�.� _- 'r ?T�. ............... � `/� 2. I OF � t , . '--------------------------------------------------------------------------•-----------.... Agreement: ty The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code,,,,=The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i(su by the bg7axd/ofhth. Signed...... -• ! �`� •Lr..r.. ....-----.-•. .ate Application Approved By-----------b..�-u�..... sa.t ........................................ Date Application Disapproved for the following reasons:............................................................................................................ .......••••.........--••••---•-•--••••••-••-••--•-••••---•---....•--...••--•------•--•-••-----••••••-------••••••••..............•--•---•---••............-----•----•---•-......•---.................... Date PermitNo......................................................_ Issued-....................................................._ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1....4...l. . 1...........OF......... 1$'- .....:.....C-'........................ (Irrtifiratp of Tautpliana THIS IS Tog, RTIFY, Piq the I ividual!S age Disposal System constructed ( ) or Repaired at...... �r.._t61:C __ •. -Q�yl --•---. g-aii .? �.j.1C.../....:-Pkt� .............. .........._-:-- .. has been installed in accordance wit he provisions of TITIFg 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......... .... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. )__10 DATE..----------•---•-----•-•-... -. -._'9%......----•.................... Inspector................... ..........---------.......---------......--••-•--- THE COMMONWEALTH OF MASSACHUSETTS BOA OF HEALTH � .1 ....I............O F..3e9,1r21.&))j � .��................................ No........................ Fla$.l..(S.).......... aiup,auttl P 11Mtr iun utit Permission is hereby granted.............--..............._4.. . C/I.._ �,.... �-- ......._.... to Construct��^ ) �Or epair (�n Indivi Se ge Dispo System at No.. Street as shown on the application for DisposaKorks Construction Permit No..................... Dated.......................................... -------------------------------- �4-=)------------- .......... DATE.--•-••-••----- <3�' I/._ d. ....................................... Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON Esc /JJE ALL_ r)-i v __.. ID Ic �x8 PT L�lDX,- Yx 6 P.T Po P.j. DEGI< - ND FAIN yS • i ',.\ 1. ..._ R'T y U I Q�-L v.w. c. 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