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HomeMy WebLinkAbout0124 J.B. DRIVE - Health 124 J.B. ®rive Marstons Mills P A = 101 035 - — ---- i r DATE : 1116103 w PROPERTY AOORESS :124-47-13 D.,tive _ -- - - ------------------ RECEII r� � -- - ---- - - NOV 13 2003 TOWN OF BARNSTABLE HEALTH DEPT. On the above date, I inspected the septic systern--tt the above address, Tnis system consists of the loll.owing: 1. 1- 1000 ga gion 3ept.ic tank. 2. 1-Di.etltigut.ion .fox 3. 2- 1000 gaLeon p2eca.6t Leaching p itz. MAP , 8asec on my inspection, I certify the following condItIons: 4. 7h.iz .is a t.it.2e Zive 6e/2t.ic 3y,6tem. (78 Code) PARCH � -- - 5. The .6ept.ic system 1.6 .in /22ope2 wo2k.ing oade/z LOT at .the p2eeent time. 6. Pumpedtank and pit at time o� .in.6pect.ion. 7. Regiaced &token tank covet. 8. Set -s/2eed ieveie2 .in the d.izt/z.igut.ion. 7h.iz ecyuaied the /iowz to the pit,3. SIGNATUR , zme _ ,J__ P . _Macomber Jr , �7 �Ompany : )4�p�h 3 _ M�S4mk2�r 6_ Son, Inc , � ooress : - -QQX _�6- ------------ - - -(.7-enjerYLLLP—_ �Ja - -2Z632- 0066 ?^one ►hiS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ME )OSEPH P. MACOMBER & SON, INC. Tans;s-Cesspools•Leechllelds Pumped & Installed Town Sewer Connections P 0 Box 66 Centerville, MA 02637.0066 775.3338 775.6412 r �•` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 124 a• B. Dlz�ive Nat.6ton,3 (7-U,3, 17cL,6,3. Owner'sName:/tev.en rtaynew Owner's Address: 2ive Naa,5.ton.6 Date of Inspection: Name of Inspector: (Veaseprint) ao-se/zh %. Nacomgea aa. Company Name:a• l • NacomC77-7 Son 1nc. Mailing Address: o x —77­ Centeizviiie. Nazz. 02632 Telephone Number: 5 0 8—7 7 5— 3 3 3 R 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 ,A Signature: �O ��/ , Date: Inspector's � The system inspector shall s 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 I 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:124 al3 Dlz ive 1�a�z,3 ons Owner: Kevin 1'az/hzw Date of Inspection: 7116103 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. _ em�Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: _7h_O__AL`2LLa zuzl-em i.6 -in /22o/2e2 wo,,z -ing o/z e z at .the /2,ze6ent time. B. System Conditionally Passes: .yZ-) 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 meta] and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: �(? Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 4,b 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 rage..) of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION (continued) Property Address: 124 1• i . Dz the Owner: ,Kevi Mayhew Date of inspection: 1/6/03 C. Further Evaluation is Required by the Board of Health: _D- 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. I. 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 mariner which will protect public heaitb, safety and the environment: Cesspool or privy is within 50 feet ofa 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: ,4�O The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet ofa surface water supply or tributary to a surface water supply. 4J4) The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet ofa private water supply well. /!� The system has a septic tank and SAS and the SAS is less than 100 feet but 5 prNate water supply•well" feet or more from a. Method used to determine distance /Jr„p��A� "This syslem 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 r Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 724 a. !3. Dlz ive Nanstons Owner:Kev.in t7aghew �.,. Date of Inspection: 1116103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes No/ _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool J Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool V Static liquid level in the stribution box above outlet invert due to an overloaded or clogged SAS or /cesspool 9?,'� _ j/ Liquid depth inceaspet+is less than 6"below invert or available volume is less than 'h.day flow Required pumping more than 4 times in the East year NOT due to clogged or obstructed pipe(s).Number of times pumped j. _� Any portion of the SAS, cesspool or privy is below high ground water elevation. �A.ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. iCAny portion of a cesspool or privy is within a Zone I of a public well. �Any portion of a cesspool or privy is within 50 feet of a private water supply well. ;/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coilform 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.] AL b (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to.correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply °` the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: .24 13• &1tive a2,.�onz Niiiz 1�azh, Owner: Kpay.in ¢yhew Date of Inspection: 1116103 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health /Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? z _ 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 e�i`c 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 CNM 15.302(3).(b)J 5 Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 124 1. 13. D/z-i.ve tl 0.17AIan A PPS PLAO 111nzG. Owner:Kevin Playhew Date of Inspection: 1116103 FLOW CONDITIONS ,.,. RESIDENTIAL Number of bedrooms (design): -4— Number of bedrooms (actual): Al DESIGN now bucd on 310 CMR 15,203 (for example: 110 gpd x if of bedrooms): ,VV6 Number of current residents: Does residence have a garbage g7inder (yes or no): 4 Is laundry on a separate sewage system (yes or no): (if yes separate Inspection required) Laundry system inspected (yes or no): Seasonal use: (yes or no):476 Water meter readings, ifavailable (last 2 years usage(gpd)):200 I=76, 000 gai'eonz=208. 22 GP D Sump pump(yes or no):A7b 2002=72, 000 g¢ e eon,3=9 97. 26 GP D Lut dart of occupancy: M COMM ERCLAL/WDUSTRIAL Type of esublishment: i(7A Design now(bucd on 310 CMR I5.203): d Buis of design now(seats/persons/sgft,ete,): Allf Grcue trap present (yes or no): ,� Industrial waste holding unk present (yes or no): A)h Non•saniury waste discharged to the Title S system (yes or no):M ) Water meter readings, if available: All Last date of occupancy/use: A — OTHER(describe): GENERAL INFORMATION Pumping Records Sourcc of information: Wu system pumped as pan of the inspection (yes or no): If ycs, volume pumped o gallons •• How was quantiry pumped determined? 2ggeAlVo ' Rcason (or pumping: d)AWIn �t9 TYPE OF SYSTEM 2Scptic tank, distribution box, soil absorption system Single cesspool �G Overflow cesspool Privy Shand system (yes or no) (i(yes, attach prevlous inspection records, if any) _C)InnovativdAltemidye (echnology, Attach a copy of the current operation and maintenance contract (to be obtained bom system owner) �C)Tight tank ,d20 Arucb a copy of the DEP approval /*Other(describe): &2 Appro imate aec of all components, dat inst Icd (if known) and source of inform lion: Werc sewage odors detected when arriving at the site (yes or no):/ 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C s' SYSTEM.INFORMATION (continued) Property Address: 124 /3. D z ive 0waer:k Zv in Nauhew Date of Inspection: 1 1 1 /0 3 BUILDING SEWER(locate on site plan) Depth als of grade: AM Materials of consnvdion:_east Iron 40 PVC .�� othcr(explain) Distance from private water supply well or suction line. , Comments(on condition of joints, venting, cyldencc of It:akage,etc,): go"int,3 aRneaR" tight. No evidence o4 ftakage. The zyztem .iz vented thaough the 2oo� vent6. SEPTIC TANK: Zoocatc on site plan) 1060 9,4'4k'v� Depth below grade: /1 Matcria< of construction; ncrete l�meta,l�d fibcrglass�l2polyethylcne othc*xplain) A0 If lank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no)-4 (attach a copy of certificate) Dimensions: F� Ate/lvle4 Sludge depth: Distance from top of sludge to bosom of outlet tee or baffle:CS_ Scum thickness; 0"'• Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: d How were dimensions determined: l um1zecl at time ° 4-n�iZect ion. Comments(on pumping recommendations" inlet and outlet tee or battle condition, structural integrity, liquid levels as related to outlet.invon,.evidence of leakage, etc): the 3e ptic tank eve2 2-3, ea2z. Zneat & out get tee ate ;,a� Pnoo 7ho Lnnk 4 uc ul�aLeii 16ortncl an owi no evji gnce o� Leakagl-. CREASE TRA r� >sfE�(locatc on site plar� �� .' • ; Depth below grader Material of construction:V4 concretr.•f1r�metaVAfibcrglas le!polyethyleneV4other (explain): >f Dimensions: 106 Scum thickness: X10 Distance from top of scum to top of outlet fee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle sL Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc,): iz not •Raebent. Page 8 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:124 7, B. DIL ive t aa4iorz-s Owner:Kev.in 11tayhew Date of Inspection: 1716103 TIGHT or HOLDING TANK14�1f-(tank.must be pumped at time of inspect ion)(]ocate on site plan) Depth below grade: Material of constructs n: W1,*concreted A metal Z0 fiberglass/ �f_polyethylene"other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): V, Alarm level: XM Alarm� in working order(yes or no): W14 Date of last pumping: Comments(condition of alarm and float switches, etc.): 7yh,t o2 ho-�dina .tanks ate ao.t paezen.t. DISTRIBUTION BOX: t/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: le)o 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.): �'�s 2i�u ion eox haz .two .Pa;�e2a.9,3. No evidence o� .60.e.idz ca22y aueiz 410 2 )Idonro n4 1PonkngP- in#.o oic ou.t of .the gox. PUMP CHAMBEPW locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Piiml) rhampv2 .ib not' P g,3eni., 8 PAge 9 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 124 a. B. D z ive 17 as s on s 77.c �, a.6 3 Owner:Kevin Clay ew Date of Inspection: 1116103 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 2- 1000 gaLeot2. 22D.c i #_ ODnnh.ing D!iA If SAS not located explain why: Type leaching pits, number: itXd leaching chambers, number: 0 ,,J&) leaching galleries, number:g ,V�) leaching trenches,number, length: C ,�' leaching fields, number, dimensions: overflow cesspool, number: 0 �`'� � l innovative/alternative system Type/name of technology:%� t1 "IJ & C7�t: , Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy nand to medium cling zancl No zignz o� hydzauiic la-iiu2e o2 /1onrL.rnq_ .So.U.5 f//ID r/ny- Vaypfa;t-on 1'i nnnm�i0 CESSPOOLS4-6,P6(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: O Depth—top of liquid to inlet invert: /0 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.): rQ13162oo .s i of 2lLP/�Dnf PRIVY. A*—,(locate on site plan) Materials of construction: Dimensions: _0 Depth of solids: /VI Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of I I OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 124 a• D. DIt ive 1raA,3tonz Owoer:Kev.i.n 1'aghew Date of Inspection: 9 1/6103 ` 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. I 1 4- 05 y M d75P 0a40 1 qs `• • � �s� �o o f 7"y -------------------- � 1 �a 3 10 Page I I of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)! Property Address: 124 B. DIL ive 1Lan�s.ton� (7.i.P.P�s, 17a66. Date of lospectioW SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /feet Please indicate (check)all methods used to determine the hi ,gh ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 11 6103 CS Observed site (abutting property/observation hole within 150 feet of SA,S q S Checked with local Board of Health•explain: ogitained a.6 � 1 ;t ca/zd Checked with local excavators, installers. (anach documentation) Accessed USGS database-explain: h.t.t,?://town. a2nztafPe. ma, u.3. You must describe how you established the hi ht, ro nd water el vatio Uzed: 9ahzzi & 17i.PPe�z Node.P, 12/� M G2ou 1r wale2 eeeva.tionz move .3ea jeve.R. axed: U 3e22)ai,i0n we.P a, a. une 11,6ed 11 PuPPe.t.in 92-00 ptate nnua 2 wate2 ePeva.tzonb. anua2y no Leaching Pit :cct Groundwater�gFee( Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Fnmpter Method Therefore, the vertical separation distance between the boao Of the leaching pit and the adjusted o feet. J groundwater table is 11 � -z—�-r-,rr.—m.•nmrs-..-.rcr..m.r.:-.r.•.Tz•r:-nw'-c'r.�r�rrr.-x-v.:*'*m. c+.n-s-i .. .. �f •T � 'PORN OF [1OARU OF HEALTH r ' S111181)1?FACF 9EKAGE 1)I8POSAL ,SYSTEM INBPFCTION FORM - PART D •- CENTIFI CAT ION I •••�••••T•.•.-•.'. �•�.:�^.-.T.T-..1f1-R:T":1^.S is.T.Tii)T,'T'1".1�•.-f--4:'rnZ TTTJ1�-\-M1t'�FL•.T-�.�.II T,t H-RRITTST�-{rTr,..r 1'•1"r'1- •�. .-.. —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 124 1. �3. i� ;,,e (r1a to M.LL' Ma ------------- ASSESSORS MAP , DLOCK AND PARCEL # 101-035 ------------- OWNER ' s NAME Kevin /�a h'ew PART D - CERTIFICATION 7 NAME OF INSPECTOR Joseph P. Macomber Jr COMPANY NAME Joseph P. Macomber &,ton Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Stre9t Town or Clty 5t;t• rIP COMPANY TELEPHONE ( 5.08 ) 775-3338 FAX ( 508 ) 790-1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dieposaj system nt this nddress and that the information reported is true , accurate , and omplete as of the time of : inspection , The inspection was recommendations regarding u performed and any g g 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 ; zSystem: PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public 11ea1L11 or, the environment as defined` in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA sectiol) of , this form : System FAILED* \ The inspection which I have conducted has found that the system fails to protect the 1)uolic health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection. form , Inspector Signature ate ne copy of tI ., c c.ification must be provided to the OWNER, ( where applicable ) and the 130ARD OF HEALTH the BUYER * If the inspection FAILED , the owner 0r.."operator shall u pgr 'wisyste thin one year of the date of the inspection , unless alloweddorthe requiredm otherwise as provided in 3.10 CPIR 16 - 305 : partd . doc V Commonwealth of Massachusetts Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 .Environmental Protection Teaticket, MA 02536 (508) 564-6813 WBllam F.Weld GoMma Trudy Cgxs 9. ,fOEA SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM (be PART A CERTIFICATIONIV ` -7�7. `MGtS� �(' �S021 Property Address. \c -AAddress of Owner:Date of Inspection: 3\2A\gb (If different)Name of Inspector: �`�Company Name, Address and Telephone Number:CERTIFICATION STATEMENTI certiF) that I have personally inspected the sewage disposal system at this address and that the information e,-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: �ses Conditionally Passes _ Needs Further Evaluation By the local Approving Authority _ fails Inspector's Signature: Date: 3,Zq`qk, 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 tc the system owner anu copie. sen: to the buw, if applicable and the appro ir,g.au horit) INSPECTION SUMMARY: Chec c A B, C, or 0: A] SYSTEM PASSES: - 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 completion of the replacement or repair, passes inspection. Indicate yes, 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, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 6/15/95) On•Winter Str•st • Boston,Massachusetts 02108 • FAX(617)S66 IDa9 • TMsphon•(617)2924000 0 Pmned on RKyeiad Paper • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A _ "CERTIFICATION (contint ` Property Address: Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The,system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation.by the Board of Health in order to determine if the system is,failing to protect the public health, safety and the environment. 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: _ 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Inp sien, nd!- a .,epiic tanK a1W luii dbborpUOn syslenl elld 1s iw fEEl .G a 5u 1acE .�c«� Suj+N,� �. i��uu.er'�: to " surface water supply. _ The s%s!e. hay a septic tank and sail 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 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but So feet or more from a private water supply well, unless a well water analysis 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 ;." . D] SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded orclogged,SAS or cesspool., _ Discharge or pondingtof effluent to the,surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �\ Owner: Date of Inspection: DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool: Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 su 1.rface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of aprivate water supply well. no Any portion of a cesspool or privy is less well than 0 has been analyzed feet but greater t han 50 feet from a private to be acceptable, attach copy of well water analysishfor acceptable water quality analysis. If the compounds, ammonia nitrogen and nitrate nitrogen. coliform bacteria, volatile organic EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety The design flow of system is and the environment because one or more of the following conditions exist: _ the system is within 400 feet of a surface drinking water supply _ the system is within.200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone Il of a public water supply well' The owner or operator of any such system shall bring consult theem local egd fa i nlalyoffice into fof the Departmentull compliance tforhfurther information trnent program requirements of 314 CMR 5.00 and 6.00. Please c 3 (revised 8/15/95) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: \�)"_A Owner: C1 mSby Date of Inspe ion: 3\2A Gk, Check if the following have been done: l.Pcrf4rping information was requested of the owner, occupant, and Board of Health. _L...Nene 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. _LA,rbuilt plans have been obtained and examined. Note if they are not available with N/A. +-N a facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste.flow �e site was inspected for signs of breakout. _III system components, excluding the Soil Absorption System, have been.located on the site. ►.ate 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. _-I a size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. e(Z.�l�(,• 'n. "� Jran(c If(.jIftvrPnt from owner) were provided with.information on the proper maintenance of Sub- Surface Disposal System. (revised 6/15/95) 4 Air OF SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Property Ad essc \�y d;�� \,ic, Owner: Date of lnsp io FLOW CONDITIONS . RESIDENTIAL Design flow: Q allons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):fly Laundry connected to system (yes or no): S Seasonal use (yes or no):_m `1 Water meter readings, if available: c. Last date of occupancy: COMMERCIAUINDUSTRIAL•C1�Pj Type of establishment: Design flow:_gallons/day Grease trap present: (yes Or no)_ w Industrial Waste Holding Tank present: (yes or.no)_ Non-sanitary waste discharged to.the Title 5 system: (yes or no)_ . • " Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occu an GENERAL INFORMATION - PUMPING REjGORDS and so r�ce oSnform tion: QRA weia System pumped as pan of ins coon: (yes or no) � If yes, volume pumped 6 gallon5 VA xv,-2 Reason for pumping: M�(\�KX1Q c\tsl_ TYPE OF�STEM 1/Septic tank/distribution box/soil absorption system.. Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,Af any) Other (explain) AP IMATE AGE of all components, date installed (if known) and source of information: �M•l \QC I fL"� Sewage odors detected when arriving at the site: (yes or no) (revised 9/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: \aLA Owner: C5( S Date of Inspection 3\ gb� SEPTIC TANK: I-- ' (locate on site plan) Depth below grade: Material of construction: ,toncrete _metal ^FRP_other(explain) Dimensions:--' tt 4125 2 i tptt Sludge depth: loll Distance from top of sludge to,bottom of outlet tee or baffle: Scum thickness: "l �t1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition-of inlet and outlet tees o baffles de th of liquid level in r Oltelation t utlet invert, structural inte ri , evide^�e o age, etc.) L- g �0 GREASE.TRANCUIC (locate on site plan) Depth below grade-.— Material of construction: _concrete_metal _FRP_other(explain) Dimensions: Scum thickne». Distance from top of scum to top of outlet tee or baffle: Distance from hotto- ni cro- t- bottom of outlet tee or baffle' 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.) .. .caw. (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: J. Q (wc t Owner: O��� - Date of Inspection: 3 `Z4�ate TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: ,,,_concrete metal FRP other(explain) Dimensions: Capacity: Rallons Design flow: Qallons/day Alarm level: j Comments: (condition of inlet tee, condition of alarm and float switches,.etc.) DISTRIBUTION•BOX:✓' (locate on site plan) ,(�,� v I \ Depth of liquid level above outlet inv ert:—vr' v'Jt+1 Comments: (note.isvei and,distuuu`wn 15 eyudl, e�id ncc of solid, carr)o�er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:Ac--. (locate on site plan) Pumps in working ordec(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM it PART C SYSTEM INFORMATION (continued) Property Address:.3 y S• \�. r C�c cMs�y Owner: Date of Inspection: a1.ZQ�a�p SOIL ABSORPTION SYSTEM (SAS):_L--�_ (locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods) . t. If not determined to be present, explain: Type' T , leaching pits, number:a, leaching chambers, number:_ U leaching galleries, number. leaching trenches, number,length:________ leaching fields, number, dimensions: overflow cesspool, number. , CommQLA ents: (note ondi( of soil, si ns f h draulic failure of ponding condition of vegetation,etcJ _ CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of ground'„a:c`: inflow (cesspool must be pumped-as part;of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials.of construction: Dimension;: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) 8 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property dress: Owner: ' Date of Inspectiom 3 t Q`D SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' - Q eA g 0 A Q � AC AD 5 ecp y" DEPTH TO GROUNDWATER Depth to groundwater: 0} feet �S method of determination or approximation: 4QS }- Q (revised 8/15/95) 9 f LOC T10N : 5EW6,6;E PERMIT UO. VILLAGE IW T LL.ER W E ADDRESS 5U LDER 5 Q &" ifDDRt-SS Do►TE PERNA T ISSUED D ATE COMPLI WdCE ISSUED : ��?� 1 ! -� � 1 1 r G I�1 tl ' ��� 1 �, s �� .� 1� �� y�e ......... F .... d....GG..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH U'K"...-------.OF...........4�k Ie.ST.IId L�.. to Apphratiun for Bi,sputitt1 Workii Tomi#rurtion Vantit Application is hereby made for a Permit to Construct ( V) or Repair ( } an Individual Sewage Disposal -- nlY ....-- ...... ...• 1 5... ....................... W--------....-----------------...----••............_..........----•-. ' -- -.Location-Addre c�—� or Lot No �w la �►,,) •.Oa^rr�S �5�.1 1�csa .ca ..........C� �;_►1... ----•--- ...Owner- �---...-•..................... -•-•- .._. ........---- W Add r ss ....A14ne—A . -------------- -------•------------------------- ----- ate. --t�s ------.M .. ----------------------- Installer Address Type of Building Size Lot Type feet Dwelling—No. of Bedrooms____�_•--------------------- Expansion Attic ( ) Garbage Grinder ( ) .a p, Other—Type of Building persons,---'/-------------------- Showers ( ) — Cafeteria ( ) P� Other fixtures ----- ------------------------ - - W Design Flow............................................gallons per person per lay. Total daily flow--------------------------------------._____gallons . f; WSeptic Tank—Liquid capacity/QlXO.gallons Length_.......... Width.-T..... ..... Di�;meter................ Depth__—% _ _c_ x Disposal Trench—No. ..../............. Widtli___.I-------------- Total Length---e----f____.__. Total leaching area--------------------sq. ft. Seepage Pit No---------I......... Diameter...../........... Depth below inlet_.............. Total leaching area----------------..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------- -------------------------------------------------------- Date---------------------------------------- Test Pit No. 1________________minutes per inch Depth of Test Pit--._____..__ --•__- Depth to ground water.__.--.-_.-_.--.-_..._.. G14 Test Pit No. 2---_-________-minutes per inch Depth of Test Pit.................... Depth to ground water--._ ----_-----..-_-__.. M ----- ------ ------ �escrptonooil_------. .-___- _-__. U.......' -------------------------------- ---- oZ _ . W -------------------------------------------------------------------------------------•------------------------------- ------------ V Nature of Repairs or Alterations—Answer when-applicable...--_-./1 --�-_--_ .� ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 11vakh. y Signed ... --••- ltl= •------•-------- t -.` _ - ------ � ---•----------------Date----Application Approved BY------- ------- ----------- --------- Date Application Disapproved f o the following reasons---------------------------------------------------------------------------------------------------•-...-•------- ------------------•----------------------------------------------•---••-----•-......--•-------•-------------•-•--•-------•-----•---------•------------.....--------------------------------------------- Date Permit No------- .. ...:................................ Issued... —�............. Date • No.l 7, ---- z��........ '.................. THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF .H:EALTH V i i � Iirtttin�t for Ditipagat Woris T witrurtinn Vr i�� Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System of ( •••-- --------------------------------------------------------•-•••••... -•---•-•-••-••-••-•• •-•••--•---•---•••......--•---. •-••-••-••••--••-•-•-•---•-•--. Location-Address or Lot No.�+ �j "< = �=� =� �• Owne �� • ---••.......................b ----�...._ ......e!.��i� by....... i....'....... 1 J.l...', k I•• --•- Address a1(..�—t C,., f[ r• - n' # "+�'_ �1�5.--•-•-•--....--•------ Installer Address Type of Building Size Lot:q!R.,__�M-__-____Sq. feet Dwelling—No. of Bedrooms.__- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) a •Other—Type of Buiiding4 c_!_;....:____.. .�.,No. of persons___ _____________________ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------------------------------- W Design Flow...........................................gallons per person per day. Total,da ly flow___-_____-___-___-__-.._-.._":-_ .-.--.....gallons./! WSeptic"Tank—Liquid capacity a____gallons Length............ Width ... ........ Diameter................ Depth' `__rJ1.--. x Disposal Trench—No.•__!---------------- Width.................... Total Length__------_....._.... Total leaching area..-.--.__--__-___-sq. ft. Seepage Pit No._____I------------ Diameter---�n_----------- Depth below inlet.................... Total leaching area------------------sq. It. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date--------------------------------------- �. Test Pit No. 1----------------minutes per inch Depth of lest Pit-----------------.-. Depth to ground water.........--_----_-.-_-- :. Test Pit No. 2___•_-______.-__minutes per inch Depth of Test Pit.................... Depth to ground water--.-_.---__-___...__-__. !� D Description of Soil � r-------------------------------------------------------------------------------------------------------- ---------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- --------------------- Agreement: The undersigned agres-:ztp:=instalf`°the_�folredescribed 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 ha'srlieen issued by the board of health. y { Signed.•',! -_ /,/ ...w!, Ul`9 ................................ ' 1 � Date ApplicationA roved':B -------••---•-•••••-•-•-•-••--••••-•-••--••-•...........................•-- • Date Application Disapproved for the following reasons:................................................................................................................ ---•----------••-•----•"---------•-•-•-----------------------------------------•--••-•-------------------------•--------------------------------------------.--.---•------------_-------•--------- Date Permit No------- ._.. Issued.._.:_-3.._.-:,7s........................... •-----•-----•"------• Date + THE COMMONWEALTH OF MASSACHUSETTS •t BOARD OF HEALTH ;....... -...........OF...........� h Sr, l ..:................ `M Qrrtifirntr of fenntpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) byL-. fz2_r:r�---------/`(✓L_, G-- ------•---•------------ ---------------------------•---------•-------------•-----------------------------...--------•------ Installer 4.� ._...ti has bei.. U� installed in accordance_with the provisions of Article-XI of The S'Cate �anitary Code as described in the application for Disposal Works:Construction Permit No.'/o_.2........................... dated...... -. . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARANTEE THAT THE SYSTEM 1N1 FUNCTI N SATIc,F�7— DATEI..............................................� �- J nspector----- ---- --------- ----------- ---------•-•------------•------_....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.............-----------........ . .. Il tl No.......................... Te,&r4 /7 7• BisVniitt1 Workii Q1,mitrurtinat rrntit Permissionis hereby granted---------------------------------------------------------•-•••...---.............--•--•--•-------•-•••--•--•---••--•••.._.........--.....•...` to Construct ( ) or Repair ( ) an/d+tddWiti IS�ewaispsstem at No.-------- ----ki.,.--- e ��U •k''fs,�i�l Alt. te/G L 5 ...............................----- .....--------•-•----------------••------•-------y--•---•--------------•--... Street ��•-- as shown on the application fo isposal Works Construction Permit No.__..._/�.�___ Dated_.___..J--"_ :3. -----------•_.... \l ol� - DATE--`- =--='-J�•=�---�,�""-=-----------------------------------------• FORM 1255 HOSES & WARREN. INC.. PUBLISHERS 'k At L- • 0013 '. 70, " sEp-ric rgvsf � 4077 Z. ` �jJG'GSRCN' oiaT. • /fie y�=.. �c � L.S7�T /„$' , ,. � ss•oNt qcc � � � e1 P,¢of�iSEG �iA'«/E .. .�il-. 6K�iGN1/ON �ONNO. Aewi?"E= /.F TbkV" AV09TE.e /S — MUST- - - alo �,Sc t/'Susso�L - 51� y RT1Ft ED PLOT . PLAN L,f3 G.i4'F 1 O N MA�6'Tow� M/LL.S S:O,A:L�E: D-ATE IW-4e ze,197.5" : - f E Ft E-N: C E: B ,P�co24>E:-,o %7- 77y I.ct Ot..9/v ,BQofS 2.5�7 P9c�� ���f o A T E' KE R'E B Y . C E R T I F Y T H A.T THE BUI L D I N G R E G. L A N D S U R V E_Y O R Sff-OWN ON THIS PLAN IS. -L0CATED ON - G} ROVN'D AS SHOWN HEREON AND 1'41.A T: C O N F O R M TO THE ai11vG` BY LAWS OF THE TOWN OF ,� WHEN CONSTRUCT E D. � JAM :;xf s J S , F - ARN.STA. BLE, SURVEY CONSULTANTS. . IN.0 ` WEST YARM'OUrH MASS . _ 1,7 BOARD OF WATER COMMISSIONERS CENTERVILLE-OSTERVILLE FIRE DIST. , . OSTERVILLE, MASS. 02655 May 20, 1975 Mr. John Kelly Board of Health Town of Barnstable Hyannis, Mass. Dear Sir: Please be' advised that the Centerville-Osterville Fire District, Water Department are going to install water for Lot #16 J B Drive in the village of Marstons Mills, Mass. Yours truly, i 4 -t- ���„�upt. J ,T TOWN OF BARNSTABLE LOCATION 1 y T- 6 . ORia-c SEWAGE # 9 1 _ 3I F VILLAGE Ill/1 �/"o,1's ��LS`ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 7 9 ?- O '4 4 4 SEPTIC TANK CAPACITY b 0 G"l LEACHING FACILITY:(type) Qh F r,A 5 T (size) f O a n GA j NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER ` out BUILDER OR OWNER Poajck [5k m 5 4 w DATE PERMIT ISSUED: 7 /p 9 DATE COMPLIANCE ISSUED: `I'- f`I " `lI VARIANCE GRANTED: Yes No Asa • w � 3 Zs Fm3....... ©...�...._ THE COMMONWEALTH OF MASSACHUSETTS Wlusr 13E BOARD OF H E A 1 BXKCSYS �YS C MPLIANCE TOWN OF BARNSTA b DE AND Apphration for Disposal Works �. fission Application is hereby made for a Permit to Construct ( ) or Repair Individ 7 System at: Date .....:............................ Loc tion-Address -.-.or.Lot No. ._.Ndi V------------------------------------------------- ---------------- --------------------------------------------.-..---- Q Owner Address w ..d - ........ ......q9----101j4)...bAcale-4 -..........._w-......�!�s0 � Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.................................. .Expansion Attic ( ) Garbage Grinder ( ) U '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ---------------------------••••. . W Design Flow..........,---/40.....................gallons per person per day. Total daily flow.................:!!! 0............_..gallons. WSeptic Tank—Liquid capacity-f040.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........................ f% Test Pit No. 2................minutes per inch Depth-of Test Pit.................... Depth to ground water........................ a •••-••••-•••---------•-----•---•-•-•--•------------•--.....-••••-•••---•----------------------------......................................................... 0 Description of Soil................................................. ............................-----------------------------------•-----------•------------------------....----•-...... x W ••-•••-••--••------------------------------••---•••-----------•-•---•--••-----......---•--......-•••---••-••-••••--•-•--••-••-••----•••-••-•-•-----•-••-••-•......•-----......-•-•-- U Nature of Repairs or Alterations—Answer when applicable._..., JST.9��ATl�s�----aF___•&--_100v... Z.4", �- �Ta" Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the b and of health. Signed ------------1 . -- ...---- ---------------------- Da[e Application Approved B ..L�l' ------- ------- ----------------------- ''� '=-. ...... PP PP y --------------------------- Date Application Disapproved for the following reasons- ----------------------------- -------- ----------------------------------....---------...----------....------------ ------------------------------------------------------------------------------------ ---------- ------------------------------------------------------------------------------------------------------- ............... ---------------- / --------Dale Permit No- -------------le..----�l :..�/Issued 1 44 - No..l. n-?I , Fics........ d,...... THE COMMONWEALTH OF MASSACHUSETTS --- - BOARD OF, HEALTH TOWN OF BARNSTABLE Applirathin.for Disposal Works Tonstr ion PlerrAft Application is hereby made for a Permit to Construct ( ) or Repair ( �� vidual SewageeDispos�al System at: ......... --.................................... L01ion-Address •. or-Lot No. )C�cvJ_ - .!�te!.S. 1.........-•-•.................................... ..........7--• -------------. ......_...._.....__...._.... Owner Address Cr ......................... ---- C�:[�r;�".✓... = 5'1..._.. Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......_....!s�K...........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Otherfixtures -------------------------------•---•---•---•----•-------------•----------•------•-------••--------•---•--...-------•----•-••-------------------••---- W Design Flow...............lt9.....................gallons per person per day. Total daily flow__-_-----_._---._ttv. ..............gallons. WSeptic Tank—Liquid capacity_/s_?oogallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.............S:._.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter......:............. Depth-below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ---------•---------------------•---------------- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------- --•----------------------------------------------------------------- ----------------- •------ -------------- ------------------- ODescription of Soil........................................................................................................................................................................ x U ---•---••--•---••-••---•--•--••--•-•-•------•--------•---•-----•---------•-----•-•-------------•--...........--••--......--------•------------......................................................... •---•-•---------------------•----•-•---•--•-•---••-------------•---•-•---••-----------•-••-•-•---•••----•---------------------------.....-----•--...-----•-•-•----•-----------------------------•--•••. VNature of Repairs,or Alterations—Answer when applicable.._-__:G_t sn vt/4r,-cLa J.... F.....A..._..... A/T e c-.0 1.... ../� J<=. �n ail• 1 7 f C---- ._.�?e M- --�------S��ag.-., :'�---= .............enos-------�'----�5------------•--•-•----------------------...........--------..__. Agreement: -� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with--- the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of� health. Signed....--------. -^�1 C. - ""'� . -f_Ir ---71 �--.r , T pace /I Application Approved BY ... '?�'----- -------------------- /Date�= —1...- f Application Disapproved for the following reasons: .--..-...------ --------------------- d ---------------- ---- ----------------------------------------------------------------------------------------------------------------------------------------------- ---------------------' --------------------------.....-------- Date Permit No.--...... A 7/e Issued ............. J _V Date 1 THE COMMONWEALTH OWASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#tftrate of (11pomplian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ✓) by....................... .................................................... --------.c ... Installer at ......................................................................�2� .. ._. tom! -- '�`1 .l-s'-a�' ..c�L"1 " - has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as de cribed in the application for Disposal Works Construction Permit No. -..,911-e--.�..lg.......... dated ............ �J�..- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....--.. ......... ------------------------- Inspector ff '7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE • °p No......................... FEE....S.P.... Disposal Verho (Snndrur#ion Vamit Permission is hereby granted............... _;, ��... :.. �.a S .tttia. ----•-------.................................--•---........................._ to Construct ( ) or Repair an Individual Sewage Disposal System at No., l_Z ._._ ....��?! ? r Af?fir. ?�- ''�!r ._...-------•-•---------------•--•---....... Street `� t ! as shown on the application for Disposal Works Construction Permit No�.--/�.......... ed........ _.._ - --_" � ..................� _ =��. _ ...... .................... Board of health � DATE------.... , ........................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS