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HomeMy WebLinkAbout1555 RACE LANE - Health 1555 RACE�y! One -- -A-,= 047 274 way ' p✓J ►L LS TOWN OF BARNSTABLE o C� LOCATION ; S S S 9 AC(— t A'JF SEWAGE # 020 0 t. ''VIJ,LAGE (MA t2E'drnl S i I�S ASSESSOR'S MAP &`LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ! o O LEACHING FACILITY: (ty (size) i a a:)e a S NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 15 is 1 aozo COMPLIANCE DATE: I S I a®e 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 faciTr"n) Feet Edge of Wetland and Leaching Facility(If a&wetlands exist within 300 feet of leaching facility) Feet Furnished by _ _-- r. � �' may, � � � yr! ._ �`.• O i � .��- .� . _ , . 55. '� � .F�: , „ r f . ILI I No. Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for Miopozal *p5tem Con.5trurtion Permit Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 1555 Race Lane , Marstons Mills John Latino -Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) T i t l e—5 l e a c h s y s t e m for tKee bedrooms to code , with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of Health. Signed �l !/ . � Date Application Approved by Date��OcO c� Application Disapproved for the fo owing reasons Permit No. Date Issued --- TOWN OF BARNSTABLE LOCATION ' SS 5 �Z�c�� I ArJF SEWAGE # a e i.1 VILLAGE IM i ASSESSOR'S MAP &&'Ldr INSTALLER'S NAME&PHONE NO. ^bi JSc �C-fJ c '17S—�77 C� SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) ' ` Rom/ C«S (size) i 2:6 a x 3L 5 I NO.OF BEDROOMS BUILDER OR OWNER I PERMITDATE:_5jl_tae!-I��COMPLIANCE DATE: c (ace 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 Feet on site or within 200 feet of leaching facilh) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by i ,ss 1 o ' i �Hh t _ ' No. t f — " Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for �Digoar *p5tem Conotruction Verna Application for a Permit to Construct( )Repair(X.)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 1555 Race Lane , Marstons Mills John Latino Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: t Dwelling No.of Bedrooms 3 ,' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. era • Title- leach system Nature of Repairs or�terahons(Answer when applicable) 5 Y for tIee bedrooms to code, with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of Health. s Signed Date' o Application Approved by 9..�... '� ..�w..M..-. Date 5---_5- o o Application Disapproved for the following reasons Permit No. Date Issued • THE COMMONWEALTH OF MASSACHUSETTS Latins BARNSTABLE, MASSACHUSETTS Certiftcate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal S stem Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic gervice at 1555 Race Lane, Marstons M s has been constructed in accordance with the rgyision f TWe g and the for s osal System Construction Permit No.�- a dated . Installerp Wm. O D ins on �. y Designer Y The issuance of s p rnit Isall not be-construed as a guarantee that the t qv ll fuyncti n as desig I /� Date 7 Inspector , ' �1 �j / f / , 'rl rrr111 R v v- r �v SYS k..,., tr►,l y 1, y ——————————————————————————————— -- a - - , $50 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Latino nigogal *p5tem Con.5tructton 3permft Permission is hereby rite t Constrt( )Re air( X)U lade,( )Abandon( ) System located at ace dace Lane, I$tarstonps� Mills and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by . f ups NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMrr(WITHOUT DESIGNED PLANSI William E. R o))ins on,S t%ereby certify that the application for disposal works construction permit signed by me dated ;;i — 0 , concerning the property located at 155 5 R a n e L2 n e - , Mar s t o n-P, =11 lR meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with a dwelling. The soil is classifi as CLASS I and the percolation rate is less than or equal to S minutes per inch. There are no well within 100 feet of the proposed septic system - There are no pri to wells within 150 feet of the proposed septic system There is no i ease in flow and/or change in use proposed • There are no requested or needed. • The botto of the proposed leaching facility will got be located less than five feet above the maAdm adjusted groundwater table elevation: f Adjust the groundwater table using the Frimptor meth vhen applicablel • the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) (J �f B) G.W. Elevation +the IvtA1l'- High G.W. Adjustment:__ = .� DIFFERENCE BETWEEN A and B _ SIGNED : DATE: (Sketch proposed plan of system on backl. y:health folder:een .� . ,. 1 `�----.�_-._� i �.� ti � k� r. ,� ,, � � i ___, `i /''r ��.� y .� CO.MMO WE.ALTH OF MASSACHL;SETTS EhECI:TIVE OFFICE OF ENVIRO\MENTAL AFFAIRS F DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON MLA,0210c t617i 292-550i, TRH DY COX: Secretary ARGEO PAUL CELLUCC1 DAVID B STP. .'HS Governor Coramissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop"Address:1555 Race Lane Nameofowner John Latino Marstons Mills Address of Owner: I Date of Inspection: Name of Inspector:(Please Print)WM. E . Robinson S r. 1 am a DEP approved systertl inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) ConpanyName: Wm. E . Robinsoneptic Service Mailing Address: P4 Box 1089, Centerville , MA Telephone Number: 7 5—R 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on- ewage disposal systems. The system: site Passes i Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �IAJ ,1,t'l, za, Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS JUL 2 � 2000 revised 9%2/98 Page Iof11 H SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'ropeMAddress:1555 Race Lane , Marstons Mills Owner: John Latino Date of Inspection: y a--V INSPECTION SUMMARY. Check OB, C, of D: A. SYS PASSES: I have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM CONDITIONALLY PASSES: One'or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system• upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate es, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 1555 Race Lane , Marstons Mills Owner: John Latino Date of Inspection: L: -,S- D. SY TEM FAILS: You mus indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d termination is identified below. The Board of Health should be contacted to determine what will bi necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded orclogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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 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 j acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for 'coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must iI dicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: 4he 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 and safety and the environment because one or more of the following conditions exist: 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) The owne,.or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of t e Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icorrtinued) Prop"Addre4555 Race Lane , Marstons Mills owner: John Lat ino Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 f1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) S TEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 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. Method used to determine distance (approximation not valid). 31 OTHER revised 9/2/58 Page 3 of 11 l - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: 1555 Race Lane , Marstons Mills Owner: John Latino Date of Inspection: �,,'•S"O—'� Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined, Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. V _ All system components, excluding the Soil Absorption System, have been located on the site. j _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example, Plan at B.O.N. Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (1.5.302(3)(b)) v/ The facility owner(and occupants,if different from owner) were provided with information on the propermaintanancii-0f Subsurface Disposal Systems. revised 9/.2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION Irop"Address: 1555 Race Lane , Marstons Mills °iwrer John Latino Date of Inspection: 5 6. 0 FLOW CONDITIONS RESIDENTIAL: Design flow: 9,<6 g.p.d.lbedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow t�,<4 Number of current residents:-0-1--3 Garbage grinder(yes or no): A,C) Laundry(separate system) (yes or no):,!�,O If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):Z-1-0 Water meter readings, if available (last two year's usage(gpd): 1999 137, 000 gal. Sump Pump(yes or no►:�L0 1998 126, 000 gal. Last date of occupancy: G�fm�� COM ERCIAL/INDUSTRIAL: Type o establishment: Design ow: god ( Based on 15.203) Basis of design flow Grease t ap present: (yes or no)_ Industrie I Waste Holding Tank present: (yes or no)_ Non•san tary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last da a of occupancy: OTHE : (Describe) Last to of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records;if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other r 0 APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) revised G/2/9E PaFc6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coetfirand) -ropertYAddress: 1555 Race Lane , Marstons M-lls Owner: John Latino Date of Inspection: Sul ING SEWER: (Loa on site plan) Depth b low grade:_ Material f construction:_cast iron_40 PVC_other(explain) Distance rom private water supply well or suction line Diameter Commen s: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) t Depth below grade: Material of construction:_k4crete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ ls.age confirmed by Certificate of Compliance_ (Yes/No) t. Dimensions: Sludge depth:_ 11 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O , t Distance from top of scum to top of outlet tee or baffle: r r Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: C 'omments: (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, a .) --a � ' �I- /� c a '" 02 GA SE TRAP:- (locate on site plan) Depth below grade:_ Materi I of construction:_concrete_metal Fiberglass _Polyethylene_other(explain) Dimen ions: Scum hickness: Dista ce from top of scum to top of outlet tee or baffle: Dist ce from bottom of scum to bottom of outlet tee or baffle: Dat of last pumping: Com ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , •' PART C SYSTEM INFORMATION(continued) 'roperty Address: 1555 Race Lane , Marstons Mills Owner: John Latino Date of Inspection:G^� TIG TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iloca on site plan) Depth elow grade:_ Materia of construction:_concrete metal_Fiberglass_Polyethylene_other(explain) Dimensio s: Capacity. gallons Design fl w: gallons day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of Previous pumping: Comments: lconditkn of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: t/ (locate on site plan) Depth of liquid level above outlet invert:` Comments: (note if level and distribution is equal, evidence of solids carryover, ev dence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate n site plan) Pumps n working order: (Yes or No) Alarms in working order(Yes or No) Com nts: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4op"Address: 155 ,Race Lane , Marstons Mills Owner: John Latino Date of Inspection: G_S_6 <) SOIL ABSORPTION SYSTEM(SAS):i/ flocate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits; number:_ leaching chambers,number:_-- leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hyd ulic fail re, level of ponding, damp soil, condition of vegetation, etc.) In g6 CESS OOLS:_ flocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 7epth of isolids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: 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:_ (iota a on site plan) Mater Is of construction: Dimensions: Depth f solids: Comm nts: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Y reuse 5/�/7� Page 9 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "Irop"Address: 1555 Race Lane , Marstons Mills JWrW: John Latino Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) IW iW i 1 C-. �l - •�xt e revised 9;2/9R Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ►opertyAdd►ess: 1555 Race Lane , Marstons Mills OWf1e►. John Latino Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: • Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions :v ` hecked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe hoowl you established the High Groundwater Elevation. (Must be completed) J3 GV rA4 . S 7 0''> '5 r revised Page ii orii /3 F F . ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH „y � .......�OUJQ.............OF..... ............... Appliration for Uispaaal Works Tonstrurtion ramit 14Application is. hereby made for a Permit to Construct (V ) or Repair an Individual Sewage Disposal stem at: qq ............................................. .. ............................. ....................... ........................... s ................ .. ...CU4� ---------------- Owner Address ........... 14 ..............................................Installer......................................... .................................................................................................. Address 9 44- Type of Building -2 Size Lot.!�:Q.19�------'-..Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder yp Other—Te of Buildin r g ............................ No. of persons.....-------------------__-- Showers Cafeteria Othefi t s ................................................................................................ **'**'*''*''*"' ....... Design Flow..........tg�� -----------------gallons per person per day. Total daily flow......... Septic Tank—Liquidcapacit�W..O..gallons LengthE�) --6'Width................ Diame*t'er4..*...10-i.l. Depth.-L'=3' Disposal Trench—No..................... Width.................... Total Length... ...___.._._.... . ............. Total leaching area.. sq ft. Seepage Pit No.......I........ iameter.-71:73. 1 .... Depth below inlet.'.. -P...... Total leaching areal 4 P> Z Other Distribution box (�e Dosing"tank ( ) '.4 Percolation Test Results Performed by.-AZEO. ..... ..1110(-Date... 17- 5rS 1.4 Test Pit No. I................minutes.............minutes per inch Depth of Test Pit-__.iZ........... Depth to ground water rXq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___._.................. ........ . .........I.... ....... --------­­------"---------------------------------------....... --------- ......*--------- 0 Description of Soil____. <=31) ..... .......7---------­---------*------ ----------------------*......I........ ... ............1�2k?------7:..... itI C.L_k_A01 ,................................................... ................................. A.Ij L U ................................................................................................ ........................................................................................................................................................................................................ 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 TL Ili U 5 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` y the board Qf. health. Signed...,J_ja,.- 7 . '6,C_Q 13 See- ........................... ................................ Application Approved By ........................................... ...../.. W .. .... .............. Date Application Disapproved for the following reasons:.............................................................................................................. ................................................................................................................................................ Date .............. -----------------*------------ Permit No.... Issued..... -------------------- . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratio In" for Disposal Works Tonstrurtion "umit Application is hereby made for a Permit to Construct (1/�or Repair an Individual Sewage Disposal Sygtem at: Owner Address PQ Installer Address Z Other Distribution box Dosing�,tank �4 Percolation Test Results Performed ................... 0-� Test Pit No. I..... .......minutesperinch Depth of Test Pit------ ......... Depth to ground water. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-been issued by the board of health. Date Date Dat /------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH dr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired Installer has been installed in accordance with the provisions of TIT1.1 ,.1ol The State Sanitary Code as described in the THE ISSUANCE OF THIS CERTIFICATE SHALL Nt%-r BE gO NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 7,9-0�44 THE CO ONWEALTH OF MASSACHUSETTS OARD OF HEALTH Permission is hereby .'--_—_—_-''----'---_-----------_-_------------------.-------'---- toConstruct 8�h� at No .......................................................Street � ou shown oothe application for Disposal Worku Construction Permit No�_ Dated ' ' / � _ � ` ronM /ass xoaoo & W»nncw. INC., PUBLISHERS. / ��� TOWN OF BARNSTABLE I 4,--derEo s -47��9 � LOCATION 11 1�T SEWAGE # AN VILLAGE /U&0j�I�NS MIL(S ASSESSOR'S MAP & LOT ` INSTALLER'S NAME & PHONE NO. 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