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0023 DERBY DRIVE - Health
2') Derby Drive West Barnstable A= 175 - 002 I 1 TOWN OF BARNSTABLE LOCATION Z3 .Dc.TS- q -Dr SEWAGE# Zply) - 335' VILLAGE L,J, {lac ns,65Ic ASSESSOR'S MAP&PARCEL J`75 ZZ INSTALLER'S NAME&PHONE NO. Q' EXQg Vp. _A i on 0GS3 SEPTIC TANK CAPACITY /Spp A20 LEACHING FACILITY.(type) S�J (size) 13 A ZS A Z. NO.OF BEDROOMS .3 OWNER c Co PERMIT DATE: /O 121 I n COMPLIANCE DATE: 102 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of 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 Al - ,r Az' 3v sir c.3 A it A3- 13- 90- r ,r Ay' 5-7/ 3 �tIK%E r� Town of Barnstable Barnstable Regulatory Services Department MAM&Cacity +,BARNBTA$LE, � p� MASS. ,� Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAQ:: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 0584 August 4, 2017 MERRILL, JANICE L 23 DERBY DRIVE WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic systerr_ located at 23 Derby Drive, West Barnstable, MA was inspected on 07/25/2017 by Matthew Gilfoy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of The septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH I, 1 omas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\23 Derby Drive West Barnstable.doc c Town of Barnstable Regulatory Services Department ''rEa ruda Public Health Division 200 Main Street,Hyannis MA'02601 Office: 508-8624644 Richard Scab,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO'REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ An`x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground Y ' ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool.within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). O 2 YEAR DEADLINE CRITERIA q Single esspoo ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: aNSEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 23 Derby Drive Property Address Janice Merrill tea Owner Owner's Name ps; information is West Barnstable ✓ Ma 02668 7-25-17 required for every page. Cityrrown State Zip Code Date of Inspection 9. Inspection results must be submitted on this form. Inspection forms may not be altered inc-any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 6t*— c2 9 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation L Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority -'� ' "' vv 7-25-17 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Go�.�VS t Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is West Barnstable Ma 02668 7-25-17 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ 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 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is requdred for every West Barnstable Ma 02668 7-25-17 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 349gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-70,000gallons 2015- 83,000 allons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �nM 23 Derby Drive Property Address Janice Merrill Owner Owner's Name in`or. -d fo is West Barnstable Ma 02668 7-25-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- Last pump date is unknown 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New SAS added to existing tank in 2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 8 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3 8 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: 1000gallons Sludge depth: 13" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 23 Scum thickness 13" Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle 4" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection. Very heavy solids were present. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection ection Form ix Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 23 Derby Drive M Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Over 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.): Liquid level in d-box was over inlet invert due to clogged SAS. Very heavy solid carry over was present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallons ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in hydraulic failure at time of inspection. Heavy solid carryover was present in leaching chambers. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately FRONT LA (� B 11 3 2 1 Al-22' B1-36' A2.24' 132.31' A3.53' B3-20' A4.57' B4-23' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 120" 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: 11-24-10 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: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 p Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 23 Derby Drive Property Address Janice Merrill Owner Owner's Name information is required for every West Barnstable Ma 02668 7-25-17 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 93 Dcr5%4 ,Dr,vc— SEWAGE# ap/p`= 4148. ., VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Q 'S3 Ex CA VA►=oN y�i-06 S3 SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type)Soo 9a 1 c 5- (size) )3 x ZS x Z NO.OF BEDROOMS 3 OWNER J cz n (r1 c r r, 1 PERMIT DATE: )1-Z 9 -/O COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ALv rc 4X a n S 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 FURNISHEDBY .DoWn eapc EnJG r Al AZ- ay A3• $3 ' A S33- Zo + A L4 �y 23 , Eoz o y .� Town of BarnstaWe RE ro. Departmclit of Regulatory Services y RAMSTAi Public ��eafl ll� Date • � s' 200 Main Street,Hyanuis MA 02601 '�pfU PAA'I A �{ Date Scheduled_ I V Time ! ` 00 Fee Pd.`jJj��OQ Soil Suitabilky Assessmentfor SP.Wage Disposal Perfanned'By:' 4,0 l ' \w Witnessed By: 0 " �Q Owner's Name Location Address Q3 b n f I W, 6a,,,4 ►c Address J Assessor's Map/Parcel: '���� Cngineer's Nanic Calo e-- NEW CONSTRUCTION REPALR Telephone IF Land Use "`-T Slopes(%) /� Surface Stones �m�lTiN Distance's from: Open Water Body sVN'7" R Possible Wet Area ft Drinking Water Well ft Drainage Way -R Property Line 0 ft Other ft S1�l ,'TCH, (Street came,dimensions of lot,exact locations of lest holes Bc pert tests,locate wetlands In proxinuly to holes) • ll�j �V C X3. F oa,K ' Parent material(geologic) 100 Depth tp Bedrock 210 6 Depth to Groundwater: Standing Water in Ilole: NUN Weeping Il0111 hit Nor Estimated Seasonal High Groundwater D E`J<ERNUNA7CION FOR SEASONAL 111011 WATER TABLE Method Used; n/ A Depth Observed standing in obs.hole: /V T --in,_ In, Depth Id Soil!t oul-n. Depth to weeping,from side of obs.hole: __, „ _ e l!L OYuulatlWuleY AdJuslment.e ft. Index Well if Reading Date: Index Well level A,I,factor A41,C)roundwater Level PE R COLATION T1418"Q' Observation , Hole tf Tittle tit 9" Depth of Perc Start Pre-soak Time @ �I 12- J _ Time(9"-6") End Pre-soak Rate Min./Inel1 Site Suitability Assessment: Site Passed _ SiLA-Failed: Additional Testing Needed(YIN) /►' Original: Public Health Division Observation Hole Data To Be Coinpleted on Back----- ***If pea•colatiou test is to be conducted wiliiin 100' of vvettand,you must first uotcty tile. Barnstable Conservation Division at Yeast orle (1) week pricir to begilau trig• QAS EPT10PERC FORM.DOC D E1E]( -OBSERVATION H®LV LOG Dcplh from Soil Horizon -'oil Texture D1e# �T Surface(in.) Soil Color Soil• Other r (USDA).. (Munsell) Mottling (Structure,Stones;Boulders, Co iste c %a' ravel 4 s . z,S Ya Depth from DEEP OBSERVATION HOLE,LOG Solt Horizon I-Tole # Surface(in.) Sail Texture Sail Color -- (USDA) Soil . Other (Mansell) Mottling (Structure,Stones,Boulders. G `��. '00".&.4 Consis enc %Gravel 4-5 DEEP oBsr,,OVATION;_-_-_-_- Depth from Soil Horizon LOG Hole# . 73 Surface(in.) Soil Texh�re Soil Color soil(USDA) 5o Other ' a (Munsell) Mottling (Structure,Stones,Boulders. tq vn ct � Consistency %4nvell i-ya D EIEP OBS]ERVATION HOLE LOG Depth from Soil Horizon Hole# Surface(in.) Sail Texhire Soil Calor Soil (USDA) ,• Other (Munsell) Mottling (Structure,Stones;Boulders, • Consi tea ncy�,y Orav� eI�T ------------ Il�lood Insui-ance Rate Map. Above 500 year flood boundary iJa Yes Within 500 year boundary No Yes. _ T Within 100 year flood boundary No yes , Depth of Naturally c!(!urronP Pervious Material Does at least four feet of naturally occurring pe area proposed for the soil absor rvious material exist in all areas observed tltrpughout the ption system? If not, what is the depth of naturally occurring pervious material? r I certify that on 19!c�(date)I have passed the soil evaluator examination approved by the Department of Environmental.Protection and that the above a.nalysis was performed by me consistent with the required training, expertise and experience described in �10 CMR 15-017. Signature iU Date2 v Q:\S.EPTlC\PEPCFDRM.DOC No. l J✓� Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for ]Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(✓S Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No.Z3 PcrS H A R W.Bc6r r% Owner's Name,Address,and T 1.No. H Assessor's Map/Parcel I - ZZ cre—olcs Cos-al— DS ,UcrS Installer's Name,Address,and Tel.No. ClCkk%o aA 1 D Designer's Name,Address,and Tel.No. 14 TccLScrr-4 l..N• Foc-cs-Icl�wlc. Type of Building: Dwelling No.of Bedrooms 3 Lot Size /5, &t7 sq.ft. Garbage Grinder( ) Other Type of Building Rt5lo1cn4 la No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1 30 gpd Design flow provided �9 gpd Plan Date h1oy Z 4, ZOO 0 Number of sheets Revision Date Title M , c v Size of Septic Tank C. Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -]:/P 'cc,l ►VZuJ 1$cn9a.l S?' Pilr+1D r- 1•cr�ov� -�hc cx�s�}i,no 1 c�.cl,ing�n�� core-1a.,r+�.�••a..�cd so i 1 � rSR)Oxc. td;4), ekc^ Scx^,p . • rcf4 Lcc. w►- k cicarn s4onr— 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 Certificate of Compliance has been issued by this Board of Health. Signe Date lD" S-19 Application Approved by Date Application Disapproved by Date for the following reasons Permit No._ 2oj7- 33S Date Issued ::QW: No. G _ Fee /U U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 1 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21ppYication for deposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(✓S Upgrade( ) Abandon( ) FrIcomplete System ❑Individual Components , Location Address or Lot No.23,flc rb Li D R tW• (3a r rn `Owner's Name,Address,and T 1.No. N;r-,J IC S C05-1&K. Assessor's Map/Parcel i"7J ZZ Z 3 D-_rS .D R Installer's Name,Address,and Tel.No.3 48 E'XC A 0 1\ Designer's Name,Address,and Tel.No. I -TcaScrry LIQ- F-or�5-Id•alc Type of Building: Dwelling No.of Bedrooms 3 Lot Size !S', (�`� I sq.ft. Garbage Grinder( ) r I Other Type of Building RCS t c�[C n'i 10. 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures I, Design Flow(min.required) �'3 30 gpd Design flow provided �'7 9 gpd Plan Date talOt/ 7 y, Z O 0 Number of sheets Revision Date Title V S, N,,n ' r M, { 9/o- Size of Septic Tank Q Ey 4 �i�� Type of S.A.S. t� Description of Soil ,�1 , Nature of Repairs or Alterations(Answer when applicable) �n�« I Y a)Cw )$cam�0.l S-t - � a � PcenouC. -�hc cx�s-) i ng ► c�cl,tir,g *r o,rNu. Cor,A-f%A 5o -c�kxcc LL);4k CICar\ rnplacG char ct's w�-11� cleQr� 5-IonL ys,Date last inspected: "Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in s accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. p� Signe Date /O ' S• 11 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2 of ?- 3-S Date Issued " 1 ------------------------------------------------- J THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( (,of Upgraded( ) Abandoned( )by 0�- B EXcaVa�1,0 at 2 3 perSU DT- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. •)w 7-3,Mated ( u ' '2 ��_7 Installer A3 EXcckt,�A 1 On Designer #bedrooms 3 Approved design flow ;�y gpd The issuance of this permit shall not be construed as a guarantee that the system wi(ll'function designed. Date ( I �� f Inspector \, RAJ __1 ----------------- No. _. Fee �pu THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(✓}� Upgrade( ) Abandon( ) System located at 73 Dc T-SL4 D{" and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date /� %�. /; '7 Approved by W, �� 1 e Town of Barnstable Regulatory Services vices � Thomas F. Geiler,Director * BARNSPAME, I 6M �0g Public Health Division jOPFa Nwy A' Thomas Mclean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certifleation]Form Date: J Sewage Permit# Assessor's Map\Parcel Designer: DO W N CAI-e &,h/I Nei N1 G Installer: �A'Cat V ell O N Address: 9-2;9 MAIN <4- Address: � 'TL—��� W Y UTIJ PQIeE UA 75 F 9V-3 FPA-L.6 On 1/!7//7 was issued a permit to install a (date) (installer) septic system at 3 tZ., 5_,�F rased on a design drawn by (addr ss) DAME-A-, 04ALA P,F</12�L,�'. dated 11lzgJ/0 (designer) •- I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes(i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. YN OF 4j,yss �o DANELA. yam (Installer's Signature) « OJALA , U CIVIL Dt No.�t6502 -Lon 8 (Designer's Signature) (Affix Des e tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RE,RE,CErVE4 D BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. O:Heatth/Septic/Designer Certification Fomi 3-26-04.doe s i � No. 2- DI o . qo D / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Miooal *p!5tem Cow6truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2 3 Te rb ("1�( Owner's Name,Address,and Tel.No. y 5N-34y-3323 W_��,ti' Jon ✓ f-6r'r1I 1 Assessor's Map/Parcel -11"Q-Lt-7 6 q 22 2- 3 D t_rZy e \A1--Bar 5 I_nstal�ler's Name,Address,and Tel.No. J�X �'4�?-0 3 ig er's Na Address a Tel.No.JD9-3&2-45 y J TU2 lQT7 ab a V 0.}0'n, + q q n ` t Main r- 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 rl Design Flow(min.required) 3 3 v gpd Design flow provided q gpd Plan Date 11 14/1 y Number of sheets Revision Date Title OM Size of Septic Tanks Type of S.A.S. QR, Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Board of Health. ,,\\ Signed Date I( /�9 V Application Approved by 1/ Date /l �'l r C) Application Disapproved by: Date for the following reasons Permit No. a oI o^ qro Date Issued No. 010 !o� .,., Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpprication for TDigpogai *ipmem Cowaruction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 23 Owner's Name,Address,and Tel.No. 7 -- W. ��'`' Assessor's Map/Parcel ✓� I �j P C1 F(C 1 22 f Installer's Name,Address,and Tel.No. U\�`y'�7 L C"�3 Designer's Name,Address and Tel.No. 6b�" 3C 5 Y ' Ex(nv0d 1Un �vwn Crj� r ICI `TenkDgr r tl 1-Clnl' �Tr1( C s) C��.I��Q 53 Adr ►ice Safi, Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder { Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) a v gpd Design flow provided `( ( gpd Plan Date 2 y 1((� Number of sheets Revision Date Title Size of Septic Tank O Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this \\Board of Health. Signed ( J�` ) p .� Date 11 /n C( � u Application Approved by Date /r'` �' r f� Application Disapproved by: Date for the following reasons Permit No. (got 0— q6 6 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( � ) Upgraded ( ) Abandoned( )by at `�f'r ?\t I i(i �I fa has been constructed in accordance with the provisions of Title 5 and the for /Disposal System Construction Permit No. dated P �g V Installer (J� r+ -1 I Designer �Dp v,I,—) Co �E�. rp 41 Dr-ram_ 1 11 #bedrooms Approved design flow 33 gpd The issuance of this e it/shall not be construed as a guarantee that the systemMction a signed.Date (/ Ins ectorp ,,. _ s No. (go 6, Fee... THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Wgpogal *pgtem Construction Vermit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pe it.. Date Approved by C' 'f PS jL '•:1 PVT I7�4 J}i Q,�'''G4.1�n s I'�e-L'tt Ji�av Thomas F. Geffer, Director BARNSTABLE, r�ss. A Publk Health DMsfou ?139. Thomas McKean, Director 200 Main Sti°eet,Hyannis, A14 02601 2-4 - - 4 Office: 508 86� .644 Fax: 508 740 630 Installer &Dedguer cCer i rncatiom Form Date: All/�//Q sewage Permit a0 10 "W Assessor's MapTarcel / 7� -0/0 Designer. O w✓1 2 ✓1. J41 Ins>taUere Address: �I mGt-4 V L/ Address- 440 �L On 49 �15 C �� was issued a permit to install a (date) installer) septic system at �� °�✓ r ) based on a design drawn by ( dress) 0.V)( ej P -1 dated /!4 ka esi er) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ` �,\H OF Mg889CyG „^ DANIEL.A. CY \ o OJALA (Installers Signature CIVIL q No.46502 r P��&O/STE��O��� 1 ✓1 �/ 1ZI�I/ I® ASS/ONAL ENG /Designer's Signature) J Afiix Designer's Stain here ( � p ) rI.,E;ASE RETURUi TO BARNSTABLE PUBLIC HEALTH JMV ISION. CERTIFICATE OF ,COW-LIA-WE WILL, NOT BE ISS EED TN';tIL BOTH HIS FORM A1NU AS-BUILT CARD AID( RECEMID BY THE]BARNSTABLE PUBLIC HEAT TH IDMSION. THANK YOU. Q:Health/Septic/Designer Certification Forn 3-26-04.doc i S i - 14 �+ ASSESSOR'S MAP NO. S S-A\5 PARCEL (019 LOCATION.P3VXreJV4'k-%?-.4,''e SEWAGE PERMIT NO. VILLAGE �,� , ;'��aLL I N S T A LLER'S NAME i ADDRESS w N S UILDER OR OWNER DATE PERMIT ISSUED , b DATE COMPLIANCE ISSUED �I/ Z) 8? 6 L .Q ' s � i �C0VN � I i� 1000 �T tl vt Z) No..... .......a. Fxs.........5....._.... A THE COMMONWEALTH OF MASSACHUSETTS y' BOARD OF HEALTH p- c .........of. . ---.----- ....... Applirtttion for Diopo,ittl for atotr ' tt r mit Application is hereby made for a Permit to Construct ( or Re r ( an Individual Sewage Disposal System at: ................» 1... ...4... .....`���`�--: �.�� �.__ �,� t` :-..�.(.!:-L................. Location..... e�j�L' , t t Np t ........... O .ne— t,/ W..--•........ ..............�.. ..y�.. .f/ .. ...............»....».»..... W .._......... .. �, . .._....... .... _. d ................ Installer Addr as s Type of Building Size Lot...Jt-2 t.�TZSq. feet .-� Dwelling—No. of Bedrooms..........5...........................Expansion Attic .( ) Garbage Grinder `4 Other—Type of Building No.. of persons............................ Showers pr YP g •-•.......................•- P ( ) — Cafeteria ( ) QOthe fixtures ..............•-•.................. ........ Design Flow......,.... -L.0............ .... gallons per In ptr ddy. Total daily low................ . .____...... to Ww rr-- � 1 Septic Tank—Liquid capacity.r:VjQ.gallons Length.�.f�_-...d�... Width:.�.X:.. Diameter................ Depth- _... _.. x Disposal Trench—No..................... Width.................... Total Length....................Total leaching area....................sq. ft. 3 Seepage Pit No.._....._1.... Diameter......1_�N...... Depth below inlet...... Total leaching area..:- 3_q__-.jsq. ft. Z Other Distribution box ()< Dosin tank ( ) tt Percolation Test Results Performed by.... . � � Date.....Y.��z�g�T fz, Test Pit No. 2...... nunutes per inch Depth of Test �,1�. .1..... Depth to ground water..ja�-�1.[�:�.�.. Test Pit No. 1......__. Pit... minutes per inch Depth of Test .Pit.................... Depth to ground water........................ O Description of Soi !(J. ., - .... ....... W t .. .r---------•....................•_................................._........_.._•--_.. V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...•-•••............................................... Agreement: The undersigned agrees to install the aforedescribed Individual S e Disposal System in accordance with the provisions of TI! '.�5 tpe State Sanitary Co. a and si !fyaurther agrees not to place the syste in operaronApproved nhcat�f Compliance has be is o o th. Signed. . . .... ..................... ..... .. Appli By.._..__..__ to-. . Date Applived for the f 1 wing reasons:.............. ............................................................................................ »».. ........................................................•• ......................•--........•--_...............•--•-....._.._..--••......._.___......-•-..._..._..........---•' ............» Date PermitNo........................................_..........»»» Issued............_.... .....--•--_...._................ Date No..... .:..a:..7 Fas.�....?f�,..�.�._ THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .. � ........... ..................................... Appliratiun for Diapasal Works Toustrurtiun ramit- --Vmot Application is hereby made for a Permit to Construct ( or Repaii ( ) an Individual Sewage Disposal System at `� ......... I_, ,• Q• 4'_ T..F : ` Location A �✓ / r t No ................. .... ..-.-...... Owner ' `•• Addre .................... ........ ���: _:!'_-�-~ /Installer Addressr� Type of Building Size Lot_..0...:...:... ....../;:.Sq. feet a Dwelling—No. of Bedrooms........... ___---------------------------Expansion Attic ( ) Garbage Grinder p, Other—Type of Building ............................ No. of persons.,.......................... Showers ( ) — Cafeteria ( ) p' Other fixtures k. A ai ::____••-•••........................... ........-•-------------------.. ........ W Design Flow...... ti_ ,......... gallons per person,per day. Total daily flow................ ............gallonns4 WSeptic Tank—Liquid capacity.� � _gallons Length_r��__.1!�__. Width:.G ._ Diameter................ Depth_ .!B.' x Disposal Trench—No..................... Width.........!......... Total Length...,................ Total leaching area....................sq. ft. 3 Seepage Pit No_________ __________ Diameter..... .:?........ Depth below inlet..... ......... Total leaching area.- 2Q.v ysq. ft. Z Other Distribution box O Dosing tank ( ) Percolation Test Results Performed by.... .......- ...__._. Date..... 1.4 Test Pit No. 1.......... ....minutes per inch Depth of Test Pit..../! .... Depth to ground water.......:.. 44 Test Pit No. 2.. :...........minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 !1 .:_t t �#.................................... O Description of Soil• •�• 1"l ) ( � d ... r (0$' . fi �_.. V ... : •--.....-•--•••••-••-•-•---••-•••••................•-•-•-----._....-••-•-•-•-•••-•-1�1�•�tl, •`......•---.-•---_...__......_:__ V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....-•••.... .•-••-•--•-•..........................................•-•----._._..._._....._...................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIm 5 t�e State Sanitary COd'e'—r The,undersignedfurther agrees not to place the system in f �. operati n u Itil ertiti t of Compliance has been Issued'by the'board of�health. .�n_. 'S ` Date Applica on Approved By..............r1wing �..'�-_•--0-.�..'._. ..•••-•--•�� _Date at ..............•---.................. Date'.......---.. ApplicationDisapproved for the f reasons_______________________•___-_____._...___--_.._......._.._________._...._.._____.........._................---........................................................... .....•-•...•-•-.....••••........_......_..----........._..••--•--....--•-•-•-•--..............____........_______.. ................ Date Permit No......................................................_ Issued.................................. ....................•- Daft THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH t:`n1A)1_J.....OF... /l/ r �- ...................................... (In if iratr of Tnmplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.....:?4!��,l f"�.........� nt 7T t?G T7 n......... .... © 7,�.r�./..CC..............................--•............................-- at....f c? ,- 1r�- L lLr r u e. ._...__Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary 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 FUNCTIO_Nf SATISFACTORY. � DATE.......................... : I t........................................ ........_........................................................... `c1r&A14HE COMMONWEALTH OF MASSACHUSETTS Sc.l ✓-al�",Vw qt twt--P BOARD OF HEALTH � �P G Disposal Warks Tunstrnrtinn Prrmit r Permission is hereby granted_.. :._.....t`. �P`'1 � ��t_ i c�_.� G/j/0 ..........--••--._,._............................................... �..•-e_ to Construct ( ) or Repair ( ) an Individual Sewage\Disposal System atNo... r?::I..........� U t tir i.��_;-��n..........-------------------•----............__........................_..............,................. Street as shown on the application for Disposal Works Construction Permit No.�&'.2-.. ... D ed.... z 1 . .......... -• •-........ .. r .........................••... •... ..................._............... .y IS r of health DATE...... 1 Z.1_.. . .�..........