HomeMy WebLinkAbout0139 TUPELO ROAD - Health 139 Tupelo Road
Marstons Mills P
A = 057 120
TOWN OF BARNSTABLE
LOCATION L 4 -o ?tc o V or,I SEWAGE #
VILLAGE 1MU6IGM ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 771-(d 0
SEPTIC TANK CAPACITY !, 6NQO g-1I1a'^S
LEACHING FACILITY:(type) �e`'cL- (size) 1c08QSatl S
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATE
BUILDER OR OWNER P�^��'� ��'1d;�5 �e 771- 1-0y
DATE PERMIT ISSUED: { Z-c) i Q
DATE COMPLIANCE ISSUED: . ��•>
i� VARIANCE GRANTED: Yes No
4j
COMMONWEALTH OF MASSACHUSETTS
a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
s DEPARTMENT OF ENVIRONMENTAL PROTECT
RECEIVE®
MAR
PARCEL ' � �® MAY 3 0 2003
LOT ' -�•� TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 139 Tupelo Road
Marstons Mills MA 02648
Owner's Name: Eckler Family Trust. Bradley Eckler,Trustee
Owner's Address: 61 Potter Street
Concord MA 01742
Date of Inspection: May 7,2003
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: (508)428-1779
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 FurthjEtvalluatio by the Local Approving Authority
Fails
Inspector's Signature:Vc/�'ti—�. Date: 610 I6
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: System in good condition.Recommend annual pumping with use of garbage grinder.
****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 I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler FamilyTrust.Bradley Eckler,Trustee
Y
Date of Inspection: May 7,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ 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:
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 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:
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:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May 7,2003
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 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:
Page 4 of i l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May 7,2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone l of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ 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.]
No_(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.
A
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust. Bradley Eckler,Trustee
Date of Inspection: May 7,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks')
_ _X_ Has the system received normal flows in the previous two week period?
_ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection')
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ — Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
_X_ _ 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?
_X _ 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
_X_ _ Existing information.For example,a plan at the Board of Health.
_X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR I5,302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May 7,2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330
Number of current residents: 0
Does residence have a garbage grinder(yes or no):Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):No
Water meter readings, if available(last 2 years usage(gpd)): 2001—97,000 gal. 2002—92,000 gal.=259 gpd.
Sump pump(yes or no): No
Last date of occupancy: January 2003
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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): i
GENERAL INFORMATION
Pumping Records None
Source of information: Checked with treatment plant.
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped:__ gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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 all components,date installed(if known)and source of information:
Compliance date: 1/21/94
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May 7,2003
BUILDING SEWER: X (locate on site plan)
Depth below grade: 30"
Materials of construction:_cast iron _X^40 PVC_other(explain):
Distance from private water supply well or suction line: 32'
Comments(on condition of joints,venting,evidence of leakage,etc.):
Pipe in good condition.No evidence of leaks.
SEPTIC TANK: X (locate on site plan)
Depth below grade:
Material of construction:—X—concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8'long x 5.2'wide—1000 gal.
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle:34"
Scum thickness: 7"
Distance from top of scum to top of outlet tee or baffle: 19"
Distance from bottom of scum to bottom of outlet tee or baffle:2"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tank in good condition liquid level below outlet pipe due to evaporation and lack of use.
GREASE TRAP: No (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.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May 7,2003
TIGHT or HOLDING TANK: No (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: X (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
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.): Box set level,no high water stains.
PUMP CHAMBER: No (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.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May'7,2003
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6(1000 gal)pit.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
No excessive vegetation over pit area leaching pit located but not excavated due to excessive depth.
CESSPOOLS: No (cesspool must be pumped as part of inspection) (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 groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: No (locate 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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust. Bradley Eckler,Trustee
Date of Inspection: May 7,2003
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.
-'u�6
33 'l
zu
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 139 Tupelo Road,Marstons Mills
Owner: Eckler Family Trust.Bradley Eckler,Trustee
Date of Inspection: May 7,2003
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 25 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)
X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Checked Town of Barnstable G.I.S. Groundwater contour map showing groundwater at el.25.Also
checked USGS Cotuit quadrangle map showing property above el.50. Bottom of SAS 9.5 feet below grade
leaving more than 15 feet separation between bottom of leaching and groundwater.
No.--72..... _ 0 d..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appfiratiou for Diapnsai Works Tinwitrnrtinn Permit
Application is hereby made for a Permit to Construct 00 or Repair ( ) an Individual Sewage Disposal
SLUtem T at:
9 9 'k/#amfiR * 7 A51Q) /W rM l�1 5
................a.._..... ........................................ --....---.............................----.------...--.--.------.------.--.------..............._.
cati n- ddress /off of-No.
- _.... .................................................................
Owner Address
Installer Address
Q Type of Building Size Lot...y `S Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (Ald
a
p, Other—Type of BuildingWOPA...FreR!s?t No. of persons____________________________ Showers ( ) — Cafeteria ( )
dOther fixtures . ----------- ai-
W Design Flow.................ZZO...................gallons per per day. Total daily flow...................._-----_____.._..._------gallons.
94 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
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 ank ( )
Percolation Test Results Performed by.-,.. �!._ K... ......�---------------------- Date.._.____..._._......,._`. ..._:._....
aTest Pit No. 1.... ...minutes per inch Depth of Test Pit...../�........ Depth to ground water__AT.... . .
Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
O Description of Soil__01.._-a`....LU ..�`.5U8 5 41E_ '
I
x
V ---------------••----------------------------------------------------•------------.............---------------------------------------------------------......-----------------------------.....--------
W ....................----................................................................................................................................................................................
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 Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compkaa ce een i/s d by the board of health.
Signed .. �... .--------------------------..........---...............---- -------------------------------------
Date
Application Approved By ..........
---- .< ' U ` .tom',. `'"" Dne
Application Disapproved for the following reasons- ------------ -- ----------------------------------------------- --------------------------------------------------------------
------------------------ --------..............----------- ........................................---...........--...-....................... ................. ........................
Permit No. ........ °� ".. - ..� Issued 4
J//( Dale
......................... ..--..--1 ......... .... .......--................
Dace
S`2
•f r I NO.. �.. '^... .../ F - FES......./!- en.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Rapoal Works To ngfrnnr#ion ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
LU1 ,; 9...cl...Lvl�ITNI9R � ; tllP LD �= /W!LL s ......................................
1 ' L catio - ddress or Lot o.
...•• ...................................•--•-......-•-••---•-----...-•-------•...----........
r^ caner Address
Installer Address
UType of Building Size Lot___y3_' ..... feet
�. Dwelling—No. of Bedrooms............................................Expansion' Attic ( ) Garbage Grinder (A/()
Other—Type of Building LiJ(1A___hk&? N No. of persons____________________________ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------- --------------• -
ZI�Z:------------------------------------------------------•---------------•---------------------••••--------
W Design Flow.................Y.0_..................gallons per per--sonmper day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---_---------------- Diameter...............__--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing t nk ( )
a Percolation Test Results Performed by._ _ _ ,......
y..........V____ ...................... Date___._..a_....................... s
Test Pit No. I...'C_�...minutes per inch Depth of Test Pit-----zs�:........ Depth to ground water_.•N?� �.__-
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' ----------------•------------•--------•--•---•------•--•-------------•-•---•----------------•-•••---.........................................................
0 Description of Soil--lJ'.. a-I---L��_-71 YI g- 5U(3_S U/L--..;� ...0..............................................M, 1 . il
x
W
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 Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of CompW issued by the board of health.
Signed . 4/g ........�,........-----.........-........--...-.....------......-...-' -----..-...-..Date...-..._....--..
Application Approved By ............. _'.. ... ......... /.��
Date .9.a
Application Disapproved for the following reasons' -------------------------------------------------------- --------------- -- -- ------- --------------------------------------
----- - -- -------------------------------------------------------------------------------------- -------- ................-----------------,j- ------------------------------------
Date
Permit No. ...........
---.--_� "�-. ----'9.7 Issued - _ -`C--.L
I Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ter#tfira e of Tompltttnce
IS S 0 CE IFY hat the Individual Sewage Disposal System constructed ( X ) or Repaired ( )
byC CJ�L. --------------------------- ---------------------------------------------.........---------------- ------
at .....L-6) 7- 9 % LU/-/ /;r 1k) d�..-.r- Insfo IOL� /n M-I L4_5
.. ---------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .............a..-.: .. .... dated -----------------------------...-... ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..---- /.. / ----.��'...--....-1 --------------- Inspector -- - ...- ....................................f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No..... � FEE...... �•-•---
i rn l nrk inn rnr imin rrnnif
Permission is hereby granted..............•---.----•---•-- ---•-----•--------•---•-•-•-------•---•-----•---------•-----------•-•......................................
to Construct (X, or Repair ( ) an Individual Sewage Disposal System
at No._ f)-r-....Qi----. GfJ N•!T M dK...I.- -7 0 l045 LO - m = M t LC-.S
--------- ----•---------------•---•--•------•---•-•••-_.....
/ Street
as shown on the appli Lion fo Disposal Works Constructio P .mit No._ __bin ated............________ ___m___._.....__.
----••-- Board of Health
DATE---------------•--.... ._........ ....................
FORM 36508 H0198S&WARREN,INC.,PUBLISHERS
r - -
r` PAT-A- _ r
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i TOTAL DAILY rLOV = 330 6pD c4
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t �' PEER I
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NO. 4733
Lopr� � ,
CEATERVILLE—OSTERVILLE—MARSTOtIS MALLS
FIRE DISTRICT
1875 ROUTE 28
CEPTERu1LLE, MA 02632
` (508) 750-23801F AX C(508) 7130-2385
OILIHAZARDOUS MATERIAL RELEASE FORM
F.A.0 42 --irs �
LOCATION:
ADDRESS OF RELEASE'ti+ gg.e— T AB(7 F`: 4a.
DATE OF RELEASE:
PRODUCT RELEASED:
ESTIMATED QUANTITY
CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY-
NOTIFICATIONS:
FIRE DEPARTMENT: YES NO( ) D ATE• AF„ z T IME:
NATIONAL RESPONSE CENTER YES ) NO(
DEPT.OF ENVIRONMENTAL PROTECTION YES( } NO( ) DWTE: TIME:
OIL SPILL COORDINATOR: YES( } N& } ATE' TIME
TOWN BOARD OF HEALTH: YES( ) N } DATE: TIME:
TOWN HARFIORMASTER: YES( } Ni } DATE: TIME:
OTHER AGENCIES:
COMMENTS:
REPORTED BY: 4_9 D ATE.
'MITE COPY-FIRE DEPARTMENT 40W Y— I.P. PINK COPY—BOARD OF HEALTH
C-044M FORM #58
J �