HomeMy WebLinkAbout0119 J.B. DRIVE - Health 19 J.B. Drive
Marstons Mills P
1 A 101 038
z
I
SEWAGE INSPECTIONS
1]6CA7I011 ' a. D. Dzive DATE 5/27/03-
VI LAGE l a .Ann t� M. 0 0,c_ lYl a A.A_ ASSESSOR'S MAP & LOT.
IrZSPEC'POB a• !. /7acomge/z a¢.
SEPTIC TANK CAPACITY 1 UU0 gaiioa�3 1-13ox
LEACHING FACIL rrY: (type) I-LI'l- 9 UUU (size) 1500 gai eonz
NO. OF BEDROOMS 2
BUILDER OR OWNER Pabz is is Saime ie z
OWNER MAILING ADDRESS
. Same
�^ fi
X
/
i \ N,
` TOWN OF BARNSTABLE
LOCATION 15W —
VILLAGE MAI-SEW ASSESSOR'S
/MAP & LOT q
INSTALLER'S NAME&PHONE NO.,6/lli�iVJduaU AW /'/AV 5 0-
SEP-171C TANK CAPACITY
LEACHING FACII.TTY: (type) f �7 Al>- (size)
NO.OF BEDROOMS
BUILDER OR OWNER o4wid Gvyo r
XgM;WTDATE. -9 t-9!. COMPLIANCE DATE: �—
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facili If any wetlands exist
within 300 feet f leachi ci ' Feet
Furnished by
.A
e t /
.)
DATE5/27/03
PROPERTY ADDRESS:-;. 13' Dz�ive
------------------- e0
Na/tztone Mazz.
------------------------ RECEIVED
02648
------------------------ JUN 0 4 2003
TOWN OF BARNSTABLE
On the above date, I Inspected the septic system at the ab T PT.
This system consists of the following:
1. 1- 1000 gaiion ze/?t.ic tank.
2. 1-D-izta-gut ion Sox.
3. 1- 1000 gaiion teaching pit.
Based on my inspection, I certify the following conditions:
4. 7h.iz .iz a t-itie �,P.ive zept.ie zyztem. (78 Code J
5. The zept.ic zyatem is in /mopes woak.ing o2dea
at the pzezent time.
6. 0azte wate2 .iz 31" geiow the .inve2t /2.i/2e oZ the
ieach.ing 12.it.
SIGNATURE:s/
Name:-J.P.- Macomber Jr_______
Company: Joseph-P. Macomber_& Son , Inc .
Address: Box 6,6
--------------------
Centerville , Ma . 02632-0066
--------------------
Phone:- 508-775-3338
--------------------
THIS CERTIFICATION DOES NOT CONSTITUTE,.;A GUARANTY OR WARRANTY
1
M1
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
\ COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 19 a. !3. Da.ive
Nanetone N-iiiz,
Owner's Name:%at2 ic.ia Sa.Pme iea
Owner's Address: Same
Date of Inspection: 5127103
Name of Inspector: (please print) Joseph P. Macomber Jr.
Company Name: Joseph P. Macomber & Son Inc
Mailing Address: Box 66
epntPryille Ma 02632
Telephone Number: 508-775-3338
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 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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /� Date: —';(7
The system inspector shall mit 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.
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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 l'2 iLe
Na/z.6ton6 M c .3, as.6.
Owner: Pattiz-icier Saime ie z
Date of Inspection: 5127103
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1 have not found any information which indicates that any of the failurt criter)ia described in 310 CMR �I
15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are indicated�below. J
Comments:
-7h o Ao em -ib .in /220/2e/L wo2k.ing a/zde z at .t`h,e,
B. System Conditionally Passes:
AM 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 ass inspection
exist' Y p coon if the
tng tank is replaced with a complying septic tank as a P
P Ymg roved P pp b the Board o
'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:
/06 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 ass inspection
Y tion if with
approval of Board of Health): P P (
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
10 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:
2
0
r
Page 3 of I 1 i
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:1 9 _ 1. !3. D z ive
Nat,3ton,3 Pl.iiiz, Pla.s.6.
Owner: /)at z is is Sa eme.ie z '
Date of Inspection: 5/,?7/0 3
C. Further Evaluation is Required by the Board of Health:
-4)6 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:
IV) 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.
V0 The�system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
4)0 The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well.
db The system has a septic tank and SAS and the SAS is less than 100 feet but 0 feet or more from a
private water supply well". Method used to determine distance 1 �!
"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:
3
Page 4 of 1 1 S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:/ -/z-ic is Sai eie2
19 J. [3. Dzive
Owner: Nat.6a`orz.6 Ni-e.Q.6, ('lays.6.
Date of Inspection: 5127103
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ c//Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
1 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
Zclogged SAS or cesspool
ctatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
�esspool �-r s L �I'� D
_ ✓✓✓✓ squid depth in-sesspeol 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
f times pumped p
_ y portion of the SAS,cesspool or privy is below high ground water elevation.
�y portion of cesspool or privy is within 100 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.
�ty
portion of a cesspool or privy is within 50 feet of a private water supply well.y 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.
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
_ _,Lthe system is within 400 feet of a surface drinking water supply
4- 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.
4
Page 5ofII
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS E S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 9
I'la/F
Owner: Pat/z�ic.ca 5a2mezea
Date of Inspection: 3
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No/
PPumping 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 ?
ZWere 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,�luding 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
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 I5.302(3)(b))
5
Page 6 of I 1 t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 1. 13. D2 ive
Owner: Pat,c.ic.ia SaPme.ie2
Date of Inspection: 5127103
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): P110 � O�
Number of current residents: 4
Does residence have a garbage grinder(yes or no):AV
Is laundry on a separate sewage system ( 'es or no):� [if yes separate inspection required]
Laundry system inspected(yes or no):L�
Seasonal use: (yes or no): ilt
Water meter readings, if available(last 2 years usage(gpd))2001—4 0, 000 ga P Pon.= 109, 5 9 D
Sump pump(yes or no): .f k� 2002=5 3, U7 ga. eon,6= 14 5. 21. qPD
Last date of occupancy:—�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):,tL4
Non-sanitary waste discharged to the Title 5 system(yes or no):.,O
Water meter readings, if available:
Last date f 0 occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records / U
Source of information:
Was system pumped as pan of the inspection(yes or no);,
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
iTY OF SYSTEM
Septic tank, distribution box,soil absorption system
Single cesspool
OF
cesspool
f Privy
IV
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 IVA Attach a copy of the DEP approval
1 d Other(describe): 4hf
Appn1r^oximate ase of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)1�1�
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:1 9 �. B. D/z ive
Na.2,6ton-6
Owner: Data.is is Sa eme-ie2
Date of Inspection: 5127103
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: ,t /kast iron /0 PVC.VAother(explain): eX
Distance from private water supply well or suction line: /P/;O-
Comments(on condition ofjoints, venting, evidence of leakage, etc.):
_�o iA oQnvria tight No evidence o4 .�Pakaae The .6y,3tem .iz
vented thaough .the zoos ven.tz.
SEPTIC TANK: Zlocate on site plan)
Depth below glade:
Material of construction: ncreteWd meta Ljkfiiberglass/J_dpolyethylene
4111 other(explain)
If tank is metal list age:�> Is age confirmed by a Certificate of Compliance(yes or no):f d (attach a copy of
certificate)
Dimensions:
Sludge depth: / u_�e ✓
Distance from top of ludge to bottom of outlet tee or baffle: ,A�
Scum thickness: .L
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bono of outlet tee or baffle:
How' were dimensions determined: ?�Qlil(Ll�s
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage,etc.):
///lan iho Avpf %n tank v»vny ?_ 3 Tnipi R ou tee'3 aa.e
in 10- riro 7ho �nnk iA Ai,7ijt-h1ar,F.Pg Aotind and Ahowi no yy,idynoy
o f .leakage. L1uu id ievei at the out—eet invent .i,3 5 9"
GREASE TRAKA6tocate on site plan)
Depth below grade:4I
Material of constructionN- 9concrete ll metaWAfiberglasW Lpolyethylene.l�other
(explain): 114
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: Aid
Date of last pumping: 1,�4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
C2 z. ,, 2a/Z ..6 not /?.,ze,3erat
7
' Page 8 of 1 I _.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 �. 3. D/z ive
Najz.sione (rl 2L6, t'ae,3.
n
Owner: l) fnirin CaOmv.iyn
Date of Inspection: 5/,)7/o 3
TIGHT or HOLDING
TANK (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:A
Material of construction:ZK_concrete,12d_m eta l,&y_fi be rg I ass,t polyethylene et.4 other(explain):
Dimensions:
Capacity: A4 allons
Design Flow: gallons/day
Alarm present(yes or no):�2
Alarm level: �/ Alarm in working order(yes or no):1
Date of last pumping:-Af—
Comments(condition of alarm and float switches,etc.):
7.i ah t o2 ho d in g .t ank.e ate no.t 1z2ezent
DISTRIBUTION BOX:Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: tid
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.ie.t2.igut-ion Sox ha.6 one .Pate2a.P. No evidence o� aoiid.6 caa2y
ove2. No evidence o� .lea age into o2 ou o e COX.
PUMP CHAMBE tip.(locate on site plan)
Pumps in working order(yes or no): N/'¢
Alarms in working order(yes or no):�a
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
/0um12 chamge2 .ia no.t /?/zezen
8
Page 9 of I 1 f =s
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 1. B. Dz-ive
/11 ugh t one 777 , aee.
Owner: Pat2.icta 3aemetea
Date of Inspection: /
SOIL ABSORPTION SYSTEM (SAS): Y (locate on site plan,excavation not required)
1- 1000 anPPon RaoraAi Pvnrh,ing Qlt _
If SAS not located explain why:
Located: See Race 10
Type
1/ leaching pits, number: t
itlLD' leaching chambers, number:
An leaching galleries,number:
,Vb leaching trenches,number, length: [�
Vbleaching fields, number, dimensions:
overflow cesspool, number: 6
irmovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition o vegetation,
etc.):
Loamy eand to medium line Band. No e.i ne o,,P hydaautic �Pa.i.Pu2e olt
Rond.ing. SO.L.Pe ate d2u. Vegetation ie noama.P. Oaete wate2
.ie 31" 9e2ow the inveat /2.il2e.
CES,SPOOLyAk4cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: '/j
Depth-top of liquid to inlet invert: Ali
Depth of solids layer:
Depth of scum laver:
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.):
Cee.6,?oo e a/zo not Pneeent.
PRIVY,G)e,(locate on site plan)
Materials of consEructi n:
Dimensions: 1*
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Plz,ivu .ie not /22eeent.
9
Page 10 of I I y }.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:1 9 I. /3. D z ive
Owner.Pat/Z.iC.e-C—L �aLmeteIL
Date orinspectioo: 5 27/03
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.
f'
r � —
w�
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:1 9 a' Z3• D zive
Owner: Pat2.i c-ca
Date of Inspection: 5/27/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
s
Estimated depth to ground water A'�_ 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:
_Observed site(abutting property/observation hole within ISO feet of SAS)
_Checked with local Board of Health-explain:
_Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
'l,6ed Gah2�u R Pl ;P/, PlodeP 12/16/94 Cnnund „47FJ2 Er411.47-62N- R[3OV�
eea Pevei.
li.6ed: IlSGS • U&ae2vat i oa we ei data June 199
4L.6ed: USGS:7echn.iea D Pet ' — —
wate2 e_iev .ion.`: aanuazy 1992
Leaching /o
Pit ect
Groundwater: eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
Of the leachingit and the adjusted '
P ) groundwater table is �
feet.
11
I
y •TTr•..-nrs.•-Tr rnrmr•nn-rra--mt+srr.+r• rt•.T+t+7rryT.►*lr�lnnrrnv l7�•sr.an Tn .. �•
TOWN OF 13a�zrz,3ta&.9e BOARD OF HEALTH
91113SURFAU 9FWA(;F DISPOSAL SYSTEM IH3PFCTION FORM - PART D •- CERTIFICATION i«•1••1•T""•.��.11•.^�T.•..7M1r..IT.Tl1 T'11rtlT1I.T71T:r«l'I riVtR�1 iIR1A'�T�1�1�/��..�\ Tfl1f 71.Tr.R1T��
—TYPI OR PRINT CI.EARL1'—
PROPERTY INSPECTED
STREET ADDRESS 19 a. i3• [hive Na2atorze M-iP-e Na.6.3.
ASSESSORS MAP, DLOCK AND PARCEL # le)- a
OWNER' s NAME Pa.t zicia Saime.te2
PART D - CERTIFICATION r
NAME OF INSPECTOR _Joseph P. Macomber Jr.,
COMPANY NAME Joseph P. Macomber & Sdfi ' Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street Town or Clty 5tat♦
COMPANY TELEPHONE ( 508 ) 775 - 3338 zIP
FAX ( 508 ) 790 _ 1 578
!f
CERTIFICATION STATEMENT "
0rdill a
r I certify thf,t I have personally inspected the sewage disposaLj system at
this address rind that the information reported is true , accurate , and
omplete as of the time of -inspection , The inspection was
ecommerldatiOtis le performed and any
regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Chect, one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this for,n .
System FAILED# \
The inspection w►, icl, I have con lucted has found that the system fails to
Protect the 'public health and the environment in accordance with Title
5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this. inspection form .
Inspector Signature / Date
ne copy of this ce ification must be p
( where applicable ) and the BOARD OF )JEA10Vided to the OWNER, the IIUYER
* 11.
If the inspection NAILED, this owner or' "oI
within one year of the date of the inapectionatunlessor la upgrado ' the eyatem
otherwise as provided in 3.10 CFIR 16 . 305 . Mowed or required
partd . doc
a /
DATE: _ 11 /21 /96
PROPERTY ADDRESS:,14 J.-B.-- Drive '-' Cu
Marstons Mills ,Mass . DEC 6 15 1
02648
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1-000 gallon septic tank.
2. •1-Distribution box.
eased bn my Insr ctlon, I certify the following. conditions:
1 . This is a title five septic . sy tem. ( 78 Code )
2, 'The septic system 'is in proper working
order at the present time.
' 3. No repairs needed at the present time.
4. 1.-1000 gallon leaching pit. 111 of water in the pit.
SIGNATURE: G`i(
Name:-J. P.Macomber -Jr.. i
Company:_J. P.MacoMber & Son-_Inc ,
Address:-.&e-ac-6b-----=3--- .--
__Centerville LMass__02632
Phone:---50.8_775_3338------- - I
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LPH P. MACOMBER & SON, INC.
TankrCeupoolrLeach(leIds
Pumped I.
InsUlled
Town Sewer Connections
x 66' Centerville, MA 02632-0066
775-3338 775-6412
U
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
3 ep artment of
environmental Protection
Trudy Coxe
a«r.tsry
David B. Struhs
U.CGv..,,,. Commulonsr
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddresa: 19 J.B. Drive Marstons Mi11s ,MasSAd&.,. ofowner
Date of Inspection: 11 /21 /96 (If different)
Name of Inspector. Joseph P.Macomber Jr.
Company Name,Address and Telephone Number.
J.P.Macomber & Son Inc.
Box 66 Centerville,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
1 certify that I have personally inspected the"wage 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"wage disposal systems. The system:
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
lnspectoes signal7�1� Date:
'v
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 eystam is a shared system or has a design Dow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional oMoo of the Department of Environmental Protection.
The original should be sent to the system owner wd copies sent to the buyer, if applicable and the approving authority,
INSPECTION SUMMARY:
Check A B. C, or D:
A) SYSTEM SES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon oomplation of the replacement or repair, passe,
inspection.
Indicate ye., no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If'not determined", explain why not)
The septic tank is metal, cra:ked, structurally unsound, shows substantial infiltration or exMtration,.or tank failure is
i . at. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by tL. Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617) 556-1049 a Telephone (617)292.5500
�� Pnnled on R"I d P.ptr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddrest: 19 J.B. Drive Marstons Mills ,Mass .
Owner. David Connor
Date of Inapeotion: 11 /21 /9 6
BJ SYSTEM CONDITIONALLY PASSES(continued)
AD Sewage backup or breakout or ho static water level observed in the distribution box is due to bsokaa or obstructed pipe(,)
or due to a broken,settled or uneven distribution boat. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution boai is levelled or replaced
The system required pumper more than four times a year due to broken or obstructed pips(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:-
AM Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the enviroameat.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
1/0 Cesspool or privy is within 60 feet of a surface water
Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh
ii
S) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONME M
Q(Q Ths system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The ryRam has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well
The system has a septic tank and soil absorption system and is less than 100 fast but 60 feet or more from a private water
supply well,ualw a well water analysis for collform bacteria and volatile organic compounds indicates that the wall is free
Gram pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
S) O''TaHFjt
1
O
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontlnued)
PropertyAddr &;- 19 J.B. Drive Marstons Mills ,Mass .
Owner. David Connor
Date of Inspootlon.•1 1 /21 /96
DI SYSTEM FAILS:
e
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for
this determination is identified below. The Board of Health should be contactad to determine what will be necessary to correct the
failure.
Backup of sewage into facility or syrtem component due to an overloaded or dogged SAS or cesspool.
jo Discharge or ponding of effluent to the surface of chs ground or surface waters due to an overloaded or clogged SAS or
cesspool.
A8) Static liquid level in thA distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
fl Pr
Liquid depth in sesvpeoF is leas than 6"below invert or available volume is less thaw 1/2 day flow.
_40 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
,Ark 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.
AO Arty portion of a cesspool or privy is within a Zone I of a public well.
W Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analysed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health Lad safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
&lr 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)
71 s ownar or operator of any such system shall bring the system and facility into full compliance with the groundwater treatmsnt program
requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for fluthsr information..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 J.B. Drive Marstons Mi11s ,Mass .
owner. David Connor
Date of Inspection: 1 1 /21 /9 6 •
Check if the following have been done: `
,,,Pumping information was requested of the owner,occupant,and Board of Health.
Nona 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.
AAs built plans have been obtained and examined. Note if they are not available with N/A
Y The facility or dwglling 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.
All system components; clu'ding the Soil Absorption System, have been located on the site.
2The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baMas 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 existing information or
approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
�5
SUBSUIU'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Adds 19 J.B. Lane Marstons Mills ,Mass .
Owner- David Connor
Date of Iaapoutivt.: 11 /21 /96
FLOW CONDITIONS
RESIDENTL-L•
Design Bow: oa
Nis- r of bodroomsM
Number of curmat rwideau:
Carbap grinder (yw or no):-!!!Y
Laundry ooanacted to ryrt4= (yw or no):j5
Se-AACLAl use (yw or ao):2L�
Water meur readings, if available: ,yri ,y
1 G 5
Last date of occvpaary:l —Zj
COMMERCIAL/INDU9TRIAL-
Type of enablirhmew: AIR
De+b-n Bow:--Aria ons/day d
Creasa trap prweat: (yes or ar,)A
lndustrial Ware Holding Tank present: (yes or no)-&19
Non-"tary wuto discharged to the Title 5 systom: ryes or no)-6/f
Water meter reading, if available-.
IA _
Lan date of occupancy: /})
OTEM- (Describe)
Lan date of o=pancy: Nlf _
GENERAL INFORMATION
PUMPING RECORDS d so f yy' pnaation: /
System pumped w pan of inspection lyer or 1 0)"
It yw, volume pumped:
Reason for pumping: .(J
TYPE OF MM
Septic uu.kldiitribulion box/sod absorption e)vtem
Over-Bow cttwpwl
_A)a privy
Shared rystem (yes or no) (if yes, attach prvvious inspection records, if any)
Other(eaplc.in)
APPRO)CMATE AGE of tell components, date u:.iuA11W (if known) and source of information:
Soware odors r?ecsrtsri .... ......
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C• • .
SYSTEM INFORMATION (continued)
Property Address: 19 J.B. Drive Marstons Mills
Owner: David Connor
Date of Inspection: 11 /21 /96
SEPTIC TANK:)Qdd 2441� e
(locate on site plan) f
Depth below grade 'Z' ak'gr
Material of construction: concrete _metal _FRP—other(explain)
+ s
Dimensions:_ /,
Sludge depth: „_— I�QtJ�' fd_iv, 1�.6
Distance from top of dge to bottom of outlet tee or baffle: _
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: �q
Distance from bottom of scum to bottom of outlet tee or baffle._
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural
�rity, evidence of leakage, etc.) PUMLR t.anlc P—V. 2_3 va
� , • mlet and outlet tees'are . in
� ce� Ligi n id 16vel at outlet ivert is _5 _11;L,T
GREASE TRAP..)OA°-
(locate on site pian)
Depth below grade:,4p"�
Material of constnlr1i6ri- 7_.•oncrete _metal _FRP —other(explain)
Dimensions;
Scum thickness._
Distance from top v.) scum to top of outlet tee or baffle:-6&
Distance from bonom n( rurn in honnm o) outet we or bahie / -
i
Comments.
(recommendation for pumping, concla—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.i_Grease Trap is not present
s
4'
(revised 9/15/95) 6
�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
PropertyAddreas: 19 J.B. Drive Marstons Mills ,Mass .
Owner. David Connor
Date of Inspoctlon: 11 /21 /96
TIGHT OR HOLDING TANK eA"t
(locate on sits plan)
Depth below Vida: V14
Material of 00astructioa4Wooaaate_metal_FRP_other(aplain)
AIR
Dimensions:
Capacity ns
Design flow: gallons/day
Alarm level:
co
r}ditioa f ad i has, J(�ad:gtjo�ofOrt�`io`�ing �an aarefloat nosw� prestosent.
DISTRIBUTION BOX:Z
(locate on site plan)
Depth of liquid level above outlet invert: NO
Comments:
(note if level Lad distn'bution is equal, tvideaa of solids v evidence of laaka�v into or_9ut of box,+tc.)
D-Box level; No evidence of sod dSocarry over; o evi e
in or out of the box. No �repairb-needed at Vie present time .
PUMP CHAMBER, "4)e—
(locats on site plan)
Pumps in working order.(yes or no)_&&
Comments:
(note condition of pump chamber,condition of pumps Lad appurtananoes,etc.)
Piimp Chamhar i c nnt, nrPaPntt_
(revised 11/03/95) 7
U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddress: 19 J.B. Drive Marstons Mills ,Mass .
Owner. David Connor
Date of Lopection:1 1 /21 /96
SOIL ABSORPTION SYSTEM(SAS}:
pocats an site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be presant,explain:
1`lPe:
laa&IM pits,number
leaching chambers,number
leaching galleries,number
leaching trnchea,number,length: d
leaching fialds, number, ns-
ovwtow cesspool,number:
Commants:(note condition of soil, of hydraulic failure,level of ponding,condition of vegetation,stc.)
No siens of Hydrau�lic failure or Ponding; All vegetation is normai.
Nn rP=ai rg needed at the present time
CESSPOOLS:six 9—
(locate on ails plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of aolida layer
Depth of scum layer. VA
Dimensions of cesspool:
Materials of construction:
Indication of graundwatar: ll5 A
6,PCofo (cesspoolC must be pumped
T�
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:4-),4 VC,
(locate an sits plan)Materiale Of construction ti� Dimensions•_ AO
Depth of solids
Comments:(note condition of soil,sips of hydraulic failure,level of ponding,condition of vegetation,etc.)
No privy present
(revised 11/03/95). g
„ J�,juRF'ACE SEWAGE DISPOSAL SYSTEM INSPECTION ,F'vl�ri
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L '_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Centerville ' Osterville Marstons Mills
Water Compariy,
428-6691
oe
DEPTH TO GROUNDWATER �C T�
_ 16' + depth to gfb nkiff r rn oY1 TqL” s
rAthod of determinesion or approximation:
�.. �...4o. ;Water-.eri �zne ' a Z t '
Qe.4 ' nBt&15le- Board Of. Health
�. _
vwi Z z7
J t
SS, �
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the �' -ion of Water Pollution Control
r Y
+•R+'\T�RtTTT.TT�\\1rT JRe'PIiTTRRtITT.IRR::'T.•\T/J11�TR'RT RiT17iTf'rt�IIRRT ..
I SUIISUIiFAC TOWN OF Barnstable BOARD OF HEALTH
F SFWA GF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
�_ �:^•r^.�r••.-::.—r...a-..--�+.+Tr..nR.rnrs�iasrrrr.+errern+�+R+rnarmvr�Tve►S+nrRnam�ee�sr� mn ..—rrr•r-„ �..A
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 19 J.B. Drive Marstons Mills ,MaSS. '
ASSESSORS MAP, BLOCK AND PARCEL i
OWNER' s NAME David Corfnor
PART D - CERTIFICATION I
NAME OF INSPECTOR jnset�h P-MA comb .r Jr..
COMPANY NAME J.P.Macomber & 16A Inc.
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Tovn or City state LIP
COMPANY TELEPHONE ( 08 � 775 3338 FAX ( 508 790 - 1578
tT
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of.-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
•:XXXXXXXXXXSystem PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature A Date 11 /21 /96
One copy of this certification must be provided to the OWNER the BUYER
( where applicable ) and the BOARD OF HEALTH. �
* It the inspection FAILED, tht owner or.roperator shall u d
Within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CFIR 15 . 3o5 .
partd .doc
I
Assessor's map and lot number ......... ................................ r ._
73
Sewage Permit number .................:r....................................... -
INEr��♦ TOWN OF BARNSTABLE
2 �U�
i BBHBSTIIDLE, i �� D��
i63 q. ��// BieilNG INSPECTOR
�p `�0
��MPY M•
APPLICATION FOR PERMIT TO ........ ...............0�........ ......... ...... ...... . .................�............................... ....
TYPE OF CONSTRUCTION .......................
` ........ ................19
TO THE INSPECTOR OF BUILDINGS: - - -
The undersigned hereby applies for a permit according to the fol wing informati n:
Location ..............�1...!" . ..... ...... ....... ..................... .......... ..�.... . ..���... ... ...��� 2 �..........................
ProposedUse ......... . .. .... . ."I,*,,***,**"-,-*--,-**-*...................................... ..........................................................
Zoning District ......... ..............................................................Fire District ... .. �Z............... .
Name of Owner dress
NameName
of Builder :fiG.(J.4 . 2 Q!YJ.c . .z. .Address .�J ... . ........ .......`.....1 .. .......
Nameof Architect ................... . ............................................Address ....................................................................................
Number of Rooms ..' ... ........................Foundation .........
Exierior ...:........ ......................................... .. .. ..................Roofing .... ..... ...... . Lle ..............................
Floors .......... :.......................................................Interior .... .... ....... .............................................
n
Heatingr�-�........................................................Plumbing ......................�... ... .......�...�..........................
Fireplace .......... .. ...................................................Approximate Cost .............../
Definitive Plan A proved by Planning Board ________________________________19_______. Area .... .�...., ....................
a�
Diagram of Lot and Building with Dimensions Fee .......... .................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
•
1
�• .J 1
hereby agree to conform to all the Rules and Regulatigns ofhe Town of Barnstable regarding the above
construction.
I
Name ..... .........:-::�::er....................................... ...................
Connor, Orrin J� & Jlizaa E.
�0
l��nn one
No ..�����—. Permit for .-----.story'--..si
......-- --'' '' wrw� ~ '
�
��
~ �
Location ........................................ ..................... �
`
Harstons
Y�i]l�/ !
----.----------------------
Owner ---' _J�..8:.Jlica..J��_Co�zu�r
Type of Construction .....���P��--------..
-
-----^--------------------'
� ��o
Plot ---------. Lot .---:`��..............
May 8 73
� Permit Granted ........................................lg
Doteof Ins pecdon . . �
� '
Dote Completed ....... �
-
'
'
�
PERMIT REFUSED
-----_---.-----------. lA
--------^'—'---'----------^--'
^—'---'------------'--------''
-------'-----'--'------'—'----
�
�
--------'----'-------------'
�
\
Approved ................................................ 19 �
^ /
-------------.------------- /
v .
-------.-------------~..—.--.
�
Y,4a4 J,-/l yp'l-7
No....1313.... 2.1................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
®... ... -r4v --------OF.... ...................
Avpliration for Disposal Works Towitxnrtinn Vertnit
Application is hereby made for a Permit to Construct ( Aor Repair ( ) an Individual Sewage Disposal
System at
-- -- -------- - ------- = - -- -- ---- --- ----------------
• (� o 'o Addr �` ------- .....,or Iiot o-
.st..f.. '+rc'r Ir
Owner Address
Insta Address
Type of Buildii Size Lot_a__________________________Sq. feet
U Dwelling No. of Bed rooms-----------�---•___------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow__ _______________ _..__..._____ allons per person per day. T ot d al aily fl ow..__._.._____._a�.. ..'.__.gallons.
WSeptic Tank Liquid capacity. alIons Length................ Width...._........... Diameter-._-_._.___:___- Depth----------------
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching -area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date---------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water__._______________.__.-.
fl:q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --••----•-•----•--------------• ...............
ODescription of Soil-------------------------------- ----------------•----•-----•----...-----...--------------••--• --•••----- ------------------------
x
W
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
----------------------------------•---------- ---------------------------------------------------------------------------------------------------------------------------------..---------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued he board of health.
Si d --------------------
--------- -------------------
D e
Application Approved By-.' �1� - - -------
------ - ---- ----
---•----- Date
Application Disapproved for the following reasons:........................
------------------------------------•---------------------------••------•------.....---------•-----.......-------------------------------------------------------------------------------------------•--•
Date
PermitNo......................................................... Issued........................................................
Date
No.... tl- ---• lot Flmla._2..................
THErCQMMONWEALTH OF MASSACHUSETTS'
BOAR® OF HEALTH
` f` ... ........OF.... 4
Appliratiaan for Disposal Works Taamitrurtiou Pumit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System a e
( o a;oVAddr ss or 7 of o
Aoellj-
Owner Ad ress
W ----------------- --------•-------------------•--
a ...............................Insta r Address
Type of Building Size Lot_._..........................Sq. feet
Dwelling 7 No. of Bedrooms__.._...._..........................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—:.Type of Building ____________________________ No. of persons..-_--••______--___-___•____ Showers ( ) — Cafeteria ( )
a' , Other fixtures ________________________
W Design Flow. ---------- ••-- ----�.�-¢gallons per person per day. T ot d al aily fl ow - gallons.
WSeptic Tank Liquid capacity,/ gallons Length................ Width---------------- Diameter---------....... Depth_.--_-_-----....
x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box.( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date------•------------------------------ -
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....,--_-_-_--_.---_----
--------------------- ---- 7...--•--•- -•-;...................................................................................................
O Description of Soil =
x
U ..................••••••--•-•••••------••-•----•-•-------•-•--------------------......................=--.............................................=................................................
W
..................-------=---------------------------------------------------------------------------I---------------------------------------------------------------------------------------
=-----------
U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------------------------
--------------------------------------------------------------------=•-••----••---------------••-------•------••_.....•--•----••-••-•-••---•-•------------•-----•-------•••-....-•-••-......---••-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of.the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of.Compliance has been issued by—the board-of health.
a _ _ ........_ _-•.................
:,. ledKf
.. -� - -------- ---
' D to
Application Approved By r 'gip= --------
'^' -' Date
Application Disapproved for the f olloieiing reasons: •------------ --•--
.............................................................t.......................... •--.......-----•------•---------••-••--------•--•-•--•-••••-----------•---------•••--•---------•-•---------
Date
PermitNo..................................I........................ Issued........................................................
Date
THE COMMONWEALTH OF'MASSACHUSETTS
BOARD OF HEALTH
t ,:
r
(In if iratr of 101,11ntphaurr
THISZ
CE , That t ndividual Sewage Disposal System constructed ( j'or Repaired ( )
k by r ..�••-
' Installer
at `-L,. -•--I y = — ---•---• ---<i A-----~ t _ e ...............••-----------....------•-----------•-----
has been installed in accordance with the provisions of Article XI of The State Sanitarv,Code as described in the
application for Disposal Works Construction Permit No.._. )......................... dated ..._..__..__.._...
THE45SI.AkCE OF THIS CERTIFICATE SHALL NOT BE CONSTR D AS A UA TEE THAT THE
SYSTEM *LL FUNCTION SATISFACTORY.
ae
DATE...�_ I .3--------=--•-----•------------------- Inspector----- ---------- -------- ----- --------.�=-'•[ ---- ----
y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................0F......... - • r,�1 '
No---~ ...•--•-- .......................... FEE..-?eg, .&
Permission is h,reby granted......... .. ...... ......
-----------........................................................
to Constr ct ( or, Repair( ) an Individual Sewage Disposal _ ystem
t
at No. _ = £� ----------- = =
St
as shown on the application for Disposal Works Construction,Per �i
Board of IIealth
DATE......... -------------------------- .
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS