HomeMy WebLinkAbout0023 DEER HOLLOW ROAD - Health 23 DEER HOLLOW ;MARST.MHLS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
J 5[5 TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: oP-J Dee,— \4o lcto t�
Owner's Name: \4LO cme ny 7!7
toco
Owner's Address: c-n r
Date of Inspection: _/ "J -- �, /� oZ.oc, a 2.n
Name of Inspector:(Please print) iam F._ . Robinson Sr, r-n r-
Company Name: William E. Robinson Septic Service to
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number: ( 508) 775-8776
CERTIFICATION STATEMENT
1 certify that 1 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 Se ion 15.340 of Title 5(310 C111R 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: „ Date: T
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth•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 off ice'of ilte
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
1
Notes and Comments
""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.
V
Title 5 Inspection Form 6/15/2000 page I
r .,:r-
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: k(cw (Z-c ..C]
Owner:
Date or lnspectloos
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. :�I'�havc
Passes:
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 stem,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no o not determined(Y,N,ND)in the for the following � •.owing statements.If `not determined
ex lain. - please
P
The septic is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits su stantial infiltration or exfiltration or tank failure is imminent.System
existing tank is repla ed with a complyings tic Y m will Pass inspection if the
'A metal septic tartk� ill pass inspetion if it its structurally sound,not leaki g and if a Certificate of
indicating that the is less than 20 years old is available: Compliance
ND explain:
Observation f sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board o Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system equired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if( ith approval of the Doard of Health):
broken pipes)are replaced
obstruction is removed
ND explain:
Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �3 2� 00\lc� \�C)c�Ll
Owner,--
Date of Inspection:
C. Fu er Evaluation is Required by the Board of Health:
Cond ions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to pr tect public health,safety or the environment.
1. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is of functioning in a manner which will protect public health,safety,and the environment:
_ Cesslf of or privy is within 50 feet of a surface water
_ CessF of or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System wi 1 fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is.func Toning in a manner that protects the public health,safety and environment:
_ The }stem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface ater supply or tributary to a surface water supply.
e system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
he system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
Th system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fronl a
private ter supply well•• Method used to determine distance
"This sy em passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria an volatile organic compounds indicates that the well is free from pollution from that facility and
the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crit da are triggered.A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: o�3�eet'
Owner: '4UOA
Date of Inspection: 13 G
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes o
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
iquid depth in cesspool is less than 6"below invert or available volume is less than day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface
•ater supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
y 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 uatrr
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 (lie presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are(riggered.A copy of the analysis must be attached to this form.]
Yes/No)The system fails. 1 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. La ge Systems:
To be c sidered a large system the system must serve,a facility with a design flow of 10,000 gpd to 15,000
. gpd
You must dicate either"yes"or"no"to each of the following:
(Tlte folio ing criteria apply to large systems in addition to the criteria above)
yes no
_ — th system is within 400 feet of a surface drinking water supply
_ _ th system is within 200 feet of a tributary to a surface drinking water supply
_ — th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zo a II of a public water supply well
If you have a iswercd"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Secl ion D above the large system has fined.The vwMer or operator of airy large system considered a
significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The s • tem owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:o� b2pr W'(c5vj Zcck-C—A
ST—
Owner: Vme.
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes �o
Pumping information was provided by the owner,occupant,or Board of Health
tI/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?
�(-,IA 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:
Yes no
xtsting information.For example,a plan at the Board of Health.
_jl_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b))
5
Page 6 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION
Property Address:,-�3 t&CA
lS
� Owner: ����
Date of Inspection:
FLOW.CONDITIONS
RESIDENTIAL
Number of bedrooms(design):,- Number of bedrooms(actual)_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_
Number of current residents:•
Does residence have a garbage grinder(yes or no):0
Is laundry on a separate sewage system(yes or no): & 0[if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no).j�Q
Water meter readings,if available,(last 2 years usage(gpd)): o2CD_)" �19L�, 00,0
Sump pump(yes or no): /0 (a _ 5("' 00
Last date of occupancy:
COMMERCIAL/INDU TRIAL
Type of establishment:
Design flow(based on 10 CMR 15.203): gpd
Basis of design flow( ats/persons/sgft,etc.):
Grease trap present( s or no):—
Industrial waste hol ng tarilc present(yes or no):—
Non-sanitary waste ischarged to the Title 5 system(yes or no):_
Water meter read' gs,if available:
Last date of occu ancy/use:
OTHER(descri e):
GENERAL INFORMATION
Pumping Records
Source of information.
Was system pumped as part f the inspection(yes or no): i�/
If yes,volume pumped:_gallons•-How was quantity pumped deterniined?
Reason for pumping:
TYPPbF SYSTEM
eptic 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:
/`f, �l
Were sewage odors detected when arriving,at the site(yes or no):
6
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1%%c -1 of I 1
OFFICIAL 1NSl'I:CTION FORAM — NOT FOR VOLUNTARV ASSLSSNI.LNTS
SUBSURFACE SEWAGE DISPOSAL SYSTEN11NSITIC '(ON F0101
1'ART C
SYS•I•M INFORMATION (contumcd)
Property Addreu:93—Otaec-
N"Q.+1•S S del� \(S
0ssncr:
Datc of impcctlow _ kt'5-65
r
BUILDING SE\V 'It(locate oilsite plan)
DcpUI below gr c:
Malerials or co struction:_cast irun _4U PVC_uUter(explain):
Distance from rrIvalc slater supple well of suction line:_
Comments(u condition of joints,Venting,evidence of Icakagc,etc.):
SEPTIC TANK: (locate un site plan
Depth below graJc: )t,41
h1attrial of Construction: micrctc metal—fiberglass�polpcUtylcne
utltcr(cxplain) — —
If lank is metal list age:_ Is age cunfumed b}'a Certificate u(Compliance files or nu):__ (attach a Cupp of
ccrlificalc) p -
Dimensions:
Sludge depth: �r
Distance front toil of sludge to buttunt of outlet Ice or bafllc: 0r 0 Scwn thickness: I—3
Distance from top of scum to lop of outlet tee or bafllc: d
Distance Gorn button,of scum to bunum of uutlu Ice or bafllc: d 1,
I Ions•were Jimtn n
sions JctcnincJ:
Cununcnts(on pumping rcconuucnd"Gons, inlcl and outici tcc or bafllc condition, structwal inlcbritp,liquid levels
as related to outlet urvul,es•idence of leakage,a C.):
GREASE TRAP: loucatc un site plan)
DcPlh bclosv graJc:
Matuial of eonstru tion:_tuncrelc Inctal lIbcrgla�ss__pul)-cihplcnc _other
(explain): _
Dimcnsions:
Scum tllickncss.
Distance from op of scull,Iu Cup of uutict tee or bafllc:_
Distance &on bottom of scum to button,of uutict Ice or bafllc:.
Dalc of last umping:
Cununcnts on pumping rcconuncndattons,inlet and uutict tcc or bafllc cunditiva,sUuctulal inlcgritp, IiyuiJ IcVCI,
as iclalcd o oulici instil,csidcl,(c of Icakagc,cic.):
7
la c
6 S of I I
OFFICIAL 1NSPEC-FION FORTH - NOT FO1t VOLUN'I'AIZI' nSSL:S5NI LN"fS
SUUSUIWACI; SEWAGE DISPOSAL SYSTEM INSI'F,CTION FORt\1
PAIIT C
SYYFL M 1NFORAIATION(cuntinucd)
Properly Address:
Owner:
Dale of Inspcclloo: � )
TIGHT or HOLDING ANK:_(tailk ,just be pumped at lime of inspection)(lucate un site plan)
Dcpth below grade:
Material of eonstrucli n: concrete_let (ibcrglass wlyelhylcne_011ie r,(explain):
Dimensions:
Capacily: alluns
Design Flow; galluns/Jay
Alarm present(yes r no):
Alwn level; Alarm in svorkin• urdcr
Dale of lass pump tg: 6 V'cs or nv):
Cununcnts(con tivn of alarm and float swilchcs,etc.):
DISTI(IBUTION BOX: (ifprescnl must be opcncd)(locale on site plan)
Deplb of liquid level above outlet invert:
Comnscrrts(note if box is level and distributiuo �cts c�equal,an cvid r
Icakayc into or out of box,ctc.): I } c rcc of Solids carr)•os•cr,ally cvidcnce of
7-
I CHAAI Il:,—,_(locate on site plan)
1'unyss in" g order(ycs or
no):_
Alarms in+s.o ing or
(yes ur no):
Cununenls(r Ie eondilion of pump t haulber,cunJitiun of pumps and ;immienances, etc.):
Page 9 of 11'
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:o�3Zi �(` ��01c7s
Owner
Date of Inspection: ' `
SOIL ABSORPTION SYSTEM(SAS): lz (locate on site plan,excavation not required)
If SAS not located explain why:
Typ
Ica pits,number: �.
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.): /
CESSPOOLS: (ce pool must be pumped as part of inspection)(locate on site plan)
Number and configura ion:
Depth—top of liquid o inlet invert:
Depth of solids layer
Depth of scum laye .
Dimensions of ces ool:
Materials of cons, ction:
Indication of gro dwater inflow(yes or no):
Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIM': (I Cate on site plan) —
Materials of c nstruction:
Dimensions:
Depth of solids:
Comments ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
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Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 03 ( t-b�lCY10RCCI(_� _
Owner: \1ec-ove".e-
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.
LA)
y3
f
•-3 7 J
3 �.
C). CJ
67_
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Page 11 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address:'Tttl o�'tn- lZ C coO
.`l
Owner. U
Date.of Inspection: cc g
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water a�_L feet
Please indicate(check)all methods used to determine the high ground water elevation:
tamed from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: f.
You must describe how you established the high ground water elevation:
` 11
Il_
i 4 \ S a S d-i e e���iooC • ad dcel�
Joseph D. Gibson �,, `'s�` ��� ` �99y 7 I too li
Title V Septic Inspector +`' - �`G" � h%� 110-V °-G� a.G� J KJ
GN'�`}�O-►.A.ti�1-1 0+1� e- 0}2�t 0 � art nil vwS- r,
866 Newtown Road
Marstons Mills, MA 02648 C,)O 4Z"' s L4,
� w`^-,(�,(�.
508-428-8048
August 18, 1998
To the Barnstable Board of Health
Enclosed please find the Title V report for 23 Deer Hollow Road, Marstons Mills.
Upon the inspection on August 13, 1998, I found the system to be in a failing
condition. I based my decision upon the following factors:
1. Fluid was above the outlet pipe and septic tank.
2. The condition of the soil above the septic tank appeared to have been
soaked with septic matter previously.
3. Soil above the middle pit appeared to have been soaked with septic
matter previously.
4. Owner had told me that at one time 5000 gallons had been pumped out
in 1994.
5. There has been no one living in the house since Nov. 1997,yet the
middle pit had 30" of standing effluent.
6. Auxillary pit that was installed appeared to have pipe higher than
that of middle pit.
7. Garage had full bath and septic pipe could not be located as to where
it would enter before or into septic tank.
8. No distribution box was found.
9. Outflow pipe was jammed against sanitary box.
If you have any questions or need further clarification of these findings, please
don't hesitate to contact me.
COMMONWEALTH OF MASSACHUSETTS
1=1
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
f DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617-292-5500
i
WILLIAM F.WELD " TRUDY COXE
Govemo: �� Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
Q CERTIFICATION
Property Address: -23�D Zj�44l, 1W4#eJ'12W 1t'1 Z 1 Address of Owner:
Date of Inspection: � �/Ya` (If different)
Name of Inspector: •7b,F'O/./ 6Z'�
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: zTaS)V# G /.4
Mailing Address: o ire N6'A,7Aa/iu &Z.
Telephone Number: S—D O.JP Ifle0IF
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
asses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
7 Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A) OV4 PASSES:
I have not found any in or hich indicates that the system violates an ai ure criteria as defined in 310 CMR 75.303.
Any failure criteria not evaluated are in r w.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or system components as described in the "Conditional Pass" section n o be replaced or repaired. The system, upon
completion of lacement or repair, as approved by the Board of H , will pass.
Indicate yes, no, or not determined (Y, N, o Descri o determination in all instances. If"not determined", explain why not.
_ The septic tank is metal a ow rator has provided the system inspector with a copy of a Certificate of
Compliance ed) indicating that the tank was install within twenty (20) years prior to the date of the inspection; or
the is tank, whether or not metal, is cracked, structurally uns shows substantial infiltration or exfiltration, or tank
ailure is imminent. The system will pass inspection if the existing septic to laced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Mww.magnetstate.ma.us/dep
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewag adwp or breakout or high static water level observed in the distribution b is dg'e to broken or obstructed
pipe(s) or a to a broken, settled or uneven distribution box. The system will s inspection if(with approval of the
Board of He ). Describe observations:
broken pipe(s) are replaced
bstruction is removed
di ribution box is levelled or replaced
The system required pum `ng more than four times a year due broken or obstructed pipe(s).'The system will pass
inspection if(with approval f the Board of Health):
broken pi ) are replaced
obstruction is emoved
C) FURTHER EVALUATION IS REQUIRED BY THE BOAR O HEALTH:
Conditions exist which require further evaluation y the card of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF EALTH DETERMI S THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC EALTH AND SAFETY A THE ENVIRONMENT:
Cesspool or privy is withi 50 feet of a surface water
Cesspool or privy is wi in 50 feet of a bordering vegetated we nd or a salt marsh.
2) SYSTEM WILL FAIL UNLESS HE BOARD OF HEALTH(AND PUBLIC WA SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTI ING IN A MANNER THAT PROTECTS THE PUBLI HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The syste has a septic tank and soil absorption system(SAS) and the SAS is ithin 100 feet to a surface water supply or
tributary o a surface water supply.
_ The s tem has a septic tank and soil absorption system and the SAS is within a Z I of a public water supply well.
_ The ystem has a septic tank and soil absorption system and the SAS is within 50 f of a private water supply well.
T system has a septic tank and soil absorption system and the SAS is less than 100 t but 50 feet or more from a
rivate water supply well, unless a well water analysis for coliform bacteria and volatile rganic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen an nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation rot va
3) HER
(revised 04/25/97) tags 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DJ SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
�[ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. ,
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
V/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
✓• Y/ Any portion of a cesspool or privy is within a Zone 1 of a public well.
Y Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coldorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
T Ilowing criteria apply to large systems in addition to the aiteria above:
The system serves cility with a design flow of 10,000 gpd or greater (Large System) a e system is a significant threat to
public health and safety d the environment because one or more of the follow' conditions exist:
Yes No
the system is within 400 feet of a su d ' mg water supply
the system is within 200 feet of nbutary to a su ace water supply
the system is located ' a nitrogen sensitive area(Interim Wellhead Protection -IWPA) or a mapped Zone 11 of a
public water su y well)
The owner or operator any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(zevisod 04/2S/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST ,
Property Address:
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No�
��// .Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
couw ,lor z a c4n ,� .l3oX
All system components, excluding the Soil Absorption System, have t�'een located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: .p.d./bedroom for S.A.S.
Number of bedrooms: 1
Number of current residents:
Garbage grinder(yes or no):-,"
Laundry connected to system (yes or no):w
Seasonal use(yes or no):
I .dam
Water meter readings, if available.(last two (2)year usage (gpd): /{�9
Sump Pump (yes or no):,&L
Last date of occupancy:147
COMMERCIAL/INDUSTRIAL:
Type tablishment:
Design flow: gallonstday
Grease trap present:(y-es-or.no)_
Industrial Waste Holding Tank p?Psent: (yes or no)_
Non-sanitary waste discharged to the Tit a stem: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of oc pancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
444
System pumped as part of inspection: (yes or no)"
If yes, volume pumped: eallons
Reason for pumping:
TYPE OF SYSTEM 0094 Nbi /mac
Septic tank/distribution bo0soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: Oz j 70� "" /1�/�� Ia/T
Sewage odors.detected when arriving at the site: (yes or no)�J
(rovisad 04/25/97) page 5 of 10
L_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
O ner:
Date o ection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other
Distance from private water supply w suction lint:
Diameter
Comments: (co of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader �7N
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: /06 0 GAZCod
Sludge depth: /D —! '1
Distance from top of sludge to bottom of outlet tee or baffle: .�a
Scum thickness: /1
Distance from top of scum to top of outlet tee or baffle: �* �oQ���
Distance from bottom of scum to bottom of outlet tee or baffle:,_
How dimensions were determined: f U/1rJD wI jrne.f
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,.structural
integrity, evidence of leakage, etc.) 7-ms,4V QV^* J' Xai-IN1D AlP1sD DLJAZPIi&
GREAS TRAP:
(locate on ' plan)
Depth below grade:
Material of construction: _c to metal _Fiberglass _Polyethylene xplain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet to affle:
Distance from bottom of scum to bott o outlet tee or baffle:
Date of last pumping:
Comments:
i level lation to outlet invert structural
(recommendati for pumping, condition of inlet and outlet tees or baffles, depth of liquid ,
integrity, evidence of leakage, etc.)
(zwis*d 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
TIGHT OR \ DING TANK: (Tank must be pumped prior to, or at time, of inspect'
(locate on site plan
Depth below grade:
Material of construction: _concrete _ etal _Fiberglass _Polye ene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallon
Alarm Alarm level: m in working order_Yes;_ No
Date of previo ;mping:
Comments. ---
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_ elba .!) Alpj Loewy
r (locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
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, co ition of pumps and appurt oes, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ,
7a ZMY& 2F .A-Wul 41� _ dui �iTJ' /�'l" ex1�
;'da. Inc a&am 8 clo.— ,.fdnlfi:�b _�Ly�n ,Q fia
pj,D�cr abU rnnr E/9t/ pnLj,r spa a o �.�ice�,s v &Ae Rung AQD d uT
.1 N / 9 4f� .�vy �i u/,d-s A Dom 07' 7-Allrr n44
CESSPOOLS: _
(locate on site plan)
Number an nfiguration:
Depth-top of hqw inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow ( must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(locate on si
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hyd ailure, level of ponding, con i i vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
.SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks `
locate all wells within 100' (Locate where public water supply comes into house)
Of
I Ig
� 39
/ooa jUe,(p,) j-_,07c -ItA4' 0VA
q¢
A10 SCAtc)
(revised 04/25/97) Page 9 of 10
----
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM °
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
Depth to Groundwater Feet F-/ldH 661-71N d f 'f4-f
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
of Site (Abutting rope observation hole, basement sump etc.)
Observation ( g P rh',
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
}L,
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
�P of �/Zovw� Es2�✓•�v"' �v y
O��'�i�> �'�aa.✓va✓wr�- its sf
Pir 30 `
This information is available
in alternate format upon request
by contacting DEP's ADA Coordinator
at 617-574-6872
(revised 04/25/97) Page 10 of 10
_ TOWN OF BARNSTABLE V
LO ATIO ' D ,� ,t-1 %� j SEWAGE # 9y V6 (p
VILLAGE zm 4i l uAJ ASSESSOR'S MAP & LOT Cf-?® "��7
INSTALLER'S NAME & PHONE NO. ` t2'C"T1L� dofQ,ST Y-r-Mk
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /9 ,>! (size)
NO. OF BEDROOMS PRIVATE WELL PUBLIC AW TER .
BUILDER ORQT. � �r�' z �►'Y1 /[fve�S ( LA jc-
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Air
3�
rZ
r
:a�s
No.._l. ` - , Fmc...... 0.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Di-nVu3al Work.5 Towitrurt"tun merit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Dis
posal
System at:
jw ✓ Location-ilddrxsss¢ �7`-'C or Lot No.
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling— No. of Bedrooms........--�------------- - - -----Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ............................ No. of ersons--.......................... Showers —
pa., yp g p ( ) Cafeteria ( )
a' Other fixtures ----------------_-.-..-.....-- . .
W Design Flow................. .-------..gallons per person per day. Total daily flow...---..-._s. .�_..................gallons.
WSeptic Tank—Liquid capacity..-.gallons Length................ Width.......--------- Diameter...-- .......... Depth.-....----------
x Disposal Trench—No. .................... Width.................... Total Length..............I...-_ Total leaching area....................sq. ft.
Seepage Pit No......ev�-..... Diameter-----40........ Depth below inlet---..--- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test-Results Performed bY------- ------------------------------------------------------------------ Date..------------------...................
�4
Test Pit No. 1................minutes per inch Depth of Test Pit...-------.--------- Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....--..................
04 ----------------------•-••-•--------•------•--•--------------------------------------------.....---........................................................
0 Description of Soil........................................................................................................................................................................
x
U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
w
x ---------------------------------------------------------------------------------------------------------------------------------------------------------------- ----
U Nature of Repairs or Alterations—Answer when applicable...,A-Q.Q.......�".........J110.0...�?�.�C .......p./-7-..--.
�'`1 ` FAT ( dy4zg D------ �- N --------�--------: KsT'�!-n ......... ..................
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 T
d b e board of health.
Signed —. .................. ....---`-------......... Date
Application Approved B - -----
Application
PP PP Y .............Ke ...-
Disapproved for the following rea.tonr: . ............................... .. . .................. .. ......................
................. . .................................... ... . ................................................ -- ....................................-- ----------------------------------------
Date
Permit No. ------- 4'. ... Issued ...................................................................
Date
L
c, � 3G ' L' � l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiuu for Diayu ial Workii Tomitrurtiun Primit
Application is hereby made for a Permit to Construct( ) or Repair ( )c) an Individual Sewage Disposal
System at:
... .......... .................. ----•-•---•-. ..........--------------------------------
Location-AddrfL s or Lot No.
1�C t
Owner J , Address
Installer ` Address
UType of Building t Size Lot.................... Sq. feet
Dwelling—No. of Bedrooms--------- ----_-_-_------_--------------Expansion Attic ( ) Garbage Grinder ( )
ps Other—Type of Building ---------------------------- No. of persons-_.-_----_-_--------.._--__ Showers ( ) — Cafeteria ( )
Otherfixtures ...................------------- .---- i --: •- ---------------- ---------•------------------•------•--•-•---••-••-•-•-••-•••-
1 r
W Design Flow................... -
_-_.__.-•__--gallons per person per day. Total daily flow............3-3.6...................gallons.
WSeptic Tank—Liquid capacity! -_--gallons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. i
t
Seepage Pit No.----- :�-.-----. Diameter_-__- U....._.. Depth below inlet--------2......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
0.4
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water..................
(Lt Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a ---•--•-•.................•--•••-•---•-•-••--••••••••-••-•...-•--••-•-••----••••••••............••-•.........................................................
0 Description of Soil........................................................................................................................................................................
x
U •.....
w
-------------------------------------------------------------------------------- ------------••-•---- ••-•-----._...---..........-•-------•••......-- ----••-•-••-.
U Nature of Repairs or Alterati/on's—Answer when applicable.-_-,40_Q------•A:'--__.----_1._f).+��� « ........ .�•�_---•.....
/. ......"�--••-•--•---...c�+!!q:�$ �. V Z �-------- x�'S-'-.-' `L=------- ..................
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 Compliant ha bee isss dd by the bo�ard_of health.
Signed .....� -(......(. a......� L — -- /Gj
b .--
(i`------- ----- ` '�................"------- Dare
Application Approved By ............. ,- .....k...�._., . _ - - --.. '.-..(�.. �.'--..
Dare
Application Disapproved for the following reasons: ................... ... ...................... . . .......--............ ..........................
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................
Date
Permit No. .. L-�l. C;�. - ---------------- Issued ----
Date
-----------.--.--,..--.----_.--.—.—.---_--, —.—.--.—_.------_ — --.---_._.---,---.—_.----,-------.--.---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
j (ILErtifira P of Compliaare
THIS IS TO CERTI� That the Individual Sewage Disposal System constructed ( ) or Repaired (� )
by.. - ""` - Uh"'�.La'-----'1.. _ ).v . �-c �---------------------------------------------------------------------
.J Installer -
at ..........................._.............._... ............... % : - Ur..� ------------i/.� -------------- .,.../'1'1 l f..L �----------------
has been.,installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -------f.... V-(--.?.n-------- dated ..-------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
f�
................. . . Inspector . ----— -----------..........................
DATE....... ._�...�� ........�.. ,,...,; -��' -.,. .. ��'�'
------- ----------------------------------------------------------------�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.._ ...........l G FEE-., )(1.`.�.--..
Mopmttl Warkii Tunotrurtiun rrutit
Permission is hereby granted_... .....-�. u. 1------------- ----------------tX" ---------------- -`
to Construct ( ) or Repair idual Sewage Disposal System
c �. "`U�tU� l------ 1 U. k )...........at No. /Jc � • :
Street
as shown on the application for Disposal Works Construction Permit Dated.._.___ f..............
17)
F✓� Board of Health
DATE............-=`••-=•-
FORM 36508 HOBBS et WARREN.INC..PUBLISHERS
i
AS aS�7
Fim ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Dhi-paiittl Work.5 Tunutrnrtiun runtit
Application is hereby made for a Permit to Construct ( ) or Repair 10-e) an Individual Sewage Disposal
System at:
•---•...../...'........................-----------------------------------•-------------------•...... .-----•------••----••----••----...------.......mot-------- ... .....------••-•-----....
J Csf fY Location•.lddress .--- .LAC—
........ - p........... hr
/V/ul/ � t�.
_................. (�K�... C�it/
W (d�!//1 Owner/ . .... -v7- r ss
04
04 Installer Address
Type of Building Size Lot............................Sq. feet
., Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building __________________--_____- No. of persons------------------------.... Showers ( ) — Cafeteria ( )
d Other fixture -._. -------------------------- --------------
�D
W Design Flow................ .......................gallons per person per day. Total daily flow------------ __..___________..._.....__gallons.
WSeptic Tank—Liquid capacity—_ ..gallons Length_____--..__.___ Width-___..___T._-.- Diameter................ Depth___-____-___-._.
x Disposal Trench—No. __._____/...... Width.....? ........ Total Length_.__�...... Total leaching area....................sq. ft.
3 Seepage Pit No_____________________ Diameter.................... Depth below inlet..__.?!!T7. 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........................
fXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.__-___.__---._.______-
a ---------------------•-----------------------------•-------------------•--••--------......----------............................................
•---.........
0 Description of Soil.......................................................................................................................................................................
W
v -----•------------•------•-----•-------•--•-•-•-----------•-•----------------------------------•---------------•••-----------------•--•-------------••--------••---••-•-•-------------••-•----------•--
w
-------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—/Answer whe
-�pplicable..._fN_. ._.....�_._......_..7.._ ..................a ... /X �.!t.4------------------•-•--•-•--••----
f
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 s be n iss e y t board of health.
Signed .......... .. ... ......... .......... ........................... ...... ............ ........
.2VIO19.
Date
Application Approved By ----- -i.�,�+- =�- - ... ........
Dace
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------- ...........-----------------------------
....................... ............................ . ........ . ............ .................................. . -- . .............. . ---------------------------............
PermitNo. .....................�..��..�.....�.......... Issued ....................................................................
Dare
1 _
1 t F YVy
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Uhnpouttl Wurk,i Cfun,itrnr#inn Prrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ('!) an Individual Sewage Disposal
System at:
33
...-•-----------------•------•---•-••-------........._..---•------------........---••-----n-.....-- -•--------------------a-.....--------------------------------------•--.......--------------......--
A Location-t\ddress—,;�3 (�` L.S{tG.L yt /V N' 1�
......................_...................••-•---......---•--..................••.......
Owner. Add r ss
. .. a�.�7 LcG `.7�..
9Q Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures----------------------------------------•----------- ------------------------------------ ----------------•-•---•-•----•-•---------------•-------------
W Design Flow..............��r__.._ . gallons per person per day. Total daily flow-----------`-33v__._.__._..........gallons.
WSeptic Tank—Liquid capacity<Ua-_gallons Length________________ Width__._-._---'-_--_ Diameter--....__..__.... Depth................
x Disposal Trench—No. ---------�...... Width.....__.......... Total Length--__a_)...... Total leaching area....................sq. ft.
3 Seepage Pit No...................... Diameter-------------------- Depth below inlet..... %%___ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..---..................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-................. Depth to ground water........................
9 •-••••-•••-•----------------•••---•-•••-••---------•----•••-••••-•---••••-•-•••••-••------•---...........--------.........-•-•-•-•-•-•--•--•---...-----....--
0 Description of Soil...................................................................................... ----------•-•--------------------------------•----------.........---•---•-...._..
x
V .....••••••••••••-•.....••••-••••••-•-•....•-•-•-----•-••--•--••---------••--••---•- •----------•-••••-•••-•-----•-•••-••-•-••--•---•--••--•----•-•--•-•••••----•-•--•------•••......--•-•-••---•-••••••-
W
x ,------------------;--------------
U Nature of Repairs or Alterations—Answer when applicable__--�[C/5`%ti:L�L__ - -7•. ->C-�, --•_----•--•-•_••.
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 iss ed ,y the board of health.
Signed .........../. ,t....................... � CF __...... ..`s/iG >,y
.................... .............
V Date
ApplicationApproved BY ............. ... ----------------------------------------------................ = /.<...-.. /..
U Date
Application Disapproved for the following reafons: . ....................... ................. .................. . . .......... ......................
---------------------------------------------------------------------------- -------------------
.............
.........
......._................
.
Date
PermitNo. ............ ----------------------.- Issued ..... -- --- ..................................................
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Q.Trrtifi. ate of (111om Bairn
THIS IS TO CERTIFY, That,the Individual Sewage Disposal System constructed ( ) or Repaired
---------........ ----------------...--
atY —........ ------ �G `--- - —taller--------------------_. .!....F..�� J ��.1......._........._--------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No- ----- .,....y.�. - ---- dated ---------------------------------...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ .---- .'. �� Inspector `:r�:�. y-//%.✓�.�,t%1.. -
,, €--------------------- -----------------------
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /J V 57
TOWN OF BARNSTABLE
Diupuunl Workii Tunutrur#iun "rrmit
Permission is hereby granted....................... 1>: -!._ _�<IJ ....__.___.C-�....!`:3-5.. t'"C~'71�.j
to Construct ( ) or Repair ( ) an Individual Sew,a e Disposal System
at No._.__.... 3� _.. `S..'? L e= L! ±''✓.....` ---/ -/1-t.-=5.........................
Street
as shown on the application for Disposal Works Construction Permit No..7N, -.Y4_7 Dated.........S3_. _11.-.�.���......_.
................................... ------ -----------------------
`V- - - -----------•---------
DATE...............•a• —h..,.. L7.................................... Board of Health
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS