HomeMy WebLinkAbout0195 WALNUT STREET (M.MILLS) - Health 195 WALNUT
Y __ MARSTONS MILLS `
\ A = 310375
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TOWN 077
O-F BARNTABL E x
LOCATION / 1',cJA.INU : sl<rzF� - SEWAGE.#
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VILLAGE— e$fowS Gti1'r� 1 �S` .ASSESS.OR'S MAP& LOT 3/0 �3 3
INSTALLER'S NAME&PHONE NO` 92niv,SdiJ . ;SCaJ 7-7 5-�6 Z ?�
SEPTIC TANK CAPACITY ao
LEACHING FACILITY: (type) l7(Z11/ L-i& lS (size) a X t 3 -1- a
NO. OF BEDROOMS
u
BUILDER OR.OWNER
PERIvIITDATE: O i COMPLIANCE DATE. :I S I aQd i
Separation Distance Between the: : : •_
Maximum Adjusted Groundwater Table t6the Bottom of Leaching Facility Feet'`
Private Water Supply Well and Leaching Facility (1f any wells,exist,
Feet
on site or within'200 feet:of leaching facility)
Edge of Wetland and.Leaching Facility.(If any wetlands exist
1
wittun,300 feet of leaching facility) Feet.
Furnished by'
y
a
i sty
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TOWN OF BARNSTABLE
LOC,.,�ON 195 W A•/A)QJ J-tk644 SEWAGE # 2 66 t-:3 91
VUTAGE rIj,4jZ5f0wS /440(S ASSESSOR'S M..P & LOT 310-37-
aJS'rALLER'S NAME&PHONE NO: k62,tAJSa)- ) Sc0f;r
SEPTIC TANK CAPACITY I , Ob 0
LEACHING FACILITY: (type) 9. t7(Z-V tr-1 E US (size) I X t 3 D-3
NO. OF BEDROOMS
BUILDER OR OWNER W ar
PERMITDATE: T bO COMPLIANCE DATE:�� S 1 aBo 1
`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 _
f�Pc 1 ovSL
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COMMONWEALTH OF MASSACHUSETTS I
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 195 Walnut St_
Marstons Mills, MA
Owner's Name: Valerie Wa dwPl 1
Owner's Address:
Date of Inspection:
Name of Inspector: (please print) W i 11 i am E_ Rob i nson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: ( 5 0 8) 7 7 5—8 7 7 6
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 Sec 'on 15.340 of Title 5(310 CMR 15.000). The system:
s/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Acu 1" Z- 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.
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 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 9 S wa 1 nu t S t_
Mar�t-nns Mi l l
Owner:
Date of Inspection: L O 9
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
re aired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
swer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
ex lain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
ound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
e isting tank is replaced with a complying septic tank as approved by the Board of Health.
• metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
dicating that the tank is less than 20 years old is available.
D explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
bstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
a proval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
p s inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
A
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Page 3 of l I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 gr,
Marstnnc Mi11S
Owner:
Date of Inspection: —0 1
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 f 'ling 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
sy tem 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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fronl 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 presenze 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
Page 4 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 9 5 walnut S t _
Marstc)ns Mills
Owner: wardwcnl
Date of Inspection: rp —0 c
System Failure Criteria applicable to all systems:
u must indicate"yes"or"no"to each of the following for all inspections:
Ye 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'/2 day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the 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.
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.]
(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 a considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd
Yo must indicate either"yes"or"no"to each of the following:
( following criteria apply to large systems in addition to the criteria above)
ye 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 .
I you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
" es"in Section D above the large system has failed.The owner or operator of any large system considered a
si nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
1 304.The system owner should contact the appropriate regional office of the Department.
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Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 9 5 wa 1 nut st
Marstons Millc
Owner: WarAwell
Date 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
1/ — 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?
_v1_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15302(3)(b)J
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 9 5 Walnut-_ S t-
Marstons Mills
Owner
Date of Inspection: 77 0
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �I I
Number of current residents:
Does residence have a garbage grinder(yes or no):A-6
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):'G�
Seasonal use:(yes or no): 1✓'0
Water meter readings, if available(last 2 years usage(gpd)): 2000 107, 000 gal.
Sump pump(yes or no): /— a 1999 , 00 gal.
Last date of occupancy: 71�`'a I
CO MERCIAL/INDUSTRIAL
Type f establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis f design flow(seats/persons/sgft,etc.):
Greas trap present(yes or no):_
Indus ial waste holding tank present(yes or no):
jn-s itary waste discharged to the Title 5 system(yes or no):
ate meter readings,if available:
Last ate of occupancy/use:
OT ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped asp of the inspection(yes or no).�
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPe10F SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
—ivy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative co technology.Attach a y of the current operation and maintenance contract(to be
g P
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:
Were sewage odors detected when arriving at the site(yes or no):�'4
6
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Page 7 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 195 Walnut St.
Marstons Mills
Owner: Wardwell
Date of Inspection: 6
B LDING SEWER(locate on site plan)
Dep below grade:
Mat ials of construction:_cast iron _40 PVC_other(explain):
Dis nce from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
8
Depth below grade:
Material of construction:_✓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) L
Dimensions: vc
Sludge depth: ,
Distance from top of sludge to bottom of outlet tee or baffle: �f
Scum thickness: 6 ,
Distance from top of scum to top of outlet tee or baffle: ,
Distance from bottom of scum to bottom of outlet tee or baffle: _
How were dimensions determined: Re— ,► .Z-� 4. C l i:5- A." �"e✓� d�c:,.�`'
Comments(on pumping recommendations,i6let and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): y J
lV i3 13K /'` �c d�• uT L.& 1' l y a k
G EASE TRAP:_(locate on site plan)
Dep below grade:_
Mat rial of construction:_concrete_metal_fiberglass polyethylene_other
(exp ain):
Dim nsions:
Scum thickness:
Dist trice from top of scum to top of outlet tee or baffle:
Dist nce from bottom of scum to bottom of outlet tee or baffle:
Dat of last pumping:
Con ments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as r(lated 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: 195 Walnut St .
Marctnng Mi_1 l_S
Owner: TAT
a-dwel l
Date of Inspection: $
T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dept below grade:
Mat ial of construction: concrete metal fiberglass_polyethylene other(explain):
Dim nsions:
Cap city: gallons
Desi n Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
D e of last pumping:
Co ents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: "''/of present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PU P CHAMBER: (locate on site plan)
Pum s in working order(yes or no):
Al s in working order(yes or no):
Co ents(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: 1 95 WaI nut St
Marstnns Mill
Owner: el 1
Date of Inspection: K'/
SOIL ABSORPTION SYSTEM(SAS): -2/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/altemative system Type%name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,conditionef vegetation,
etc.): , e
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet,in e
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.):
PR (locate on site plan)
Materia s of construction:
Dimens ons:
Depth f solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 195 Walnut St.
Marstons Mills
Owner: Wardwell
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 b 'lding.
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Page l l of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 9 5 Walnut St.
Marstons,-MI11-s -�
Owner: Wai=divell'
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:
Pbserved 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:
f> <; S
5 �5 n
6 � r
11
ti
w 50
NoAM 1\W Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: tYes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTSZippYication for Mitpotar *pgtem Comaructiou 30ermit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Asse9s5 sVl�fap�uer St. , Mar tons Mills Valerie / Wayne Wardwell
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consis—
ting of a D-box and 2 precast leach chambers with stone all
around.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo of Wealth.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
1 r �/Jlfi�
Fee
.a . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes /
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ci�N
:
,. ZIpprication for Migozal 6p!5tem Cow5truction permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
195 Vlu St. , Marstons Mills Valerie / Wayne Wardwell
Assessor's ap arce
Installer's Name,Address,and Tel.No. Designer's:Name,Address and Tel.No.
Wm./EE Robinson Septic Service
P 0 Box 1089„Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank T�Sypeof-S1 >�
.S. Y'�` f
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consis-
ting of a D-box and 2 Arecast leach chambers with stone all
around.
Date last inspected: l 1
f 1
Agreement: 1 ,y
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'lin`operation until a Certifi-
cate of Compliance has been issued by this Bo �ofealth. _ _
Signed Date `"
Application Approved by _ �t Date
Application Disapproved for the following reasons
Permit No. / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS 1
Wardwell BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( X)Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service
at1 95 Walnut St. , Marstons Mills hasrb a constructed in accordance*"'
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Wm_ E. Robinson Se_ Designer
The issuance of this pe .' shall of be construed as a guarantee that the syste b fun on <esigned.i'
Date Inspector
------------ (ir--
No.- 20L r I Fee $5 0 ,.. .
t
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Wardwell
lie;pooal *pztem Construction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at 195 Walnut St. , Marstons Mills
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction ust b c plet d within three years of the date oft 's "erim /
Date: ' Approved b
1 �- PP Y � „
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OT[CF,_This Farm U To Be Used For the Repair Of Failed
Septic Systun Only.
CIgRTII+iC�►'1'ION OF SKE'1'+CH ANb AP».IC,�'1TgOl�i FOR A D�
WORKS CONST UMON PEitMPP_(WTfHOUT DESMNED PLANSI
L Will iain E. Robins on,5%vreby>certify dm do) fin La works
comm a a Penn sighed by we dated C� -- � / _concerning the
Prapertylocatedat 195 Walnut St. , Marstons MIlls meets Aofthe
following criteria:
• The failed syrstem is to a Midentid dw drmg ody. That art:no vial or business
uses zzoc iawd with dael>in&
The soil is cuss&& CLASS t and the petoo�t rate is>=am or equal io 5 minus per such
T1kerC sre IM wtrbtn 100 feet of 1be p nnxxM scpuc kvucm —
Tina-set no WdlS wttbtn 150 an Of the pfOp06Cd SCPW$'fie
rb=t is M� iA flow aadkir chma m ux p mpmd
• There ar, m vatisnoes tet¢tesed or needed.
The bontm of the leadbim wilt alit 6e located less tfiaa Epee fim aha m the
� a tdit elevation-FA&jMft WOMM. x table using the Frimptor
method when kE
tf the S. -S.will be with 2M An of aayr veptand wedanilk the Oot=of the proposed
leaching f cdky will as[be:loud less than fotuteen(14)foes above the mavrotmt add
water rule gyration.
Please compkee the
Al Top of Gw nd Sit bm Ekvatim tasing GIs 1
a l G.W.Elevation +lk MAX. MO G.w_Ad*tment =
DIFFERENCE MAVEEN A and S
e- 1
SIGNED: /v ► ..-,z 6••
DATE_ 4 B
(S DMM pmposed pica of system on bade].
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. NIA 02108 61 i-292.5500
WILLIAM F.WELD TRUDY COXE
Govemo: Secretary
ARGEO PAUL CELLUCCI r1.,9 B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �''� o missioner
PART A a
CERTIFICATION REc VE0 r�
Property Address: /Qir l//Uhi�tS* /Y/ram s /l���/s Address of Owner: �[L
Date of Inspection: 7- 3,—,7 / (If different) AUG 7 1997 W
Name of Inspector: j0 n G ; TOWN OFBARNSTABLE
1 am a DEP approved sys em inspe for pu sua t to Section 15.340 of Title 5 (310 CMR 15. . HEALTH DEPT.
Company Name: J0114 io��p c�ko e YvJi C- , 40
Mailing Address: J SU Wa/•7aY" )r .S OhS Yi/�S emu,
Telephone Number: (� £
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
L-fePasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 014, Date: -7-��
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection, The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system.violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank,-whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a-conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Pay l of 10
DEP on the World Wide Web: httpa/www.magnet.state.ma.us/dep
1% Printed on Ged Paper--_
� t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION (continued)
Property Address: W4/Ar14 St /1'uVA01'?S
Owner. ��/k�yy �,,y, i Vlu W�ths
Date of In pediofi: �r�i
S-3`97
6] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
_ pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
< broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
s' The system regulred pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
.00 inspection if,(with approval of the Board of Health):
3I,11ml-,0ioI"I broken pipe(s) are replaced
.4 � .rt . « 1 obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH;
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
., WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation.not valid).
3) OTHER
d
(revised 04/25/97) Pago 2 of 10
i
b '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ��sp f„N f Sf, ,kS�ey�/•!'i��S
Owner:
Date of Inspection O�
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 ckgged SAS or
cesspool.
Static liquid level in the distribution box above outle: 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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50.feet from a private water sup*well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well wa*r.analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either`'Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a.surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone fl of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Pagre 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: f9S Eva 1-,.-t
� J
Owner: Prv�y
Date of Inspectio
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
y _ Pumping information was provided by the owner, occupant, or Board of Health.
_✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, e>Eehaftg the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
✓ _ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:Owner- �2
Date of Inspection: f
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 7 Q g.p•d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes.or no): Nv
Laundry connected to system (yes or no):--!(-!°t
Seasonal use ryes or no): Afv
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no): Aw
Last date of occupancy: yfGN/J,•cf'
COMMERCI.AUINDUSTRIAL•
Type of establishment:
Design flow: >;allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present:. Ives or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available
Last date of occupancy: '
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informal on:
System pumped as part of inspeaion: (yef or not A/o V0
If yes, volume pumped: f:aI Ions
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)
I/A Technology etc. Copy of up to date contracts'
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: jSVV 7 $U
7vr✓n Y�'Ccv�s �t'rrJ9i �!7 L/60
Sewage odors detected when arriving at the site: (yes or no) Na
(revised 04/25/97) Page S of 20
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /9 141a n 4� ST, /00rs/o%7f
Owner: P1117 4rr.44 i 9�- ror Si 11,
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
II
Depth below grade: 3v
Material of construction: _cast iron _40 PVC ✓other (explain)
Distance from private water supply well or suction lire
Diameter OY
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: 2
Material of construction: oncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Cenificate of Compliance _(Yes/No)
Dimensions:
Sludge depth: zZ „
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: Z 01
Distance from top of scum to top of outlet tee or baffle: ,r
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: Yu ler
Comments:
(recommendation,for pumping, condition of inlet and qutlet tees or,baffle, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) 7w," er krh 34' 1 ov
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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Pago 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /9.5- W,1/1HH 113 Wen
Owner: �eYy7 �I�� `i< /trrsiu TkaiS
P
Date of Ins ectio(�:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
CapaciN,: gallons
Design flow: gallons/da�
Alarm level: Alarm in working order_Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence tQf solids carryove/, etvide-nice of leakage into or out of box, etc.)
�i4HC//17N��S .y 1i17�S7(.•C SIT✓y' -
PUMP CHAMBER:
(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.)
(revised 04/25/97) page 7 of 10
• rs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
/}((continued)
Property Address: /ys t�C��Nu Sr /r/�/S DOHS �yjr�iSf""u.
Owner: vo'l 4/�4." '; 7pr5 i���o TICc
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:
leaching chambers, number:__
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic,f i ure, le el o. ponding, condition Qf veggetatiopn, etc.)
H C / v1 r; Sg 7 i s rci e v
1 Q it P a " ' , Poo APoo X a C42, tiff � S oi,< 0,qC
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(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.)
(revised 04/25/97) Page 8 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address,:: �LJ,j (//u�%vu� a'' A144r�r"s ���/�S�/�u,
Owner: / r'�'/'� �i'�r T i'.5i r���i fkuS
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
T/
Ta cover
2
.TI
3 i2 " To c.vv 'er
y
;2 32'
6
y
(revised 04/25/97) ?Ago 9 of 10
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /95- Wit f'i /V/,115 /04,
Owner: P411"" X�rkn/9—
Date of Inspection:
Depth to Groundwater 2 3 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
✓ Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the'High Groundwater Elevation. Must be completed)
w/"�h !.t/p/•PY i�?!/!.t/v v! G? �j 3 r jj-a'�ocr/ e�I S�i a� Gl j^��.1. vci h� f.h
(revised 04/25/97) Page 10 of 10
L 0 C.A,T I O N f gi t:���h•� °� S E W A G E P E R MI T N 0.
o
VILLAGE
INSTALLER'S NAME i ADDRESS
JOHN A. AALTO BACKHOE SERVICE
a nustreet
West$amstable, Mass. 02668
BUILDER OR/ OWNER
3 To-o-ch Al
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
r
F
cz
1 -
No.-------.....
........... � -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....---.... ... ......OF........ .:...........................................................
Applira#inn for h4po,5a1 lrorkfi Tnntrnrtton rruti ...
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--------------•------•-1 ys'..ftlot,�-�.10:..........!��... _.._...----•-----•--•-----••-•-•---•----.-----...-•---•-------•--.._..------------------------•••-
a -Loc tion-A ss or hot Ng�
......................„........CAZ:LA...._.. ....................................... ..___..__._.._____/___� _ �.1..�::i_._.. .L.....Y.:.�... �.N
aOwner dd.ress
�' -- ...:..
Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_................................_..........Expansion Attic ( ) Garbage Grinder ( )
aOther—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............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 tank ( )
a Percolation Test Results Performed by........................................................................... Date................
_________________ .
a Test Pit No. 1________________minutes per inch Depth of Test Pit................,__: Depth to ground water_._::.-___.__•__._..__.
ti, Test Pit No. 2................minutes per inch Depth of Test Pit--------------- Depth to ground water.--___:_________________
:. •--------........................................................
ODescription of Soil........................................................................................................-----------------------------------------------------------•••-
x
U Nature of Repairs or Alterations—Answer when applicable.____/#J(o-��_______1�c��`__���!:�_��!ry�._Y--______.__-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b is ed by the board of he lth.
> ned. /fir 2 ® ��... ------- ......................
Dat
y n
Application Approved B -- ,y••--- P ... . -,,..._..-- -----•-�-- -- �--�
Date
Application Disapproved for the following reasons: ----------------------------------------------------------------------------------------------------------•---
---•-••-••••-••-••-•-••..................................................................................................................................................................................
Date
Permit No. Issued. ". -2------- .....•-----------
Date
No.- ......•. .... '......
THE COMMONWEALTH OF MASSACHUSETTS
.. BOAR® OE HEALTH
I.--- -- -------------OF.......: Gt� .._ .-.-----------------------___.
Applira#ion for Uiipoii al Works Tumi rurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
.System at: _
Location-A ess or t N
�,yy 6f may.
--...•-•-------------------........ .r"t.;.......— 9=4.�. . ...................................... _.....-•----•---- � •!i:!a✓.yfR f . -... !!e .��-,
Owner ddress s
a ............................ cam/ / G«/ �" ..? •fi. ••���. ..?_s.
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( )
~ _______________ No. of ersons_________________--__-______ Showers — Cafeteria p•, Other—Type of Building _____________ p ( ) ( )
Q+ Other fixtures _----------•--•-•------•------•• -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic 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 tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------•--------------------•--•---------------•------...---•------------....---••••••••-.................-...............................................
0 Description of Soil.........................................................................................................................................................................
x
---------------------•------------------------------------------..._=-•--••--•-----------•--------------•------- ----- ..............................�.....................................
V Nature of Repairs or Alterations—Answer when applicable.--__14.S�I{-_._.___� a"._.__5 _�_ __ Ci°� ._..r•____._____..
'gje,_.-.----•-----------------------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with _
the provisions of:i:'"
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b is.ued by the board of lisAlth.
r Date --'
Application Approved By. . - — ' "` '`l,�
Date
Application Disapproved for the following reasons---------------------------------- ---..__._._.--------------------------------------------------.....-•---. ?
------•--------------------••----....------------------------•••----••--••-••-----•-----••-•-•••---•--------•-••--••--••-•-••----------•-••-••-----------------•--•------•------••--•-••--••--••._._.._.
Date
PermitNo......................................................... Issued.----.... •-- ..............`-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�.............. .....eT r�. 1.....OF.......... . ... xZ4........°.._.._................................
Trrtifiratr of Tautplianrr
TITS ISlTO CERT FY, T "t e Individual Sewage Disposal System constructed ( ) or Repaired
by..... ---- -----------........... -••-•-••••--•-------•------•--
(/ ,�
G Instiller
�1 is /7
4.' i 'l -{F
at �' ' -----••--
has been installed in accordance with the provisions of TLC j o� State Code as describes in the
r
application for Disposal Works Construction Permit No__ __.__ ____: �_._ da.ted___. '..."_._ ................ ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....` ' `1 ._. ........................................... Inspector...._ ..............................
T THE COMMONWEALTH OF MASSACHUSETTS
w._
D, BOARD OFF HEALT
d..........OF.............� .. ..T..'. :................
No .'_..�.C= mil_ ` FEE........................
IPermission hereby granted------ ---- =
to Construe( ) or Reir ( an Individual Sewage ispos �Syst '
. 7
_�- /
at
Street
as shown on the application for Disposal Works Construction Permit No.--__ .'___._._____�Dated.�}`:���_�.'�.r�:.....
•-• Board of Health
DATE7
---•-------=------- �.....)-----------------------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF. BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTTRA I.ON
07c' -
MAP NO. 1500 PARCEL, NO. - -'
ADDRESS OF TANK: ! "VG`� 7 J l6t -1u.+5 rt)i/!S 'VILLAGE: `1 r�ltl5., r! t
N%.amb�r Qtrmm
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) :
�. OWNER NAME: l �1�`i �gCrr?r t- �t fe S !i`i 4 PHONE:----wl—��/
INSTAL: DATE: .t�ir / ' BY:
INSTALLER ADDRESS: -CERT.1-40.
*TANK LOCATION:
(`D6COFi`S aC TANK 4 � ` JL_ocAT2ON W Z T H mcoPQCT T O mU SL"7,►D N
`TYPE O TANK 'AGE ;W`YRS. FUEL/CHEMICAL ) �„
TESTING CERTIFICATIQN C I PASS C ] FAIL DATE-', i
1 '
LEAK DETECT ION'—[- ]ICHECK IF NYA',ri TYPE/BRAND
ZONE OF CONTR I BUT I ON" �C y] YES ["t l-NO-»... .DATE-PTO .BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES [ ]_NO`"`•DATE, ''-
{
CONSERVATION [ ] CHECK IF N/A DATE
_ r
BOARD OF HEALTH TAG NO. C Y76 ] DATE
k
PLEASE. PROVIDE A SKETCH SHOWING THE TANK •.LOCATION ON THE BACK OF THIS CARD
_Awlt
Q
S 1 d-L4
{
�oFtHe TOWN OF BARNSTABLE
OFFICE OF
sss
out
BOARD OF HEALTH
ur.
039. 367 MAIN STREET
HYANNIS, MASS. 02601
February 22, 1989
Ms . Tarsilla DiGiano
Mr. Perry Ermi
195 Walnut Street
Marstons Mills Ma. 02648
Dear Ms . DiGiano & Mr. Ermi : '
Enclosed is brass valve tag # 876. Please attach
to the fill pipe , of your underground tank .
Due to the unknown age of your tank we must presume
it is twenty (20) years of age . You must have it
tested- every year and remove it byFebruary 1994.
I have enclosed tank testing information for yop.
If you have any questions please feel free to call me
at 775-1120, Extension 183.
Sincerely yours ,
Thomas A. McKean
Director of Public Health
TM:cst
Encl .