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HomeMy WebLinkAbout0015 ANGELA WAY - Health --- 15 ANGELA WAY West Barnstable 133-075 'I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is West Barnstable MA 02668 September 3, 2008 required for p ' every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be alteted in any way. s Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name r� 43 Triangle Circle Company Address Sandwich MA 02563 Cityrrown State Zip Code 508 364-0894 1328 Telephone Number License Number r B. Certification z C, UZI certify that I have personally inspected the sewage disposal system at this ad ss andlt at this information reported below is true, accurate and complete as of the time of the:F 1pectior The iipspection was performed based on my training and experience in the proper function and aintenauee of site sewage disposal systems. I am a DEP approved system inspector pursuant t 'Sectigj15.W of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i September 3, 2008 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. // 115 t5-3016.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal SItern•Page 1 of 15 II— Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is required for West Barnstable MA 02668 September 3, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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): brokenpipe(s) are re laced ❑ P ❑ obstruction is removed t5-3016.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M ,0 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is West Barnstable MA 02668 September 3, 2008 required for p 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. t5-3016.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is required for West Barns P table MA 02668 September 3, 2008 every page. Cityrrown State Zip Code Date of Inspection 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 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: 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 '/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. t5-3016.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is West Barnstable MA 02668 September 3, 2008 required for p every page. Cityrrown 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. t5-3016.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 . 1� Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is required for West Barnstable MA 02668 September 3, 2008 every page. City/Town 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)] t5-3016.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 p 9 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is West Barnstable MA 02668 September 3 2008 required for p , every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 gpd Number of current residents: 2 Does residence have a garbage grinder? Removal of grinder is recommended ® 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 ears usage d n/a—well in use 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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): t5-3016.doc-08i06 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 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is required for West Barnstable MA 02668 September 3, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No 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: Age: 14+years. Certificate of Compliance issued 3121194 (Board of Health permit#93-612) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-3016.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 M 15 Angela Way y Property Address P Y Jon and Janet Cook Owner Owner's Name information is required for West Barns P table MA 02668 September 3, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3 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.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 2 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: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 4 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 12 in How were dimensions determined? As built card t5-3016.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is p required for West Barnstable MA 02668 September 3, 2008 every page. City/Town 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.): Pumping is recommended within one year and maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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): t5-3016.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 N 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is required for West Barns p table MA 02668 September 3, 2008 every page. Cityrrown 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 At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-3016.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is p required for West Barnstable MA 02668 September 3, 2008 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: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. t5-3016.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is West Barnstable MA 02668 September 3 2008 required for A , 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.): t5-3016.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 n -. Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Angela Way 'M Property Address Jon and Janet Cook Owner Owner's Name information is required for West Barnstable MA 02668 September 3, 2008 every page. City/Town 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. ANGELA WAY LEACHING GALLERY LOCATIONS A B C F. a zo D-B0x 1 40 Ft 22 Ft SEPTIC 2 15 Ft 29 FL TANK A B C EXISTING DWELLING # 15 NOT TO SCALE t5-3016.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 'A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Angela Way Property Address Jon and Janet Cook Owner Owner's Name information is West Barnstable MA 02668 September 3, 2008 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 40 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 40 feet above groundwater table. t5-3016.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 v Commonweofth of Massachusetts ,John Grad Executive Office of ENronmentai Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 Environmental Protection Tealicket,MAU2536 (50 - 'r0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ORT A CERTIFICATION ✓/�� fC `/�'/7 V 1 15 Angela Way W. Barnstable 6 199�► Property Address: 9 Y Address of Owner: Bqq ti Date of Inspection:718197 (If different) �FPj�lf Name of Inspector:John Gracl Rafferty:Box 591 W.Barnstable Ma.02 8� Company Name,Address and Telephone Number: S 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: X Passes This inspection is based on criteria defined in Title V Conditionally PFillation s code 310 CMR 15.303.My findings are of how the system is Needs Furt r By the Local Approving Authority performing at the time of the Inspection.My Inspection does not Imply any warranty or guarantee of the longevtly of the Fails septic system and any of its components useful life. !acoply Inspector's Signature: Date: 7114J97 The System Inspector shall s of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 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: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. 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, 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 11115/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Angela Way W.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 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 IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic Compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ 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. Backup of sewage in 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 clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Angela Way W.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 D] SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: 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: 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) 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 11/15195) 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 15 Angela Way W.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. , X None of the system components have been pumped for at least two weeks and the 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System,have been located on the site. X 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. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) • 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 Angela way W.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 RESIDENTIAL: FLOW CONDITIONS Design flow: 550 gallons Number of bedrooms: 5 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available: nla Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL? Type of establishment: r0a Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: Na Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection. (yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance, TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1994 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15Angela Way W.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 10'6'H 5'7°W 5'8" Sludge depth:V Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 15' 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.) Septic tank and all components are structurally sound.Recommend removing sprinkler system off cover to tank.Recommend pumping septic system every two years for maintene GREASE TRAP:_ (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: Na Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) Na (revised 11/15195) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Angela Way W.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible: excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits, number: n1a leaching chambers,number:n1a leaching galleries, number: 5-galleys 26'xto•xa' leaching trenches,number, length: nla leaching fields, number, dimensions:n1a overflow cesspool, number:n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Sas is structurally sound and functioning properly.Recommend raising covers to galley's. CESSPOOLS:_ (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) n1a Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: nla Dimensions: n1a Depth of solids: n1a Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Na (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Angela WayW.Barnstable Owner: Rafferty:Box 581 W.Barnstable Ma.02668 Date of Inspection:718197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' n LT, ` RA N / D �R Pe a cD 3� DU DEPTH TO GROUNDWATER Depth to groundwater.12 feet method of determination or approximation: USGS Maps and Charts (revised 11/15195) 9 a 7 DeparGiient of E,W onmental Management/Division of Water Resources ' ._.t►' ri WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address /0 r as /s �NGEC Kf to At/ N S E W o f (feet) (circle) City/Town lel.Z.�712�vSr',fzBC� Well owner//y/N�r d � .Sf/si Tit/C (roadl Address ,t00. .6uu --"ye' N S E W of �� pQA°N'St�Hd« All (mi.in tenths) (circle) Board of Health permit obtained: yes ®-_ no ❑ I/'fersect. w/ (road) WELL USE WELL DATA I. Domestic Public❑ Industrial E] Total well depth <3r/OZ.ft. Monitoring❑ Other Depth to bedrock ft.. Water-bearing rock/unconsolidated material: Method drilled —'� ��.�--- �/ ,/ 3 Description Date drilled Water bearing zones: ° f Type OG h '�CJ �U� 1) From To CASING Length�ft. Dia(.I.D.) 2) From To I' '� in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: dia.. Grout-0 Other Slott/�_length _from to,& I' STATIC WATER LEVEL(all wells) Static water level below land surface 38 ft. Date WELL TEST(production wells) Drawdown - ft. after pumping -2 hr. k�;b. min.at /S gpm How measured t Recovery ft. after—hr. min. 0 LOG of FORMATIONS COMMENTS g; m Materials From To Driller177 `5h n- /0j)l Firm e Address T` i City/Town Supervising Driller RegA 5� Si nature oI urpervising re istered we/l driller Pleeseprinrhrmly BOARDS OF. HEALTH COPY ENVIROTECH LABORATORIES Mass. Cert.#:MA063 449 Route 130 Sandwich,MA 02563 • (508) 888-6460 CLIENT: Main Post & Beam LOCATION: Lot #26 ADDRESS: Rte 6A 19 AngPl a Way W. Barnstable, MA W. Barnstable, MA COLLECTED BY. Desmond Well SAMPLE DATE:11_z,_Q i TIME:-I:nnpM DATE RECEIVED: SAMPLE ID: JOB#: New well WELLDEPTH: 102'/58' RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 5.86 Conductance umhos/cm 500 116 Sodium mg/L 28.0 26.5 Nitrate-N mg/L 10.0 0.77 Iron mg/L 0.3 0.40 Manganese mg/L 0.05 Hardness mg/L as CaCO3 500 Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride mg/L 250 Turbidity N7L 5.0 - 4 Color APC units 15.0 Background bacteria/100 ml (MF method) 200 LLERA 602 ug/L N.D. T: Iron level is not a health hazard. Low pH indicates high corrosive characteristics. See report attached. WATER IS SUITABLE FOR DRINKING PURPO OR PAR ETERS TESTED. DATE �� IC aL =03 '59 GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Field ID: 15A Lab ID: 6332-01 Project: Maine Post & Beam 15 Angela Batch ID: V62-0262-W Client: Envirotech Sampled: 11-04-93 Cont/Prsv: 40mL VOA Vial/NaHSO4 Cool Received: 11-04-93 Matrix: Aqueous Analyzed: 11-08-93 PARAMETER CONCENTRATION REPORTING LIMIT (u9/L) (u9/L) Dichlorodifluoromethane BRL 5 Chloromethane BRL Vinyl Chloride 5 Bromomethane BRL 5 Chloroethane BRL 5 Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane I BRL cis-1,2-Dichloroethene * BRL 1 Chloroform BRL 1 1,1, 1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL I 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropane BRL 1 Bromodichloromethane BRL 1 2-Chloroethyl Vinyl Ether BRL 1 cis-1,3-Dichloropropene BRLBRL 1 Toluene BRL 1 trans-1,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethyibenzene * BRL 1 meta-and para-Xylene 1 ortho-Xylene * BRL 1 Bromoform BRLBRL 1 1,1,2,2-Tetrachioroethene BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS a,a,a-Trifluorotoluene 30 33 111 % 87 - 113 % 1,2-Dichloroethane-d4 30 28 93 % 83 - 117 % BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986). 1 No.�=� ----- Fee— --- BOARD OF HEALTH TOWN OF BARNSTAB LE Application forlVell Con5tructionpermit Application is hereby made for a permit to Constr>,}ct lte ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel lk -----------------------------------------------------------------nL -------- Owner Address VIA g Installer — Driller Address Type of Building ` \ Dwelling-- c—Q 1-q_l —---------------- Other - Type of Building--------------------------- No. of Persons-------------------______________ Type of Well—_5.0 t_e e~" =— —--- - Capacity-------------------------------------- ----- Purpose of Well—'(Do,.-,-�` ----- -- - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certific to of Compliance has been issued by the Board of Health.a Signed —------- � -73 — date Application Approved By— - - --------------------------------------- ---_ —_—— date Application Disapproved for the following reasons:------------------------------------------------------- ------------- —------------- - ------------------------------- ------------------ ---------- --------------------- _ date Permit No. = -- - � — ——--- Issued - - `�date --- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS P.O CERTIFY, That the Individual We Con tructed ( ), Altered ( ), or Repaired ( ) by ��� - ( - C - (..- - --....... -... —--- - - - — -----_ __ oIn aller `at —\T�f/ — --- — ------------- has been installed in accordance with the provisions of the Town Barnstable Boar4 of Healt rivate Well Protection Regulation as described in the application for Well Construction Permit No. -3---i-2 Dated-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE —- —- =----------------------------------------------------- Inspector---------------------------------------------— — ----_— . . , C�4 j' r S fA / ' ail / ♦ n La 7-- -- � ----- 0-- _--Nor.. � --- - Fee ----- - � BOARD OF HEALTH .. TOWN OF BARNSTABLE M _ Application-jorlDeCr Cootructionpermit (lication is hereby made for a permit to Construct It ( ), or Repair ( )an individual Well at: o DL6 �9 nG e(A. w9 ,l -_ _ __ ----- ----- --- = '� f- - ------------------------- Location — Address Assessors Map and Parcel ` 01 G3e -------------------------------------------------------------------------------------- Owner Address ----------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- Installer — Driller Address Type of Building Dwelling - ��'cQ- ��°��---------- --------- Other - Type of Building------_ :`--------------------- No. of Persons----------------------------------------- -- Type of Well-- C c_e eh�- -- - ---------------------— Capacity-------------------- Purpose of Well---0o^ r,5 c-_------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a ertif'c to of Compliance has been issued by the Board of Health. Signed -- "`?____-J� y , `1 _— /�� �J date Application Approved By -- =!1?-!! ------------------------------ date Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------- -- ------------------------------------------------ ------------------- - - - /"` � - -------------------- date PermitNo.-----------f----- - --------------------- Issued----------- ------------...................— Tdafte-- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS O CERTIFY, That the Indiv' al WConstructed ), Altered ( ), or Repaired ( ) b I Lam' 1 �PI l �_ - ---_ y ---- has been installed in accordance with the provisions of the Town of Barnstable Boar of Heal Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated------------------------- T THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------— - - - Inspector------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Vell Congtructioupermit No.1`-;-Y"- -------- � (b j Fee—�------------- 1 P�&Z/ Imo 6VKLI ,_Permission is hereby granted---- - r ---- - --- --------------------------- to Construct 71 41te ( ), or Repair )„an Individ a Well� �/V No. — --------Jv, (-' -�->� -- --�D - 1/�1'i/ --------------------------------------- S eet i as show on a applic do for a Well Construction Permit _No.---- -- ---;—�-------------- -�J---------------------------------------- Date d----------- --�----- _21-------------- � Board of Health DATE--__�-.�,���� --- ---------------------------------------- °Jc-11�,51�C3 5 0 ' rjA 5L '6Et' NV7dl_ •�•rS f0066d co a�C Qd' 107 rn 00 'dLj r `o ,,fib 40If r C 00 .5t � N OF BARNSTABLE LOCATION C-+tZ�-- GVEF'`) , SEWAGE # L, /�- il Y1LLa4 � 1„j�_IC- ASSESSOR'S MAP & LOT la3-10-79- •f Tl INSTALLER'S NAME & PHONE No. p SEPTIC TANK CAPACITY (S'aV CIA L__, LEACHING FACILITY:(type) f�&__ In j(, NO. OF BEDROOMS S-- PRIVAT WELL OR PUBLIC WATER BUILDER OR OWNER .lYitj� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No l i r - , r i i ! i . No...q3_,__Wk,..-- Fps...../ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..1_0.W�-3. .............OF.........�.�1'r��,.�.��!!�r.�.�g-- pplication is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal ystem at: .M.r��. . ..�. ......1 4?.` '�------••----..... .�-C? 1C..... .. 6 1--------1��1 ... 1 �.._.. _.r..... `� !'C1.��--- A•ddress ... .`���/^r✓!__t!la�fllKcS� o tion-Address or Lot vo...... _^ W .. ........C05TO------ ........ .�►1' .. -• . .�... Installer Addres � � Type of Building Size Lot_.Y____.q J__________Z©-----Sq. feet U Dwelling—No. of Bedrooms.............. Expansion Attic ( ) Garbage Grinder ( t4 H .......... Other—Type of Building No. of persons............................ Showers 0.i YP g ---------------•--•--------• P ( ) — Cafeteria ( ) W Design Flow.Otherfixtures ......................................................allons per person per d��y. Total dail flow...........................................ga�llons.o� G; Septic Tank—Liquid*uid ca acit KAID allons Len h.l'..-'G. . VV idth .:��..__ Diameter D th. _ __ W P 9 T P Y g d � � P � Z3 <W Disposal Sl l"to........5......... Width... Total Length_.. (4_.`.... Total leaching area.44116------sq. ft. Seepage Pit No..................... Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by. .�1��.�!. f_ i� i '1�1 .?_ ."Date.. .... ` /9 - + Test Pit No. 1..... .....minutes per inch Depth of Test Pit...-?•-A._t--i- Depth to ground water...?�.i'DAX rX4 Test Pit No. 2._....•.....__._minutes per inch Depth of Test Pit....11r..0......... Depth to ground water.... c..,!� ----------- =-------------------------- -•-••--------.......g ,,. ..-------------------------- •------------------------ •-•------------- O Description of Soil..Y...L."'.......t.. ''�� - �. ._:1.�..: (� .IaSP. "� - ------- -----------------------------------------`Z Z.0........ 4eA.1 .... T2W.ram - sT, ----- - - - - - U Nature of Repairs or Alterations—Answer when applicable_____________________________•-----____-_._-------____-__-__-__------_-----_____-•-•--_.---___. -----------------------------------------------•----------------------------------•----..........------•----------------------------------------------------------------------------------------..-•-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T/'1'•-• the provisions of T IL i 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha issued t e o d af-4 It ined. -• = - --- ------- •_ - - -- Da t e Application Approved By..... ........ .............. .. ___... Date Application Disapproved for the following reaso d,�4/ Date Permit No._.:71.. ......._... Issued_------- • ilsrz IVo.._!'///,(//�. �C! I ' — O •.J Fu$......1 . r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 76 App irFation for Bispos ai Workfi Tongtrurtion Vamit Application is hereby made for a Permit to Construct' O or Repair ( ) an Individual Sewage Disposal System at .....�1.9 .....I-�-5 ----Iw - . .................. �- ►° r %�-- j --•- ..__..._ -- �nless or t No.�1� - •- -------- ••---- ---(Oe. ............ ........ .. ...... �Addres Installer 'Address d Type of Building ` ' Size Lot. Sq. feet Dwelling—No. of Bedrooms.............. .........................Expansion Attic ( ) Garbage Grinder ( t4 0 `4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other:fixtures . d -------•---------•........... -------- - WDesign Flow............? ........................gallons per person per dry Total daily flow-___-------•----_-•-----.----"---------.....gallons.f 9 Septic Tank—Liquid capacit J � gallons Length.O._: .-_- WidthrJ ' _ Diameter................ D pth..�..^" Disposal i�-00- _-__.- ........ Width._- -0......_.... Total Length__.�- --...... Total leaching area.4- - -------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. '� ?. =w_ � r' y? � _....._.. Date.. ... 1 / f Test Pit No. 1................minutes per inch Depth of Test Pit_;_.__.._._....I___ Depth to ground water-__ C�,_ ,_ fs, Test Pit No. 2................minutes per inch Depth of Test Pit..... ------- Depth to ground water..._ a0 f� _.. Description of Soil t p "' 4� 1 ' $ �' '* �� W ------------------------------- --------------------------------- � ' �''. ._1 �. � �� "�`�c ................. U Nature of Repairs or Alterations—Answer when applicable.----............................................................................................ -----------------------------------••--------------------------•--------------------.....-------------------------------------------------------------------------._._...---------------------.....•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with I.1 T I-1 a.-. the provisions of l:t, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificated Compliance has issued by h oa of heal Signed •••--•... ._...._. ... .......... cDate -•- Application Approved By..... ---•••• ••'! .-• . ........-4.--- . Date Application Disapproved for the following reason • ................................ --------------•------------.--••--------------...------... ......--•------- Date Permit No. -• ----------..13 b----------------------------- Issued.......Z( t Date- THE COMMONWEALTH OF MASSACHUSETTS . OARD Z�1_ ! T "jj� .................. .. ..8 ... (Irdifiratr of TontpliFanrr b TH I TIFY, Othe Individual Sewage Disposal System constructed Y" or Repaired ( } y C? °�......� 1. ............. sfhll'er at----------------�._�._.._ (�----. _------ .... 111�•a .� A�lkff_"----------•------------------•------------ has been installed in accordance with the provisions of T tE 5 of he State SanitaryCode as described in the application for Disposal Works Construction Permit No._ ��___''" j dated .............................................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...` ... .._....-•-••...._. Inspector 4p!_J THE COMMONWEALTH OF MASSACHUSETTS OARD F �HaEA TH .............. �1..`!.. . ......OF......... ........ .. .. ..... ............ NO._.... -• ...� FEE.. ... ......... Disposal orb Tonotrttr#ign runfit Permission is hereby granted........... at ��.._.. ....... -•_.. .-•-•••••--.....•--••••-•-•--••-••--•-•-•••••........•-- .. . ........ to Construe ( )fir air ( �aq v� ual SevtG�gjeitp sal S s e , %r� .... Street as shown on the application for Disposal Works Construction Per it No.. . .__ _#/ ated.......................................... -------- ------ ' Board of Health ------------------------------------------ DATE............................................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS tTOWN.OF BARNSTABLE LOCATION o PAV SEWAGE # VILLAGE ASSESSOR'S MAP 6z LOT INSTALLER'S NAME 6z PHONE NO. -j 6iyS /uC rG SEPTIC TANK CAPACITY / O LEACHING FACILITY:(type) eclos (size) / 0OO NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER :.r BUILDER OR OWNER �ou 6Dt ne r- Nc-r DATE PERMIT ISSUED: r,:/ //zz DATE COMPLIANCE ISSUED: 15 — 0 VARIANCE GRANTED: Yes No Ouse j d