HomeMy WebLinkAbout0124 WHITE MOSS DRIVE - Health 124 WHITE MOSS DRIVE, MARST.MILL.
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ISTIN.0 SPOT El E1lAtnN 0
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ISTINd..CONTOUR. 3: . "0 �►
OPOSED.CONTOUR 0 i A.0 L � 41013I4 �.
A.
Tb THE LOCATION ,t� ANY UNDkRGROUNp. 0; ;L E V Y
+Vt RAGEI WELLS., OR OTHER.Q!lLItI:S.SHOWN ON o 1oo5o�q � No �t34i �,� ;A'•�
S.PLAN IS APPROXIMATE ONLY A5 DETERMINED
)M RECORDS AND/OR 'VERBAL INFORMATION, Fc�stE��v �w
CONTRACTOR IS REtPONSIBLE FOR THE , IORA
21Ln,pN OF THE IrXISTING LOCATIONS INFIE a ,
N.
VY B ELDREDGE ASSOCIATES, INC. . .
-tea _ CLIENT .. P- L 'AN
W )INEERS = LANDSCAPE AACHITECTS J06 NO.-1 a
LANNER8u — LAND SURVEYORS DR: eY� ��� y/�'�=;
IN
889 WEST MAIN STREET CHKD,BY,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF &MMONMENTAL AFFAIRS
DEPARTMENT OF ENVIILONMENTAL Psonmw
ONE WINTER STREET,BOSTON uA 02108 oar 292 sw
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Gavemor
Commissioner
SUBSURMCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAW A
Prorey Addrew.ref ismie-ftSS JW,MFrsTarrs Mills tM• Name of Oansrr 0 owq 00?
°gL6gr Adtlress of Ownar:
D°�of ` s1��� R E I D C. E L�lr I S
Name of lapar�m:tl�mae Pais
I am a DEP opp Ih m antpeatsr prrauaM m SoCSm ls.m of Title s(mo em 1 s 0001
COMPW11.n.:E_L.IS BROTHERS CONST CO.
TdWhww H PORT, MA
CEFITtlaCATM STATH 1Tf
I cwtify that 1 have personally inspected the sewage disposal system at tNs address and dart On information reported below is taro.accurate
and complete as of the of hapectior►. The Inspection was performed based on my training and experience In dw proper function and
nalntsnance of on-aiN wage disposal system;. The system:
Passes
_ Conditionally Passes
_ Needs Furpw Evaluation By the Local Approving Authority
bwetwo
The System Inspector shalt submit a copy of this inspection report to tin Approving Authority(Board of Health or DEP)wmn tmrty 130)days of
completing this inspection. H the system is a shared system or het a design flow of 10.000 gpd or greater.the inspector and the system owner
shad 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 soft to the buyer.N apple".and the approving eadnority.
Py--Ce I o v-&014 -Oo Li
NOTES AND COMMENTS Cd
O0� 9
revised 9/2/98 PageIof11 —
44)Primed an WOW Papa
t .
SUBSURFACE SEWAGE DISPOSAL SYSTEM empECTM FORM '
PART A
CERTMICAMOR iooe9harod)
a :Jai w1���t"e,mess fir, rnr�rsl'ens m<<ts,m�.
Daft Of 1 (0 Lc�t'r
Summu Y:
A. SYS I PASSES: �V.J
I hove not bund any information which indicatos that any of the failure conditions described In 310 CMR 15.303 exist. Any failure
criterio not evaluated are Md<cated below.
S. SYSTEM ALLY PASSES:
One or more system components as described M the'C Pass-section need to be replaced or►epaired. The system,upon
dwmpleeon of the replacement or repair.as approved by the of Health.WIN pass.
Indicate yes.no.or not datondned(Y.K or MD). Describe bum of to elf ietsa+neas. If-not detwmbwd-.explain why not.
Tho septic M&le motel,unless the owner or has provided the system hapectai with a copy of a Certificate of
Con fattrdhed)bn ng tat h the tank was wi te thin tworty 120)yews pry to the deft of the Inspectlon;or
the septic tank.whether or not metal.Is cracked.at unsound,ohms substentM in0tration or exMtradon,or tank
Bane is iununinant. The system will pass Inspectlom N the existing septic tank is replaced with a complying septo tank as
approved by the Board of Health.
I
i
Sewage backup or breakout or high stetio water IOVI I observed In the distribution box Is due to broken or obstructed pipe(s)
or due to a broken.settled or uneven disuibuNon bar t. Mw system wib pass inspection If(with approval of the Board of
rIN Health),
broken pipes)one replaced
obstruction is removed
-- distribution box is IeveMed or ed
The system roq**d pumpkV moo then four*me year due to broken or abstnrcted pipe(s). The system will psss
h�spocttcan if(with approval of the Board of Hodthh
broken pips(s)are replaced
obstruction Is remmed
revised 9/2/98 Pole 2d11
r
sues fiFACE SEWAGE DBPOSAL SYSTh3S GWDptdCnm tram
PART A
rN Cal ,lRow(coroe na
P�raperty AddMw:l9 WhtTe�"(Ylcs� Des: Yt PfM-"fa-A% 'lYl.l t ts)mf -
o—.%= qj AZ L YALgkw
Duo of b-4pecti l S j t(f(0 U
C. Fl NDER EVAsli1ATTOTi E REQUNW BY THE WNW OF HWTH:
Co ufte ms exist wltidt retptiro AwdW ovaluadan by thf Bowd of Hodlh In ordw to datrundno if the sytatem It f ill"to protfat Ow
WAUo hooM,ostoty and the ewirmmo t.
1) SYSTEM CTNLL PASS IAA M BOARD OF HEALTH DETERRIUM EIt ACCORDAIWE WITH 310 C Rt 15.3Q3(IXb)THAT THE SYSTEM
IS RIOT Ft=TWWW W A MAUM WISH WILL PROTECT TO I PMW HEALTH AND SAkTY AND THE
ElWIlROWAWT-
Cosspool w privy Is within 60 fast of surface water
Cesspool or privy is within 60 fast of a bordo wodand or a salt Owsh.
2) SYSTEM WILL FAIN,11AH.W TW BOARD OF HEALTH(Aft WATER SUPPLIER.AF AIM THAT THE SYSTEM IS
R�ICT>O 0 A THAT PROtECTB THE PUUJ TH AND SAFETY AND THE WVIROMW
The system has a sepdc tank and soli sbswgft e sy twn(SAS)and the$AS is with 100 left of a surface water supply or
tributary to a surface water a**.
_ The system has o oopdo to*and soil absorpdon sV am and do SAS Is wftMn a Zane 1 of a pukk water supply wall.
Tho systwn has a sapdc tank and aoit Wmrpdon sy tun and the SAS is within 60 feet of a pr(va o water supply Wed.
The system has a aopde tardy and sob absorption sy tom and the SAS is less than 100 test but 60 feet)or more from a
private water supply well,unMss a wsN water wWy Is for ca form boatels and volatile orpnic compounds indicates that the
wa11 to tree from pe W*m from tlmt l&cWW and the posom of unnvx a-doe" caul wduste sdtsoW is equal to w less
Own 6 ppm. IMfdtod used to dabwnbw distanwe (epprorirrtati m nft aafidt.
3) OTHER
revised 9/2/98 Pap 3ofll
. SUBSURFACE SEWAGE DISPOSAL SYSTEM MSPECTION FORM
PART A
CERTIFICATION loandraned)
IC t4apertyAddross: tal.} WI�ITe mass Dr•YY1RrSTo»shflit,lb�YYlfk
Owner: C1 Ri L 'AL.�e r
Date of'6 pertion:
D. SYSTEBI FAILS: /v
You must indicate either"Yes"or"No" to each of the following:
i have determined that one or more of the following failure condit Dns exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be ontacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component du 10 an overloaded or dogged SAS or cesspool.
Discharge or ponds ng of effluent to the surface of the and or surface water due to an overloaded or dogged SAS or
cesspool.
Static liquid level in the distribution box above outlet im art due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or nrailable volume is less than 1/2 day flow.
Required pumping more then 4 times in the last year M T dire to clogged or obstructed pipets).
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 tone 1 of p public well.
_ Any portion of a cesspool or privy is within SO feet of i private water supply wed.
_ Any portion of a cesspool or privy Is less-than 100 fee but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
collform bacteria,volatile organic compounds,amTd!l
and nitrate nitrogen.
E. LARGE SYSTM FAGS:You must indicate aither"Yes"or"No" to each of the following:
The fallowing criteria apply te large systems in addition toe:
The system serves a facility with a design flow of 10.000 9p I or greater(large System)and the system is a significant threat to public
health and safety and the environrwnt because one or more f the following conditions exist:
Yes No
y _ the system is within 400 feet of a surface drinking ter supply
the system is within 200 feet of a tributary to a sui face drinking water supply
the system is located in a nitrogen sensitive area( Wellhead Protection Area-IWPA)or a naPPed Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system ft accordance with 310 CMR 15.304(2). PlMe consult the local regional
office of the Departmern for further information.
revised 9/2/96
SUBSURFACE SEWAGE DISPOSAL SYSTEM msPECTtON FORM
PART 8
CHEOMAT
Ada ass: 1�:L1 yu�"e� Moss DY'. M A�r'f`rvr,5 Y►i i
Prepa.ty ,YY1(a
OWINX ftiiL Aicic�r
DMofb S jUU
Check If the following have been dons:You must indicate either"Yes"or"No"as to each of the following:
No
Pumping information was provided 6y the owner,occupant,or Board of Health.
Nona of the system components have tam pumped far-St least two weeks and-the system has bewreceivinginormd flow
rates during that period. Large volumes of water have not been imroduced into the system recently or as pareof this
— ir►apectron.
As built plans have been obtained and examined. Note N 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 she was inspected for signs of breakout.
AM system components,excluding the Sal Absorption System,have been located an the site.
The septic tank manholes were uncovered,opened,and the interim of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of U*dd,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
N
_ Existing information.For example,Plan at B.O.H.
Determined in the field Of any of the failure aiteft related to Part C is at issue,approximation at distance is unacceptable)
(15.302(3)1b))
The facility owner land occupants,if different from owner)were provided with Irdormation on the properAmintenaac"f
SubSuefane Disposal Systems.
revised 9/2/98 rue 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
praparly Ate: ►�K Wei te,�+1oss Dr.hnwl�9ns►��t ls�m A
Ones aloe In�pectt�nc��
RoW CONDITIONS
RED. v
Design flow_ p.d./bedrgpgt.
Number of ( 1:� N umbw of bedrooms facwol)1
Tots)DESIGN flow .�
Number of cnurent r
Garbage grinder(yes or no):.2�0
Laundry Iseparato system) 1((yyess or no>�ff yes,separatelnspection requirod
Laundry system Inspectedh" no)
Seasonal use)yes cc no): —� 9— ;74 `1.,:Water meter readings,if g(last two yea►'s usage(gpd):
Sump Pump(yes or noJe
Lae date of
TRIAL:
Type of establishment:
Design flow: and (Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)•,,,^
Industrial Waste Holding Tank present:(yes or no)—
Non-sanitary waste discharged to the Tido 5 system:Ives or no)_,.,
Water meter readings,if avaliable:
Last date of occupancy:
OBI:(Describe►
Last date of occupancy:
GENERAL VBVRMATUM
MWORDS and of n a_t►�
SYstarn pum d as pert*I k0pect�i:)yes or no),&Ci —IT
If yes.volume pumped: gallons
on for pumping:
TYPE r6Y3TErA
Septic terWifisttibutfon box/soli absorption system
-- Single cesspool
T� Overflow cesspool
Privy
Shared system(yes at not (if yes.attach pmvious inspection records,if env)
I/A Technology oft.Attach copy of up to date operation and maintenance comrect
Tight Teak Copy of DEP Approval
other
APPROBATE AGE of an components,date installed fif known)and source of hnfamation:
mga
So odors datected when arriving at the site:(Yes or no) P-77
revised 9/2/98 Psge6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM MISPEC IOUI FORM
PART C
SYSTEM RWOtMIATM(0011dra"dl
�rapetty Address: l��} Wh►Te� h(1oSs plr, YY'VPrr<j;yjT Vv1 i�Is VA A
Owndw-
Sl/�1cr�
BURMG SEWER:
(locate on site plan)
ri
Depth below / V40
Material of construction: cast iron PVC_other(explain)
Distance from private water supply well or suction line
Diameter
CommaMs:Itonllitlon of joints,venting,spidence of leak tc.)
yk:
SEPTIC TANK-
Rotate on site )
Depth below grade:
Materiel of construction: Yoncrate_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,flats age Wage confirmed by Certificate of Compliance_(Yes/NO)
Dimensions: -Jew
/ ,k L
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: a
Seim thickness: ca
Distance from top of scum to top of outlet tee or baffle: 41-5
Distance from bottom of stun to bottom of oudetAlr of bef8e:
Now dimensions were determined: _ /:2Xy� pv�AA,
� �-
omments: O�
(recommendation for pump) ,con of inlet t toes or baffles,depth of liquid level in relation to outlet invert,structural integrity,
en evidce of leakage.etc.) Iota
S P
wA
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyeth re_otheriexplain)
DImenslons:
Scum thickness:
Distance from top of scum to top of outlet toe or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Dade of last pumping:
Comments:
(recommendation for pumping.condition of inlet and outlet tees or baffle .depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Pap 7ofll
SUBSURFACE SEWAGE DISPOSAL s1fSTldill INSPECTm FORM
PART C
SVS7M MOOMMIM(cam..
Address: tau Wtiv►rtiP,ass'br. Ysrans rnr 11s�YyM,
O 'mra
mmmr: 1GY► � eY
Date of barpeetiafr. �s�l rojo c�
TIGHT OR HOLOMIG TANK: (Tank must be pumped prior to,or time of,inspection)
(locate on site plan)
Ownh below Wads:
Material of construction:^concrete metal_,Fibergless•_Polyeth ne_othedexplain)
Olmenslom: - -
C"c1tY: gdkrns 'x=
Design flow: gallons/day
Alarm present
Ahem level: Alarm in working order:Yes No
Date of previous ._,�_
Comments:
(—matian of Inlet tee,cmmMon of defm and float switches,etc.)
DISTRIBUTION BOX:IAA✓
poeate on site plan) TT
Depth of liquid level'above outlet invert: N
r%lbomments:
mots and distribution Is a W.evidence of solids carryovef,evidence of lopkage into or out of box,etc.)VA CA
►1
0000
PUMP CAMBER:
Pocate on site plan)
Pumps in working order:(Yes or Nol
Akenns in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and apprtgnsnce,,etc.)
r 1
revised 9/2/98 r+psefit
r
SUBSURFACE SEWAGE DEPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM 11110FORMATION 1con0numill
�+ y Addr�ss; 9-4 Cer mo Ss Dr irv. wSTons lm Rs Inq.
Owner qAz1- A,Lgc,r
Date of InspWdon:
SOIL ABSORPTION SYSTEM(SAS), �/�
(locate on eke plan.if possible:a not required,location may be approximated by non intrusive methods)
It not located,explain:
Type:
leaching pits,number:
leaching chambers,number:_
leaching galleries,number:_ F'
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of s ' signs of hydraulicfailure,level of pending. soil,conditiog of g , lion,a c. y&
s
CESSPOOLS: yJ/
(locate on site plant "
Number and configuration:
Depth-top of liquid to inlet invert:
pth 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,corm idon of vegetation,etc.)
PBNVy:
(locals on site plan) v
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soli,atgns of hydraulic fall=*,level of pondmg,tor Jition of vegetation,atc.)
'k
revised 9/2/98 Pop 9of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTK M FORM
PART C
SYSTEt�Jt gFOiE'JlATiON lcoradl
r*alwh Address+ 1 ai{ (,�1nC�muss pr. Mw OmL Yv i 114,'I p,.
.�Ai L Al.a�ea'
Deft of me-pit Pli.
/v
SKETCH OF SEWAGE DISPOSAL SYSTM:
includo ties to at least two pammmsent ralwance landmarks or Iwndunmks
locate all wells within 100'(Locate where public wow supply conga;into house)
I
31
l
4-1
e2
� 19 l '
3
195
revised 9/2/98 ioo(u
SUBSIqIFACE SEWAGE DEAL SYS7BJ OISPECTINI FORM
PART C
SYSTEM gNFORNATION(Gwdk reds
Addross: 1 a44 W"-re.MOSS, (fir.h kU-y-1 on S Yni k s j lm A-
C OU o rrso R 6mpoer3on:Glp�L. "ve J J/G JGG
lifts Report name
Soo Type—
Typical depth to groundwater
USGS Date wehshe visited
Obsorvation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
AA/ 4--
Surface water
Check Cellar yDO
Shallow wells
Estimated Depth to Groundwater_Feet -
Please indicate all the methods used to determine High Groundwater Elevation:
y/ Obtained from Design Plans on record
2 bservad Site(Abutting property,observation hole.bassmarrt sump ate.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps r
Checked pumping records
,f II
V Checked local excavators.installers
Used USGS Data
Describe how you ostabl)shed the High Groundwater Elevation.1_11M be comp)ateM
fW - -
revised 9/2/98 reget1or11
(.� TOWN OF BARnnNSTABLE �!
LOCATION is u kAi " MOSS Uci �t SEWAGE # y �
VILLAGE rY)"eln /'1'1 I S ASSESSOR'S MAP & LOT 0 9/-,.dojj
INSTALLER'S NAME & PHONE NO. C 1//)� QA6,71vr Cc-nSJ- C
SEPTIC TANK CAPACITY
LEACHING FACILFTY:(type) (size) O® n a
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER P(lihhl C,
BUILDER O ' O WNE
DATE PERMIT ISSUED:.
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/
'� tr.91�i� t�®s5 �2- � �--- �.
� I
� r
�� � �
i
3�!
3�
� f
_' 0 00 TOWN OF BARNSTABLE
LOCATION (,�i"f 17z /y ' ( V'`1j95 Or. SEWAGE
VILLAGE Mai 2.6-A VtA; 0 S ASSESSOR'S MAP & LOT 0,3 r0
INSTALLER'S NAME PHONE NO. 3 b 16
ct
-SEPTIC TANK CAPACITY l Qd6 �� l(A1�►S
,;LI.EACHING FACILITY:(type) (size) 660 (ldt s
NO. OF BEDROOMS PRIVATE WELL O PUBLIC-WATER
BUILDER OR OWNER 6 cve \otc t Otuel. Cos ,
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No l/
_. -
?^�`�� ,
A
'Z� � ��'�
�� �� �
�� �
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-- 9 '36�o
No........APPED ��QQ ..............................
PfniE COMMONWEALTH OFPMASSACHUSETTS
ZL
BOARD OF HEALTH
,��=Z
6 18ftcd . @= TOWN OF BARNSTABLE
Appliratiou for Diripaml Wurk.6 Towitr�?an
inn amit
Application is hereby made for a Permit to C�onst uct ( ) or Repair ( Individual Sewage Disposal
System at:
!� oca' � 9rrss �pLot�No)
Owner dd
--- )P
�!v/ ress
� ----� �=-- ------.... ''r ----
Installer Address
UType of Building Size Lot...................... ....Sq. feet
,..., Dwelling— No. of Bedrooms._..........�------------------------Expansion Attic ( ) Garbage Grinder ( )
04 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........---.gallons 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. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................--. Depth to ground water........................
04 ----------------------------------------------------------------------------------------------------------------------------------- ------
*...
.-----
......
ODescription of Soil........................................................................................................................................................................
x
W ••... -•-----------------------------------•-••-•--•-------------..........------------•-•----••-•---- ----... •.
U Nature of Repairs o Alte ations—Answer when applicable... f. �......:..
f -------•---�.
.. -------- -`` -------------------------------------------------------------•-•-..--..............-----------.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State EnvironmentalVeen
—The undersigned further agrees not to place the
system in operation until a Certificate of Com liance , issued by th o r f he#h.
Si ned .. .... . �`�'...�.: ....,
re
ApplicationApproved BY - .............................::...............................................:..................... ......lO.... .. .y-......
e
Application Disapproved for the following reasons: ..................... .............. ...... .............. .--. .--- .... .....................................
.. . .................... . .............................................................................. . ................ ................................. ........................................
/_ 2�9 Date
Permit No. Issued (O ...�� ..,fs°--------
------------
ate
.•...v.•...-s-�.�..��.. „ .ti__ ... ..-,�.. .,..__.. .- .b._. ....� _.r.�c_..f:�it_:!-s��--r.,y,...-......,. .....-...v�.:..,,.�.+..,. ..r.-........_ »+'....-...-._�-,.ti..... ...�-_- .....�--'}�'ri-•
No................_....... �, a Fas..............c:. c� J
HE COMMONWEALTH F MASSACHUSETTS
BOARD OF HEALTH
r TOWN OF BARNSTABLE
Apphratinn for Dlripwial Murky Tomitrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( 4n Individual Sewage Disposal
System at: IA"m
f XA,A,11
- --------..�------ -•-------------•-------------•---------
Loc.�o :�.dress- r t.N -
ki
................ ----...... ...... ..
Own �1 Address
' t�✓�'
Installer ddress
Q Type of Building Size Lot.......................Zq. feet
� Dwelling— No. of Bedrooms............... ................... ....Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria ( )
dOther fixtures --------------------------- -------------------------- •'-•.....----•---.._..---•••------------••-••------..........
W Design Flow............................................gallons per person per day. Total daily flow.....................
._......- gallons.
0� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................. Depth................
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 ( ) 0
aPercolation Test Results Performed by.................................................... -----•-------•------- Date..--------------....--------------......
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 --------------------------------- ------------------------------------------------------------------------------------- --------------------
•----
*...
......
0 Description of Soil............................................. ------....................-----------------.......------------------------...-•----•-•------....-----•--------.....----..-•---
x '
--- ------------------------•------------................----------------------...._..-•--------•-----------------= _ = �------------- ---•------.....
V Nature of Repairs ofr Alte/rations—Answer when applicable.___.. .. .. ._.. %7.. ?.. .._...., -P!LVG-...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental C(Sde —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the+oard lof health.
Signed ..................................... ----- ..f...��............. ..".
/ .j :........ ....
re
Application Approved By ........... .. . .............. .�.r�.....3... .y-.....
We
Application Disapproved for the following reasons: . .................................:.... . ...............................................................................
.................... .. ......................................... ..:c................................ ...........
Permit No. -- .......2q Issued -----------2/?area
.......................................... - .............----.... Dace......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THI�S ,T0 RTIFI, That the Indlvldual,Sewaglaesr,uDcrlsposal System constructed or Repaired
y .._....... � --------
( )
J
�� C . N .....at ........._ .... i/ .._.. � �
.0- � ...................
has been installed in accordance with the provisions of TITI.E 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...__........................................ dated ......_... ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�T Inspector .:...... .. or�.- .:.-..............
DATE.............. ' +.._.._'5F.L _.. ----- _... p
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CiIy — 2C?C�l TOWN OF BARNSTABLE c
No.................... FEE...........E...........
Dtapnsnl Workii Tonotru#Uan lernti
Permissionis hereby granted-- --------------- ---------------------------------------------------•---......------------------------------------------•----------...--
to Construct ( ) or Repair ( ), an,Individual Sewage Disposal System j
at No.. �l ... .... /G'-!.....................................
/
7 Street q— Z 9 q
as shown on the application for Disposal Works Construction Permit o._/ ___ Dated.._...�r����_!!�!................
Board of Health
DATE-------- -��5--�•-----
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
-%� ASSESSOR
S MAP N0:
c
- PARCEL NO.- -
No...97:1VI d= � FEB........ �
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ ........_0F......... �' s. ..............
Appliration for Dispogal No Tows rudinrt rprutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
.1h� GL6 ,
.....�1n-----------------•----
o tion-Ad ress or Lot No.
- ----------� -------------------------- 4o ---le X--
--------------
wner Address
W '1 .PAI.-- ez--------------------------------- --------5 •.-. •._-. ...........................................
Installer
� Address
Type of Building Size Lot......26;Z .Sq. feet
Dwelling—No. of Bedrooms...........5-----------------------------Expansion Attic (V,0) Garbage Grinder (/Uri
aOther—Type of Building ............................ No. of persons..........--................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------•--.-----------------------------......-------------------------------•-•----------............
W Design Flow............ ......................gallons per person per day. Total daily flow....--------.- ....................gallons.
WSeptic Tank—Liquid capacity-j4M.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 ( ) / /It,
'-' Percolation Test Result Performed by..-LJ.. .--t.E�ldCIdope.-... f!l��fate.......... )/6- � ...
Test Pit No. 1.....t....minutes per inch Dept i of Test Pit.................... Depth to ground water-.---------------.------
fi Test Pit No. 2................minutes per inch Depth of Test Pit..............--.... Depth to ground water..----..................
Descriptionof Soil----------�. .�--------------------------------------------------------------•-------------------
W / �// �.-- .-----------------•----------------------•---------------•------------•--------------------------------•--------------
�/�-----f . ..................................................................................................................
U Nature of Repairs or Alterations—Answer�applicable......................................................................... ......................
----------------------------------------•-------------------------------------------........------•-----.....------------------------------------------------..........................................
Agreement:
.The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.,,
Signed---- �... ,��� (� f-----.--••---• ��� 't
Dat .
ApplicationApproved By------.... V.....�._ - - ^. ................................... ....................Da.--..............
Date
Application'Disapproved for the following reasons---------------------•-•----........--------------------•---•--•-----------------------------------..........--
------------------------------------------------------------•-----------......---------•-------•-•----------•----------...........--------------•---------------------------------------------....------
Date
Perrait No.... --?-nA •Lf l.----------•-•-----.... Issued_.......................................................
Date
No._•- 7----11 Fizz....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... OF........ K t # .�t'a .`, I r ..............
Appliration for Disposal Works Touotrurtion lirrutit
Application is hereby made for a Permit to Construct (1/1 or Repair ( ) an Individual Sewage Disposal
System at:
tt f' » 1 E x f x sir �' '- 1r'1• a�/, `f
Lo ation-Add ess or Lot No.
.a Owner s Address
Instaaer Address
Type of Building Size Lot...... feet
Dwelling—No. of Bedrooms........... Expansion Attic 4( ) Garbage Grinder (Ak,)
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ................................. .
W Design Flow............. .........................gallons per person per day. Total daily flow.............. ..:__._ ......_.._.._._....gallons.
9 Septic Tank—Liquid'capacity.;/ &_gallons Length................ Width................ Diameter---------------- Depth.......-•----_-.
Disposal Trench—No. .................... Width--------------------- Total'Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) f
0.,,
Percolation Test Results Performed by / _.1`._ r E�rr Q z�mvt" Date______._ � ;5
Test Pit No. I..... _-----minutes per inch Dep h of Test Pit.................. Depth to ground water--:___-__ ___-____--.
t14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-___-__-___---___-_-
a •-•---•••-••............•••••.-•_-
....---••-----------.-.
-.........._-•-••---•-- -_.. _...--•-•-•-•
il
Descriptionoo ......._.. ._. _e,.. � �
...........................................4 � • •
.•.--
W •----••--•----- ------------------------ _.,= t ° „� ,-: ._.., .. •-••--
ol
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
--------------------------------------------------•--------•----------------•-•••-•-•-•----•----------•---------•.••----••-•----•-•-•••---------------••••-----•-••.....-••---•---•--•-•-------...---••.
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed... `�� - -• '� '�` € ''s *. ........
C t to
ApplicationApproved By-----•--•-• ------- -'.li.�'"- ----••--------------•----------•-• ........................................
Date
Application Disapproved for the f ollowl g reasons:----•---------------------------------••----•------•---•---•---------------------••---•-•- --•------....._.__
-----------------------------•----•-••--••-•---...-•-----------•-•---•---------------------•-----------...---......._.....•..-----•-•------•-----...-----------------------------------------------•-•••-
Date
Permit No....�-•-�-�-- -�.:�._...--•--•--------._- Issued...................------
Date
THE COMMONWEALTH OF MASSACHUSETTS,
BOARD OF HEALTH
... ..OF.... ................
Cwrrtif iratr of Toutpltttnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (14 or Repaired ( )
'by........ .........'? !�.. . ?f ---------------------------------------------------------------------------------------------------------------
}� Installer
:. ... �rrf LV !i li dE � fyrr tf�. � ----------
has been installed in accordance with the provisions of III j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit `o.... �.� ----------- dated----------------------------___..._.__._._._._.._...
,THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT rHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... .-!_�i_- . ................................... Inspector........... . .... ..........................
-THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... Gf k ...........OF............ "'y. TAr
NTo.....j�. "` FEE........................
v Disposal Works gonotrurtion Prrutit
Permission is hereby granted.......... '`l.J:C_' -.... I>sa_ 0.�-.0-------------•-•-••-••••-••.......................................
to Construct (s ) or Repair ( ) an Individual'Sewage Disposal System
at No.... � .-a ..1 ...... -1k..--,�' {' `� r. ,? ` ! 1
�' Street �
as shown on the application for Disposal Works Construction Permit No..P-I Dated..........................................
.-- Crc>•Board of He M-� --
DATE................................................................................
v
N � alth
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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