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HomeMy WebLinkAbout0019 WALNUT STREET (M.MILLS) - Health . WaInnt Street s� - _ - Marstons Mills A= 149 069 a TOWN OF BARNSTABLE L l`ATION `cti SEWAGE # Is " � VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS J PRIVAGWEL R PUBLIC WATER 'Fc'�J BUILDER OR OWNER��1 DATE PERMIT ISSUED: I)o G,) DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No a t Lj ; ,� k - L, 3 - TOWN OF BARNSTABLE LCICATION VN SEWAGE # g v hrNA \ VILLAGE �.I-� g�, �` 1� ASSESSOR'S MAP & LOT ` .• INSTALLER'S NAME & PHONE NO. 'SC V\ SEPTIC TANK CAPACITY C3DX ��nb l LEACHING FACILITY:(type) (size) (,J I;-+ S 1pv ,I NO. OF BEDROOMS PRIVATG>R PUBLIC WATER ?<-�J BUILDER OR OWNER ,t'(yr G"V DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� 9 , -sq ► A � a�x aS t 4-o -see t L 30 Cc) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is Marstons Mills MA 02648 November 2, 2009 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out 9*5 forms on the I computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name rab 189 Cammett Road Company Address Marstons Mills MA 02648 renm Cityrrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification LU ca I certify that I have personally inspected the sewage disposal system at this address and that the c,l information reported below is true, accurate and complete as of the time of the inspection. The inspection c� 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: u4 Passes ❑ Conditionally Passes ❑ Fails C) r—) ❑)Needs Further Evaluation by the Local Approving Authority C) E 3 M November 2, 2009 Inspector's Signature Date 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. ""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. L66 I 09-241 McLeavy-Fisher.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage osal SystIP/age of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is Mar tons Mills MA 02648 November 2, 2009 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time SAS shows no signs of surcharge or saturation. 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 09-241 McLeavy-Fisher.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is Marstons Mills MA 02648 November 2, 2009 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 1 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. 09-241 McLeavy-Fisher.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is Mar tons Mills MA 02648 November 2, 2009 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal analysis must be less than 5 ppm, provided that no other failure criteria are triggered. A copy of the anal y attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged 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_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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09-241 McLeavy-Fisher.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. 09-241 McLeavy-Fisher.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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? ® ❑ 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: ® ❑ 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(5)] 09-241 McLeavy-Fisher.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w., 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is Marstons Mills MA 02648 November 2, 2009 required for every page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: 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 Unknown Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 09 241 McLeavy-Fisher.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Mar tons Mills MA 02648 November 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None inspection? ❑ Yes ® No Was system pumped as part of thep If yes, volume pumped: gallons How was quantity pumped determined? 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) ❑ 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: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 09.241 McleavyFisher.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------ ------------------------------------------------------------------------- Dimensions: 8.5' long X 5.2'wide- 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 27„ Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 09-241 McLeavy-Fisher.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are intact and clear, liquid level was found at bottom of outlet invert. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 09-241 McLeavy-Fisher.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is Marstons Mills MA 02648 November 2, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (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.): No solids or high stains present. Liquid level at bottom of outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-241 McLeavy-Fisher.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators. ❑ 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.): Stone and soils were probed with no evidence of saturation, SAS showed no signs of surcharge into d-box. 09-241 McLeavy-Fisher.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): 09-241 McLeavy-Fisher.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher _ Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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. y 43 � 30 5 25 / \ \ \ \ \ \ \ \ \ \ Walnut Street f Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Walnut Street Property Address Cathy McLeavy-Fisher Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 4 and topo map shows property above el. 60. 09-241 McLeavy-Fisher.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 � 0 Vk Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments G Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000.Inspection forms may not be altered in any way. A. Certification 1. Property Information: Pmr Add L.C� s owner's Nam 9 Nam ��4�± 5f Owner's Addr � 8 A441-.5 Cltyrrown state zip Code Date of Inspection: ,;t w 7'j( Date 2. Inspector. f54alvo Al Name of Inspector — Company N me -- �l Company Address L CWrown Q T-I � �%o J state dip Co(e Telephone Number -C Certification Statement: `l I cer*that I have personally inspected the sewage disposal system at this address that the - information reported below is true,accurate and complete as of the time of the inspe The insectfo was performed based on my training and experience in the proper function and mainten'nce of ort site sewage disposal systems.I am a DEP approved system Inspector pursuant to Se " n 15.34�of Title 5( 18 C�iIR 15.000).The system: a r- 1Wpasses ❑ Conditionally Passes ❑ Fails � M ❑ Nee Fu� e r Eva Nation by the t-oml Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Boa.rd of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flown 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. '**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. t5insp.doc-11t2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System. Page 1 of 16 Commonwealth of Massachusetts ` .� itle �.. icia:l" � sp a%e�.n.°fi r . Not fpr Voluntary Assessments Subse 6ce Sewage Disposal System Form. A. C.ertificafion (cont.) Property cityrrown State Tip Code 0s /—a Owner's Name Date of tnspealon Inspection Summary:Check A.B,C,D or E/always complete all of Section D A.)..System Passes: i have not found any information which indicates that any of the failure criteria described in 310 OMR 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 riot)is structuraffy:urisound,exhibits:substantiaf infiltration or exfiltration or tank failure is imminent. System will pass inspection if the-existing tank is replaces with a complying sepkc tarik as approved by.the Board:of Health. *A metal septic tank Will pass inspection if it is structurally sound,n6t leaking and if a Certificate of Compliance indicating that the tank is Less than 20 years old is available.. ND Explain: t5insp.doc•11/2004 Tide 5 Offidat inspection Form:Subsurface Sewage Disposal.System• Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection' Form Not for Voluntary assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) liye,lnuf 6t Property Address cityyrrown State Zip Code Owner's Name Date of Inspection B) System Conditionally Passes(core): 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): 171 broken pipe(s)are replaced ❑ obstruction is removed 0 distribution box is leveled or replaced Na Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system wig pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 1-5.303(l)(b)that the system is not funCtlonhV in a manner which win protect public health, safety and the environment: Cesspool or privy is within 50 fleet of a surface water ❑ Cesspool or privy is within 5U feet of a bordering vegetated wetland or a salt marsh t5insp.doc•11/2004 Title 5 OfiicSal inspection Form:Subsurface Sewage ois l system. wag pose Page 3 of 16 Commonwealth of Massachusetts Y. Title a ton, Not for Voluntary A sessments �. Subsurface Sewage Disposal Systern Forin A. Certification (corit.) Pr Address Gltyffown state Zip Code / Owner's Name Date of inspection - C) ;Further Evaluation is Required by the Board-of Health front;): ... Z. System will#ail unless the Board of 14s41th:(and-PubUF water Supplier,if any) determines that the system is functioning in a manner that proteins the public health, safety and environment: Q 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.stirfa�Water supply. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and"SAS.and the SAS is;wthin 50 feat 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 DER 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- t5insp,doc 1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address �a.r'S�i�n� /L71Ils City/Town State ZipCode /o?`?6 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or / clogged 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 Y2 day flow Q Required pumping more than 4 tones in the last year NOT due to dogged or obstructed pipes).plumber of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. Q / Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Ej-/ Any portion of a cesspool or privy is within a Zone 1 of a public well. Q [2/ 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 conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the Presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) Yes No ❑ The system fails_t 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. t5insp•dOc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal system page 5 of 16 Commonwealth of Massachusetts Title rOffic l n3pectio:m A _ Not for Voluntary Assessments Subsurface Sewage Dismal System Form A. Certification (Cont.) Property Address ,414r�/oil.s ,l?�1ls Cityfrown State Zip Cafe Owner's Nants Bate of Inspection E) Large Systems., To be considered,a large system the system must set°ve a facility with a design flow of'1O,0OO gpd td 15;00O`gpel. For large systems,you must indicate either`yes"or"no"to each of the fallowing,in addition to the .questions-in S$Ction D. YES NO d Q the'system is i tiri 406 feet of a.surface drinking';iitersupply • 0 :'the system-is within 2co feet of a tributary to a sur66e drirticing water supply ® Q the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone l4 of a public water-supply well If you have answered"yes'-to any question in Sedon€the system is considered a significant threat, or answered`fires"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 Seclion©shall upgrade the system in accordance with 3.10 CMR 15.304_The system oWnershould Contact the appropriate regional office of the Department, t5insp doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 r Commonwealth of Massachusetts Title 5- Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist Property Address / City own State Zip Code id- 7-C�u owner's Name Cate of Inspection 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? l� ❑ Has the system received normal tows in the previous two week period? ❑ Have 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) ❑ 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? ❑ 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: ❑ 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)1310 CMR 15.302(3)(b)j t5insp,doc•11/2004 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Ville 5 _+ ie:1.h'tns ection-.F-6rm Not for voluntary asessments Subsurface Sewage Disposal System.For G. system information PrJoy,Address / State CitylTown Zip Code_ Owner's Name Date of inspection Residenfial Flow CondMons:. Number of bedrooms(design): Plumber of bedrooms(actual): DESIGN flow based on.310 CMR 15.203(for examp(e: 110 gpd x.#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes M/No ls-laundry.on a separate sewer system?jf yes separate inspection required) ❑ Yes [P,, &o Laundry system inspected? ® Yes 2--*No Seasonal use? 0 Yes 0� No Water meter readings,if.available(last 2 years usage(gpd)): Sump pump?. . ❑ Yes 9� No Last date of occupancy: -Date Commerciaftdustrw Flow ConditEons: Type.of Establishment: Design flow(based on 310 CMR 15.203): tt Ga ons per day(9pd) Basis Of design.flow(seats/pemons/sc�k,etc.):: Grease trap present? _ Q Y®s Q No Industrial waste.holding tank present?, [] Yes ❑ No Non-sanitary waste discharged to the.Title 5 system? ❑ Yes ❑ No Water meter readings,if available: Last elate of occupawy/use: Date Other(describe): t5insp.doc 11/2004 Title 5 Official inspection Fort:Suttsuftccce Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 cial r ��ectc�rorr Not for Voluntary Assessments wr Subsurface Sewage Disposal System Form C. System Information (cont.) P party Add Cityrfown - - state Zip Code 1'-)-7-ems Ownees Name Date of Inspection General Information Pumping Records: Source of information: � d>izdyl"O F_g Was system pumped as part of the inspection? ❑ Yes �o If yes,volume pumped: sailors How was quantity pumped determined? Reason for pumping: Type of S stem: t Septic tank,distribution box,soil absorption system iP ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Aitemative 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(N known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc•1112OD4 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusefts Not for Voluntary tarry asessments ` Subsurface Sewage Disposal System Form c. system information (cont.) Add J� City/Towm State 2.fp Code . Ownees Nerte Date of Inspection Building Sewer(l)cate on site.plan}:.. lye)ai Depth below grade: geed Material of construction: [j.cast iron 3/4�ptic Q other(explain): Distance from private.water.supply well or suction line: fear . . - .. .. . - Comments(on condition of points,venting,evidence of leakage,etc.j: Septic Tank(locate on site plan): Depth below grade:_. a yet Material of construction: Kconcrete ❑metal 0 fiberglass : 0 polyethylene y [I other(explain) If tank is metal,list a90: years. Is age confirmed by Certificate of Compliance?(attach a copy of . oertificate} 0 .Yes.O No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 7 _ Scum thickness _! Distance from top Of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or.baffls. . Hour were dimensions determined? ����cz t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Umposal System Page 10 of 16 r Commonwealth of Massachusetts Title S Official Inspection Form gr : - Not for Voluntary Assessments M '3 Subsurface Sewage Disposal System Form C. System Information (cant.) Property Address Cityfrown State Zip Code 1 a'7-chi Ov meez Name Date of inspection Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc~): Grease Trap(locate on site plan): Depth befog grade: leer Material of construction: [3 concrete Q metal 0 fiberglass ❑polyethylene [l 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 bale Date of fast pumping: Date Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc,).- Tight or Holding Tanis(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: C1 concrete ❑metal ❑fiberglass C1 polyethylene Q other(explain): t5inspdoc•11/2004 Title 5 Official Ins pection Form.-Subsurface Sewage Disposal System page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) 19 &Ielln"tl:: f Propefty Address Cityrrown State Zip Code Ownees Name Date of inspection Tight or Hokfiing Tank(coat.) Dimensions: Capacity. gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Q Yes[) No Bate of last pumping: Date Comments(condition of alarm and float switches,etc.y Distribution Box(if present must be opened)(locate on site plan): Depth of liquid(evef above outset invert y Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of)eakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc•1112004 Tide 5 Official Ins. pecdori Form:5ttbsia4ace Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Foy �� Not for Voluntary Assessments Subsurface SewageDisposal sal System Form l� c. System information (cunt.) ZIA State Zip Code City/Town Owner's Name Date of inspection Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Solt Absorption SysteM(SAS)Qoc ate on site plan,excavation not required): 1f.$A$not located,explain why: Type: Q leaching pits number -� leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typeiname of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): or Ire c. 4r -o kfi t5insp.doc•1112004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 et at° ecad :fo i -. . Not for Voluntary Assessments Subsurface Sewage Disposal System'Form Information cont.) m E �. S�ste . /�_l` 4ly 7 P party Add ress Zip Code city/Town Owner's Name Date of lnspeotion .cesspools 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 ❑ No Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of poncling,condition of vegetation, etc.): t51nsp.doc.?112004 Tine 5O fidal lnspeWon form:Subsurface Sewage Dispmi System Page 14 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form c. System information (cant.) n l 5 I-v ��►r� f 5 t Address Property "9�,ems A, C41 frown State Zip Cade Owner's Name 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 welts within 100 feet. Locate where public water supply enters the building. A Beck t5insp.doc•1112004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15of 16 I v ComnWnwealth of Massachusetts + Title 5 Official Inspection Form Not for Voluntary Assessments ; 7 subsurface Sewage Disposal System Fora C. System Information (cons.) /S' rd� f Prc�periy Address City!town State Zip Code Owner's Name Date of Inspection Site Exam.. Slops Surface water Check cellar Shallow wells Estimated depth to ground water: C3` Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: max 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) Cl Accessed USGS database-explain: You must describe how you est bushed the high ground water elevation:lit to f/C. G y /- '1A_ T- - C(� fe 410 t5insp.doc-11/20U - Title 5 Official inspection Farm:Subsurface Sewage Disposal System Page 16 of 16 1� waf G ru c(e �o 04 If loll II 34 G��U�t✓lG�`Nr"'��� TOWN OF BARNSTABLE LOCATION -1 WC.LWi_�, SEWk6E# n SP VILLAGE ASSESSOR'S MAP&PARCEL . R'S NAME&PHONE NO. c.�� a,k_ _ tN nd SEPTIC TANK CAPACITY LEACHING FACILITY.(type), I +f c0or,5 (size) NO.OF BEDROOMS n OWNER PERMIT DATE: C Mk-MNCE_f3ATE7 - I t;blm 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 43 5 30 25 h \ h h h t h h \ \ \ \ t \ h h h \ h h s r f f f f f f f 1 \ h h \ h h h \ 1 f f f f r J 1 J f f r f f t \ t r ! h \ \ f J J} 4 \ \ h \ h h f ! f h t \ \ h h h h h r i f f f f f f r h t h \ t \ \ h h h f ! ! f f ! ! r J L TOWN OF BARNSTABLE + , , ATION l OU I PI I r.T 5 rW SEWAGE# VILAGE Aal5kO_ $ /V(� l�S ASSESSOR'S MAP& LOTZ'_ 2� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /UO D (o g LEACHING FACILITY: (type) I ' fi'' ✓5 (size) NO.OF BEDROOMS 3` J BUILDER OR OWNER �Oy1 Ulu L e�✓.6S PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility y© �. 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 o leaching facility) Feet Furnished by S Gt c,/o I No..9 ._qb. ' ASSESSOt S f 4 p i 0:.— Fx$.......c1..�,�...... THE COMIJJO&EW,�-&LTH OF MASSACHIJSETT�/��^� t BOARD OF HEALTH TOWN OF BARNSTABLE Applirativtt for Di ipwial Works C owitrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( k4 an Individual Sewage Disposal Sy,stern at ......----•-� 1....5..,� .- W ......lb-k--•---------�`�1n........ •--------------------- ---..-.......... --•----••---•-----••-•---•--••---......------ • - Loc;ttion•Address ` �� or Lot No. .�v�. .... ---------------•------------------------------- . ---------------------.....---------------......---...------------..........------ r ,� Otcner Add r sr --------- - Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.___ '--__•---------------------------Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_kdvOgallons Length-_------------ Width---------------- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching.area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ----•-----------------------•--••••--------•----•--•-----•--•-•••-••--------•---•--------•--•-•••---......................................................... ODescription of Soil........................................................................................................................................................................ W U -•••--•.....--•----------•--------•---•-•..............•-•-••.....•••--••••------••--------•--•-----.....-•----•---••-•----••-•-••---•....---•-----••-•-•-••--.......-•-•-•................-•-••-----••. W ----------------------------------- -----------•------------......--•---.......------•---•--••-••----- - ------------------------�----`-- ......................................................... ,-- U Nature of Repairs or Alterations—Answer when applicable.___...__ ._�i � ...... .......... 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 lace the P g g P system in operation until a Certificate of Compliance has been issued h the board of health. Signed - - - ..................................... ---- Date q Application Approved By ................ .. ....... Application Disapproved for the following reasons: ........................................................................................................................................ ............................................. .. . .............................................. .................... ........... . -- .. ---- . .........................----.. ........................................ Dare PermitNo. ......... ...-.. (.2----------------------- Issued --............................................. ..... a........ Date NO._ ._ . . ✓ I FEB..... .Y .�. ......... THE COMMONWEALTH OF MASSACHUSETTS/��� BOARD OF HEALTH to TOWN OF BARNSTABLE Apphratiun for Di ipoml Wnrk,i Tnnitrnrtinn 11amit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: !; r ............�Ci ------.____-M- -/�------•. -•----•------------------------------{-----•-------.......--------•--•-------•----..........-•---- Location-Address or Lot No. -•••••--•••-----_....•-•----- •--••• ••---•....•-•-•--------•••-•................•-----......---•- Owner Add r ss t Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..........:................................Expansion Attic ( ) Garbage Grinder ( ) A4 Other—Type of Building --_------------------------ No. of persons--------------------.------- Showers ( ) — Cafeteria ( ) P4 Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.l0b0galIons Length---------------- Width.........------. Diameter................ Depth................ x Disposal Trench—No. .................... Width........._.......... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................--- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results, Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (x, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ �+ ----------------------------------------------------------------•-••---------------•-••-•---•------•------------------------------ -........... •--•-••........ 0 Description of Soil........................................................................................................................................................................ x U. .._.......••••-••••••...•--•--••••••-•••-•••----•••-••-•••••---•--•--•-•--•-•••••-•-••--•-----------•--•--•-•----•-•••••-•••--•••-•----••-•--•--••--•••••••••--••••••..................•••••....._...... x ------.--••-•••••- U Nature of Repairs or Alterations—Answer when applicable�.�- .-� Q�_.--�X�5 � r .....�C.5 � L-.._____.... ..��,o64 `�.; ':L�OnCA...Cr�C.s_Vj&...4sx V �,� C?^� fi (� � G.`�����c 5...t . ..a_ �� ����C� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued the board of health. Signed _ .. ..... . ............................................. ... .... ..... Dare ApplicationApproved By ................. .1 >... 1... , ).............................................................................. ........i .�.to =c� Application Disapproved for the following reasons: ....................................................................................................................................... ....................... ......... .. . ............................. -- . ................ . . - - ......................................... . ........................................ PermitNo. ----------7_57..- - ----------------------- Issued ........................................................Dace.. ....... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fErti irate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constricted ( ) or Repaired ( by .... o�._at ........ G----l ----- ---_..M.. 1:;,A ._......._.......... .-..... ......... . . . .. . ...... ............. .... - .. 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. ......9 :...-.. - dated ._..._._............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................... " . ....: ....._........ Inspector-------G ..... . f ............../r `, ... -�=), -- --------.-----_—,--.—---,--->----_------------.-----_.--.---_:��_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE N FEE.7r:....:........ �i ern tt1 nr� (9nnotrudion Wrmit Permission is hereby granted.-- ..:tx-:cL�k---�.... ........................................................................................ to Construct ( ) or Repair (\A an Individual Sewage Disposal System atNo.....1•G- ........... •---•`•k •--- ---r.-.-�' `;•--------------- ------------------------------------•-------•--------.---._..------.---..--------------- street �p C as shown on the application for Disposal Works Construction Permit ------ Dated____,/._: �- �Bard of Health DATE................. ...-a n•-•` ............................. �/ FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS