HomeMy WebLinkAbout0018 STAYSAIL CIRCLE - Health 18 Staysail Circle
t Marstons Mills P
.A, 1058 '.016008
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1
No.-0100 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppliLation for NspoSal *pstem Construction permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System F?rdividual Components
Location Address or Lot No. Owner's Name,Address,,and Tel.No.
�
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
c. 6 ov
Type of B lding:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Certificate of
Compliance has been issued b Board of Health. j
i d Aa Date J /
Application Approved byL&L) Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
4�
1 No. r i t/ THE COMMONWEALTH OF MASSACHUSETTS Entered m computerYes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppliLation-for Disposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repairk(✓S Upgrade( ) Abandon( ) ❑Complete System H"Indtvidual Components
Location Address or Lot No., S��'�/ �C.\1 - Owner's Name,Address,and Tel.No.
3 M oc C�Gw• C k y S-c law\4
Assessor's Map/Parcel bjo A ()()Li
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
c, t f 61 ,c c
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
m Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) !gbx 4�-C(P`k�J1i'�M �A c
Date last inspected:
Agreement:
t4.
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 Certificate of
Compliance has been issued b t s Board ofHealth.
igned + °' a`�r Date
p �
Application Approved by ® l Date
Application Disapproved by Date
for the following reasons
I Y'T
Permit No. r!`� Date Issued /
• r r ,
------------
--------------- --------------
} THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
} r Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( )
Abandoned( )by ��,, l,S, �r C.✓��/l.
=— at M cA c kjD A rA t N�S has been constructed'.�cc/o d -Ieg j
with the provisions of Title 5 and the for Disposal System Construction PermitNoOj(/calate'd j d (��! �l
Installer SC6 Vt M 1�MV�\s(., Designer
#bedrobms Approved design flow n jl/11rI gpd
The issuance of this pennq shall not be construed as a guarantee that the system will tion as designed.
Date j .tf t Inspector 1 / A.
No. '`Y` Fee
j THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstent Construction 3pPrm t
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must b co Ie a ithin three years of the date of this permit
Date Approved by
i r V
,M1 I
TOWN OF BARNSTABLE
LOCATIONS _S � � � L ��r(• SEWAGE#
{VILLAGEM e( M tt `S ASSESSOR'S MAP&PARCEL o a
INSTALLER'S NAME&PHONE NO. 3C;3)6 �•-Gy��iC, �"�}� �11 6t�9 ry
SEPTIC TANK CAPACITY
LEACHING FACILITY. (type) ��( . `. a( e) (`?� C,L4,,t,,fAt
NO.OF BEDROOMS
OWNER �' \ C'1 O-c'C,,
PERMIT DATE: COMPLIANCE DATE: % %oZ 117
Separation Distance_Between the:
Maximum Adjusted Groundwater Table to the 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 Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
i
1.�
a 1 e cA� %A 40 d3 lax
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL S3
LOT
TITLE 5
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: N�D
Owner's Na me'
Owner's Address: 1) � � /
ECE
Date of Inspection p NovE E
� 5 ZQ03
Name of Inspector- please print) �• 1`�LI�C'f�'"t
Company Name ji �� TOWN OF BARNSTABLE
Mailing Address: " py HEALTH DEPT.
.
Telephone Number: t "771
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information rt.poned
below is true; accurate and complete as of the time of the inspection. The inspection was performed based on nay
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 r
Inspector's Signature: Date:
L..
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
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 I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. A SS stem Passes:
V I have not found an information which indicates that any y of the failure criteria described in 310 CMR
15.303 or in 310 CMR.15:304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a.complyingse tic tank as'a roved b y the Board
P p pp � B rd 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:
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
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4.4`
Owner:
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 public health, safety or the environment.
1. System will pass unless'Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which.will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is freefrom pollution from thatTfacility 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
T
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
4 �1
Owner:
Date of Inspection:
A System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to'each of the following for all inspections:
Yes N
Backup of sewage into facility or system ga
— P m component due to overloaded or c]o ed Y Y SAS or cesspool
P
Jb
P
t/ Discharge or ondin of effluent to the surface of the around or surface waters due to a v P g J n overloaded or
clogged SAS or cesspool
VStatic 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 '/day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy is within 50.feet of a private water supply well.
_ Any portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria
�� are triggered.A copy of the analysis must be attached to this form.]
//A0 (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
— i 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
Pb
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B.
CHECKLIST
Property Address: p
-6to�� A`11'o vul'vp
Owner: h7p A(
Date of Inspection:a t66U-6_Z2 4_,-X 3
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 ?
_ jZHave large.volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
LZ_ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site
Were the septic tank manholes uncovered,.opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions,depth of liquid,depth,of sludge and depth of scum?
V_ _ 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:
YZeso
Existing information. For example,a plan.at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of I l
OFFICIAL-INSPECTION-FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION
Cld
Property Address:
t
Owner:
Date of Inspection: /
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):�� . Number of bedrooms(actual):
DESIGN flow based on 310 CvIR 15.203 (for example: 11:0 gpd x#of bedrooms):
Number of current residents: Q
Does residence.have.a garbage grinder(yes or no): Qy
Is laundry on a separate sewage system (yes or no) .(if yes separate inspection required)
Laundry system inspected(ye or no):
Seasonal use: (yes or no): (' ..
Water meter readings, if a ailab]e(last 2 years usage(gpd)): 01`3 1" �V
Sump pump(yes or no)-kJ
Last date of occupancy:
COMMERCIAUINDUSTRIAL/&�'
Type of establishment
Design flow(based on 310 CMR.15.203): gpd '
Basis of design flow('seats/persons/sgft,etc.):
Grease trap present(yes or no):_
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source:of information:
Was system pumped as part of the Inspection(y4kr no)X
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason'-for pumping-'
OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_'Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy'of the DEP.approval
_Other(describe):
Approximate age of aJJ eom onents, date installed(if known)and source of information`.
Were sewage odorsdetected when arriving at the site(yes or no) AO--
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
� ,� a
Property Address: i
Owner: �`
Date of Inspection: C�
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK: locate on site plan)
Depth below grade:
Material of construction: ncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:— 1s age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) c� /
Dimensions: X 51
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom f outlet tee o baffle: 7—
How were dimensions determined:
Comments(on pumping recomme ations,4nlet and outlet tee or baffle condition, structural integrity, liquid levels
as elated to outlet invert,evi ce of leakage, tc.):
GREASE TRAP✓ &(locate on.site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address k A19 iLai
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: "d`(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete .metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: ✓(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: � �
Comments (note if box is level and distribution�outletsqual, any evidence of solids carryover,any evidence of
1 kage into or out of box, etc.):
/t
PUMP CHAMBER: Jb-(Focate 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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued
Property Address: i-11ni, 114v&
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
eaching pits,number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation,
et
I/
lei
CESSPOOLS: cesspool must be pumped as part of inspect ion)(]ocate on site plan) l e
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY:�cate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /WJ61 A-YlKlyd,�d,
Owner: AL
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
o ,1 II '
y
3�
3c}d
..L7,n CC
Q P
moo Jcal�
Lead-) P i
10
Page I I of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: le&tl
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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 150 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:
11
Permit Numbe.r:. Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Z4 6,La Y6
/� (�1/^G Lot No. .
Owner:
.Address:
Contractor: Address:
Notes: .. �'/"����✓
STEP 1 Measure depth to water*table
to nearest 1/10 L. .......................... .................... .Datz Z/�J
month/day/Year
STEP 2 Using Water-Level Range Zone
and•lndex Wel'I'Map locate
• l
site.and determine: i
Appropriate index well........... ......................v� .... (��
I
Water-level range zone ..........
STEP 3 Using month) ort."Curre n
- �/ report. t
Water Resources Conditions"
determine current depth to
water level-for index Well .-- --
month/year
STEP EP Using ,Table of 1Nater-level Adjustments
for index well (STEP 2A), current depth
to Water level for index.well (STEP 3)., i
'and water-level zone (STEP 2B)
determine water-level adjustment-.......................... ) 1 61
....................................
'STEP
=P S . .Estimate depth to high'water
by subtracting the water-
I vel adjustment (STEP 4)
from measured'depth to water
level al site (STEP 1) .:................
Figure 13,Reproducible computation germ.
i
f ri.�RRq. �
�i�r:
:� I,..._.............,�.. -_ .....»,�,,....�....�:I..,..:1 �"7� �,.,.....,........_m,.....,,.....,..,��-_.....,,...�j.:.:_,.,,,. ....� ,.,, I i:flr���«S'a�y....,�1__..,,.,...
`.t�l �Lc�`l,ti
�:___._ .___...._�._.._.��..__.__�.__�Y......�.
� ��
. .,,
!
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ltr #t mal Works TumUits#tutt thrmit
Applica ' n is here y made for a Permit to Cons ct ( or Repair ( ) an Individual Sewage Disposal
System/at:
..... .. ....._...... .......... ...........................q.:................----• f ^ /.. .<11 .... -- ....
/ Loc t•on-Ad ess or Lot No.
...............Y..Q ................. O d { .................... ....I......._.......---...•-• .---- •.............................................---....
O ne Address
a � 1 ..................................................... ............•---------••-•----.--- _------ ------------------------------------------------------
Installer Address
Type of Building Size Lot---! ZBS Sq. feet
�. Dwelling No. of Bedrooms.................. ...........__.._...Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow............................. S..gallons per person per day. Total daily flow---_.......133_a.................gallons.
WSeptic Tank—Liquid capacity��de.gallons Length_ '�"- Width_'_'_."!�*_Diameter________________ Depth.-�"`7`.''
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......`........... Diameter.A�..._.o v Depth below inlet.... Total leaching area......6P .sq. ft.
Z Other Distribution box (X) Dosing tank ) //
~' Percolation Test Result Performed by.............�b................................. ................... Date......�I.� .......
as Test Pit No. 1______ ________minutes per inch Depth of Test Pit.....--•--.__..-� .
__-- Depth to ground water__/ ....
fX4 Test Pit No. 2................minutes per
^^inch Depth of Test Pit.................... Depth to ground water........................
a ----------/___oF--'S-o,t• ..................................................m...........................................................
O Description of Soil......... r`� S�-�� =v�`�6frt.Z-------------------------------------------........---- ----------------------------------
U ---------- ------......!/- ---- ------
rW -•--- ------------------•-- ------ «Pr .? e .......................--.............................
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 iITiE 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 y th oard o iealth.
Signed................• ......................
Application Approved )� -- _..! s._.�t_ � _ jl� ZV�Y
Date
Application Disapproved for the following reasons-..........................=.....................................................................................
----------------------------------------------------------------------•----------------------------------------•-----•-••-•-------•------••••---•-•.....•-----------. ..................................
Date
Permit No..... .......� ................ Issued.........?1. E. . S
Date
11�
No................_....... ` FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
-- - BOARD OF HEALTH
Appliratinn for Disposal Works Cnnnitrurtiun amit
Application is hereby made for a Permit to Construct (X or Repair ( } an Individual Sewage Disposal
System at:
............................................ _ / tea/S, r �i,z.................................
Lotion-A ess/' or Lot No.
O(wnet Address
-- .._..__.:�� �R!!?........,_lC—Instta ller�Q•......................... ..... ......._... Address...------................-•�.............
d Type of Building Size Lot.. ............:`...Sq. feet
Dwelling—No. of Bedrooms.................. ._.____.....__.._...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ________________________•••- No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures ,_.......................... .
W Design Flow............................ -'`........__.gallons per person perday. Total daily flow...........�� -' .................gallons.
WSeptic Tank—Liquid capacityf .e/C>.gallons LengthZ� -'." Width:y'-1'_``` Diameter________________ Depth-5-.,7."
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 ()C ) Dosing tank ( )
~' Percolation Test Results Performed by.............Z ...................................................... Date......9�/.. .. _.....
aTest Pit No. 1-------��------minutes per inch Depth of Test Pit----- ....... Depth to ground water..Z��__--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._..__--__-___---_-___-
� a `.-------•---TG�s --.-------------
O Description of Soil........ - 5.5�� S ds�,/ -------- •-•----•-•-- ---------------
</= �� 7 =%/ , 5�. -----------------------
.. . �_m.lam ;1�------
x L C/�..
U z�Z....�y.. ..............
W _.............y........ /e7�i r/+s....... �-- r o ya•r s. _ _:J_...._.
UNature 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 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.
Signed...........................................................
•••. ................................
Application Approved :.: �� ����=•.~-` === ..........••.... ..1/ •-•---
Date
Application Disapproved for the following reasons:-...............................................................................................................
..-•----------•-•-------•-..........-•••••••....._••-•.._.....---••-•-••••-••-••--••--.......•••••-•••-----••-----•-------•-----••--------------------•-••-•••--•••••••-•-----------....••••----••••.•--
G-7 2 Date
Permit No............... J �'.....................•--------•--,-------- Issued..-•-----�-�4ate-��-•-•- ��
THE COMMONWEALTH OF MASSACHUSETTS
~�----•— BOARD OF HEALTH
.................................I........OF................. .......................I......................
Currtifiratr of Tnntplianrr
THIS.IS TO CERTIFY,, hat the Individual Sewage Disposal System constructed ( ) .or Repaired
L? ......•. •_tom-.�. .cC ..............•. ••
nstall
at Cn = ✓�... f=�� r c. /c�c �A Y1� I S
------. -- ---•--------------•----•---•--------------------•---------•----------------
has been installed in accordance with the provisions of '1`1 5 of The State Sanitary Code as d scrib d in the
application for Disposal Works Construction Permit No..__...U.�._.._�'-?.7-_'��-...... da.ted.............1._( ...��.__.jG 9........
TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................................•-•--......•••..•••-• Inspector-------.................................. ..........................................
THE COMMONWEALTH OF MASSACHUSETTS' ,- ,:.:,
BOARD OF HEALTH
o
/ 7� ..........................................OF...... ...!...5..!...�...�C... a
No......................... FEE...-•-...-- .
Disposal Works U trlwwn vrrmit
Permission is hereby granted................ !.!!........ to............................................................................
to Construct or Repair ( _),an IndividuaL-Sewage Dis psal terp
at No.•-•••••---�'......••�'•................ .�I` .(`.< c�....
Street /'6 4T 6;'
as shown on the application for Disposal Works Construction Permit No..--. _-•_-___ ___7 ated--____-_1/ . 3��_ .......
-
........................••--•••-•-- 1--•----••--------------•------------•--------------
_ Board of Health
DATE................ - -•---/.•-----------------------•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
0/�- ' v
TOWN OF BARNSTABLE
L'JCATION Zo 7 /, {5 �> s ./ c , d� SEWAGE # -,7�
VILLAGE /�J�r;;7`�.�s ��'�1�5 ASSESSOR'S MAP LOT 6
INSTALLER'S NAME & PHONE NO. J 0
SEPTIC TANK CAPACITY
LEACHING; FACILITY:(type) '' ��,f (size) Z414
NO. OF BL"DROOMS _3 PRIVATE WELL OR PUBLIC WATERhv
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COZIP.LIANCE ISSUED:
VARIANCE GRANTED: Yes No
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