HomeMy WebLinkAbout0068 HILLIARD'S HAYWAY - Health Sg`Hilliard's. Hayway
Barnstable
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BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppricatiou jf or Yell Cougtructiou Permit
Application is hereby made for a permit to Construct( �� Alter ), or Repair( an individual we 1 at.--
Locatio - ddress Assessors Map and Parcel
JEk
YZ
Owner Address
Installer-Driller Address
Type of Building /
Dwelling 4/
Other-Type of Building No. of Persons
Type of Well 411� . Capacity
Purpose of Well e)N6&
t
Agreement:
The undersigned agrees to install the afore described 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 Certificate of Compliance has been.issued by the Board of Health. j
Signed
Dati
P"z//Z, 31'1JI17
Application Approved By
/ Date
Application Disapproved for the following reason . !!//
Date
Permit No. V V Lvi _70 Issued
Date
--------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed(/), Altered( ), or Repaired( )
by All
Ave� L,tAZ,
Instal
at ' T AM"
has been installed in accordance with tk4 provisio s Of the Town of Barest r 11ea Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
i
Fee
No. �O
BOARD OF HEALTH
TOWN OF BARNSTABLE
2pplication ff or Vern Con4truction Permit
Application is hereby made for a permit to Construct( '� Alter ), or Repair( ) an i dividual we 1 aL--
co ; 1. Ito t At 94�? 1
�Locatio �dr� � _ Assessors Map and Parcel
,l Owner ddress
Installer-Driller Address
Type'of Building /
Dwelling t/
Other-Type of Building + No. of Persons
Type of Well ��� � Capacity
Purpose of Well /-
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
? 4
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of C,-Qmpliance has been issued by the Board of Health. -
Signed
Dat
/7
Application Approved By V • �_.
�Date
Application Disapproved for the following reasons:
1
Date '
Permit No. n)LIV17-7 Issued
Date
-----------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE '
f
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed e), Altered( ), or Repaired( )
by 4 1/ / vf— C,uW
� Installer
/1 0Teas been installed in accordance with the provisio, s 4 the Town of Barnsta le jPRar f Health Private Well Protection
Regulation as described in the application for Well Construction Permit No! ` `X 69 Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY. r
Date Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE
Vern Cow5truction Permit J
No.
v" Fee
Permission is hereby granted to��//' p�- 6 ,(zl /
Installer
to Constructt(-�� Alter( ), or Repair( ) an i�d/i/vidua/lell at:
Sfreet /a✓ �`- ����
as shown on the appli ation for a Well Construction Permit No. aced
Date Approved By
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26 2013
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
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
S June 26, 2013
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•3113 Title 5 OjInsect rpm: SewLDispoyefem•Page 1 of 17
i
L
Commonwealth of Massachusetts '
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Hilliards Ha wa
Y Y
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26, 2013
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:
Inspector's Note==> The septic p p system described herein Is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and 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.
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
i
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26 2013
page. City/Town 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:
I
❑ 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
5
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
CGM ,e'°v 68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26 2013
page. City/Town 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 Y2 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
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26, 2013
page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 68 Hilliards Hayway_
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26 2013
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's"Name
information is required for every West Barnstable MA 02668 June 26 2013,
page. City/Town 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
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gp ))�
Detail:
well in use
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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:
t5ins•3113 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
c�M 68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26, 2013
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: occupant
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26, 2013
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:
5+ years. Certificate of Compliance for current system issued 7/18/2007 (Permit#2006-542)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 2feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8.5 x 5 x 6-1000 gallon
Sludge depth: 4 in
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
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26, 2013
page. City/Town 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 30 in
Scum thickness 1 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
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 not required at this time. Maintenance pumping is recommended every 2-4 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Hilliards Hayway
GSM SyO°W
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26, 2013
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:
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 68 Hilliards Hayway
Property Address
Hilliard's HaYw Y a , LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26 2013
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
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 was not located due to lack of swing ties on as built card and landscaping considerations. A
bucket of water was poured into the outlet end of the septic tank and the water was heard splashing
down into the distribution box, indicating that it is operating normally without backup. Condition of
septic system has been determined by inspection of the soil absorption system (pages 12-13)
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.):
* 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
T
. t
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is required for every West Barnstable MA 02668 June 26 2013
page. City[Town State Zip Code Date of Inspection
D. System. Information (cont.)
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.):
An observation hole was dug into leaching gallery stone and no effluent contact staining was
observed in the stone or overlying soils. No standing effluent was observed to a depth of 12 inches
below the top of the stone layer.
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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is
required for every West Barnstable MA 02668 June 26, 2013
page. City/Town 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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of"Mass�cW§btts
- t Title Ito lr� o
ri Subsurface Sewage Disposal+System Forms=;'Not"for Voluntary Assessments`
68"Hiliiards Hayway
Property Addr@ss.
Hi(liard's Hayway;'LLC �,
Owner Owner's-Narbe
informatifor everyon is West Bar`.nstakile: MA 02668:_ Jun"e`26, 2013
regw�eii
page. CltylTown State' Zip Code Date,o.fi Inspection
D:_Syste'm Information ;(cons•)
Sketch Of;SeWage Disposal System.Prot/de:a view of the sewage disposal system inciuding"ties;to
at least.two permanent reference landmarks or benchmarks. Locate all 'Wellswithin"100 feet. Locate
where;public water supply enters the buildi4.Check"one of the bokesbelow
hard-sketch.in the area:belo ' -
El drawing'attached'sepa-'ately
t/
i
LCACN 106.
-
C G kLL
SGPTIC
TNr�
1� �L RDS
t5ins '3113, 751e 5 Official Inspection Form Subsrrrtace`Sevm a Disposal System•.Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is West Barnstable MA 02668 June 26, 2013
required for every
page. City/Town 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: 25+
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: 7/10/2007
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:
Town of Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be over 5 feet
above the bottom of a witnessed test it in which no water or groundwater mottling was noted. Town
p 9 9
of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater
table.
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
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 68 Hilliards Hayway
Property Address
Hilliard's Hayway, LLC
Owner Owner's Name
information is West Barnstable MA 02668 June 26 2013
required for every ,
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
,
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable
�¢THC t
•. °' . Regulatory Services -
. _ Thomas F.Geiler,Director
BARNSMBM
��� Public:Health-Division '
i
Thomas McKean Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304.
Installer&Designer Certification Form
Date: Sewage Permit# % Assessor's 1VIapTarceT
CGE Engineering Wm E Robinson Sr -Septic
Designer: g g Installer: P
Address: 21 Hilltop Drive Address: PO Box 1089
Bourne Centerville
On Wm ,E Robinson. Sr. Sept*issued a permit to_install a
(date) (installer) -
septic system at 68 Hilliards Hayway, W Barnstaled.on a design drawn by
.(address)
CGE :Engineering dated ��
(designer)
i
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.
eater than.W lateral relocation of the SAS or an vertical relocation of an component.,
greater Y Y p
of the septic system)but in accordance with State &Local Regulations. -Plan revision or
certified as-built by designer to follow.
�VZH OF M�SSq
•
(Installers Signature) RONALD F.
a BUKOSKI ��,,
CIVIL
No 32024
P. FQ T E
(Designer's Signature) (Affix_Deli p Here)
PLEASE:.RETURN':_ TO. .BARNSTABLE. PUBLIC -HEALTH _DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT:BE--ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Heald/Septic/Designer Certification Form 3-26-04.doc
f
CGE Engineering, Inc.
CiNil ♦ Geotechnical ♦ Environmental Consulting
Engineers & Scientists
December 17, 2006
Project No. 061011
Town of Barnstable
Department of Regulatory Services
Public Health Division
200 Main Street
Hyannis,MA 02601
Re: Residential Property- Septic System Repair/Upgrade
Janice M. Brockie
68 Hilliard's Hayway
West Barnstable,Massachusetts 02668
Public Health Division:
For approval,please find attached two original sets of design drawings for the upgrade to the
septic system located at 68 Hilliard's Hayway, West Barnstable.
The following variance is requested from The State Environmental Code Title 5: Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage, 310 CMR 15.000.
1. Title 5 Regulation, 310 CMR 15.22](7), states that the top of all system components,
including the septic tank, distribution box or dosing chamber and soil absorption system,
shall be installed no more than 36"below finish grade.
Request: For local upgrade approval,that the proposed absorption system consisting of
concrete Chambers be approved with soil cover ranging from approximately 2.78 to 4.28
feet. Existing sewer-pipe inverts control the elevation of the proposed gravity flow septic
system, while maintaining the existing surficial topography and offset requirements from
on- and off-site water supply wells. A.carbon filtered vent has been added to the
absorption system. The concrete Chambers and riser have been specified for H2O loading.
If the Barnstable Public Health Division has any questions, or requires additional information,
please do not hesitate to call the undersigned. Please send any correspondence regarding this
application to CGE Engineering.
Sincerely, ,
CGE Engineering, Inc.
Ronald F. Bukoski, P.E.,L.S.P.
President
21 Hilltop Drive,P.O.Box 456, Sagamore,MA 02561 (508)833-2250 Fax(508)888-1065
�I
Town of Barnstable = P#
Department.of Regulatory Services
Public Health Division Date
►bs S. 200 Main Street,Hyannis MA 02601 ,
Date Scheduled'.7 .9 1,9 Time Fee Pd.
Soil Suitability Assessment for Sewage Disp �ali
Performed By t4 K QJ I[t Witnessed By:
LOCATION& GENERAL INFORMATION
LocationAddress•� Owner's Name QrA^//CE- $ROCK/6-
�S 1V/LL/,q q D 'S M4)1 W A Y ® � Address 66 4//e-/4,Z p 'f ')Al k/A)1
(A 7 w, aa/r,v c•nq uce; ,W4
Assessor's Map/Parcel: /0 YJ- '/" Engineer's Namee�A�O OPT$
NEW CONSTRUCTION REPAIR Telephone# -0 S 33
Land Use 'R Ag 5'n/T/AL Slopes(%) RAUI. Z 4VrZ Surface Stones /View
1.
SWr164J Aat
Distances from: Open Water Body IJV ft Possible Wet Area ft Drinking Water Well T/d''O ft
Drainage Way 7 MQ ft Property Line .5d:,&fd/7- ft Other ft
SKETCH:(Street hame,dimensions of lot,exact locations of test holes&pew tests,locate-wetlands�n proximity to holes]
1
Parent material(geologic) SZ 4G/AA D ufW AX H Depth to Bedrock SOT F�✓-;d��/7 SR�F�
Depth to Groundwater. Standing Water in Hole: >lYY."~ Weeping from Pit Face
N
Estimated Seasonal High Groundwater ?
DETERMINATION FOR SEASONAL HIGH WATER TABU
Method Used: 7-0"&RA? 16_ff_zfr-,Q✓,4T/0PJX G!J'GS 6W-46v64 C4r/p/r/or7t //�06 /Q80U6/�0/tr>'gL
Depth Observed standing in obs.hole: 1 1V'V____ in. Depth to soil mottles:
Depth to weeping from side of obs.hole: y /y Y s,in, Groundwater Adjustment &4 4. tt.
Index Well# Reading Date: Index Well level�- Adj,thetor- Adj.Groun&ater L evel,. „
PERCOLATION TEST DittpJdAk Thne.l�.der
Observation
Hole# TP-/ Time at 4"
Depth of Perc 37-SS M Time at 6"
IONS rr
Start Pre-soak Time @ Time(9"•6")
End Pre-soak tp'23
ZYJ_8 µV)
Rate MinJlnch Aw W.
Site Suitability Assessment: Site Passed X Site Failed: Additional Testing Needed(Y/N) A/
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 1007 of wetland,you must first notify the.
Barnstable Conse;'vation Division at least one(1)week prior to•beginhing.a
Q:\SEPTICVERCFORM.DOC
DEEROBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency, .Gravel)
O / it a r► a O 3 /��0
za —I yy'r C. of lix
./•✓tr DAw� a .r• ,
DEEP..OBSERVATION HOLE LOG Hole#LZL�/ /11Zf17
.. Depth from Soil_!orizon Soil Texture Soil Color, Soil Other
Surface(in.) (USDA) (Munsell)r; Mottling :(Structure,Stones,Boulders.
` Consistency,%
#A . , Aa
,4 O Sao ✓,o&I A r
J�'E�COG pr/ O.S xl.
DEEP OBSERVATION HOLE LOG Hole#.S.7' 2, )IIZI �_7
Depth from Soil Horizon Soil Texture Soil Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%O v
yL H f
/j
,a �•S /IV Z!x Al 8 /r,�
LOG
Hole#
B
DEEP OERVATION HOLES
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders.
Cons' e
I
I
Flood Insurance Rate Map:
Above 500 year flood boundary No— Yes .
Within 500 year boundary No ►� Yes
Within 100 year flood boundary No Yes
Depth of NaturallyOecurrine Pervious Material
Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,expertise and experience described in 310 CMR 15.017.
Signature l .Date
0b6) gx_t-2Z4v
Q.WEPMCVERCFORM.DOC
N 87*36'30'E 116.19' j i r- — —
WOODED
VENT WITH
CARBON FILTER
GRAVE
DRIVEWAY
49
POST&RAIL
FENCE
38
cn
34
GARAGE
S� \t
Lu
LAMP
POST
o I \�
DECK
8
G
.4BEDROOMS
PATIO
CRAWLSPACE
B.M-38:i7 MSL
CW.-BRICK STOOP
EXISTING
MIN ,LEACHING PIT 10
EXISTING D-BOX
APPROX.LOCATION\ Ij
UNKNOWN EXISTING 1.000-GAL
U.G.LINE ;. CONCRETE SEPTIC TA<K i
'po
LAWN
10,
...... ......
. ...........
--LOT 45
35,420 SF;t-
26
--S-300
14
22
- - P
EXISTING WATER SUPPLY WELL
ps
............\AVL
TOWN OF BARNSTABLE
',t-LOCATION ,�iy //� - A e.I J 7I SEWAGE}}##�
VILLAGE G„ a n ei ASSESSOR'S MAP&PARCEL O�FiCJ
INSTALLERS NAME&PHONE NO. S d 0 3 L
SEPTIC TANK CAPACITY G -a
LEACHING FACILITY:(type) " S G v e- (size)
NO.OF BEDROOMS 3
OWNER h4 3 J , G
PERMIT DATE: Se COMPLIANCE DATE: ?`-/g--a 17
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) . Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
r
,yF P
:T
r +
(�1•✓ I S
No. D V a rc, Fee
THE COMMONW=ALTKOF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
.�� 01ppYfcation for ;h5poeal *psstem Con!truction Permit
Application for a Permit to Construct( )Repair( )Upgrade(X )Abandon(X ) ❑Complete System Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
68 Hilliard's Hayway/ --' Janice M. Brockie (508) 362-8689
1til�ap s rYapParcel 045 68 Hilliard's Hayway, W. Barn. 02668
Installer's,�1vame-Address,and Te No. (� Designer's Name,Address and Tel.No.
A0, s a . , . I �� S Ibn Bukoski (508) 833-2250
! � 10A,A'i � CGE Engin. , Inc. , P.O.B. 456, Sagamore
Type of Building: 02561
Dwelling No.of Bedrooms Four Lot Size 35,420 sq.ft. ^ Garbage Grinder( )
Other Type of Building N/A No.of Persons Showers( ) Cafeteria( )
Other Fixtures N/A
Design Flow 440 gpd gallons per day. Calculated daily flow 465 gpd gallons.
Plan Date 12/17/06 Number of sheets TWO Revision Date
Title Septic System Upgrade, 68 Hilliard's Haymyf W_ BarnGtablA M&
Size of Septic Tank Exisitng 1,000 a Type of S.A.S. (3) 500g rnnr- M;;mberg
Description of Soil 0-15" A, L S ; 15-28" R, T, S ; 98-144" ry Sand, No ttl=ng�Z GW
Nature of Repairs or Alterations(Answer when applicable) Pump & abandon existin le incr nit-_
4 f > c
RONALD F.
Date last inspected: o` BLIKOSKI
CIVIL
Agreement: , No.32024
The undersigned agrees to ensure the construction and maintenance of the afore described on-'; a�u�sgre ystem
3:>
in accordance with the provisio�of Title 5 of the nKhalt
en Cod@ and not to place the systen CCeerttiifi-
cate of Compliance has been issued by this do
f
Sig
ne4fort
��/ DateOf
Application Approved by Date
rfa
Application Disapproved following re o s
Permit No. ^� Date Issued
—Ar
No. D� C � ' f/( Fee
THE COMMONWt'i4�LT.l OF MASSACHUSETTS Entered in computer: Yes
nog i
PUBLIC HEALTH DIVISION -TOWN BARNSTABLES MASSACHUSETTS
,�I 1 ZippItcatton for btgpool *p6tem Conotruction Vermtt
Application for a Permit to Construct( )Repair( )Upgrade(X )Abandon(X ) ❑Complete System RjIndividual Components
Location Address or Lot No. n Owner's Name,Address and Tel.No.
68 Hilliard's Hayway /✓� - Janice M. Brockie (508) 362-8689
sse r �;ss apfarc g1: 68 Hilliard's Ha
N]apel 041514 yway, W. Barn. 02668
r, Installer's Name3Address,and Te.No. Designer's Name,Address and Tel.No.
Ibn Bukoski (508) 833-2250
/1 0A,A-� �'� CGE Engin., Inc., P.O.B. 456, Sagamore
Type of Building: 02561
Dwelling No.of Bedrooms FOu' Lot Size 35,420 sq.ft. N0 Garbage Grinder( )
Otizer Type of Building 'NSA- ' "' No.of Persons Showers( ) Cafeteria( )
Other Fixtures N/A
Design Flow 440 gpd gallons per day. Calculated daily flow 465 gpd gallons.
17 06
Plan Date 12� � - Number of sheets TWO Revision Date
p Title Septic System Upgrade, 68 Hilliard's Hayway, W. Barnstable,MA i
t' a 'Size of Septic Tank Esisitng 1,000 g Type of S.A.S. (3) 500g conc. Chambers
Description of Soil 0-15 A, L.S. ; 15-28 B, L.S.; 28-144" C, Sand.. No mntt1 i ng,/
F S
r s + Nature of Repairs or Alterations(Answer when applicable) �P & abandon existin j 4 Mq
g new ° RONALD F. c
4 ft of double was of
o
Date last inspected: _P o.320240 .
Agreement: F SoI s T E
0NAL
The undersigned agrees to ensure the construction and maintenance of the afore described on-site s system
in accordance with the provisions of Title 5 of the nviro en' Codq and not to place the syste ' per ti until aCertifi-
cate`of Compliance has been is�d b this o d of al k �~ 1�
Sign �� Date
Application Approved by Date l�O
Application Disapproved for the following re �o s
w„,r
Permit No. ' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CEAIFY, that the On-site Sewage Disposal System Constructed(. )Repaired( )Upgraded
Abandoned(XX)by (Kd_�&►vsy 1
at 68 Hilliard's Hayway has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No ated
Installer Designer
The issuan o .'s pe 't shall not be construed as a guarantee that the'(y to 1 l•func ions=des'gnedDate Inspector /PI/
w r
j
----^--�—--------—---------:`, ———————
No. Fee—�r-�—�"�^
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mtopool *p!tem Con5tructton Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( X4Abandon( X4
System located at 68 Hilliard's Hayway, W. Barnstable, MA 02668
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction ust b completed within three years of the ate of thi. e
Date:_ 71b Approve .
-�ti pE NAkiyt�,
L nfi CERTIFICATE OF ANALYSIS Page: 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 6/3/2003
Hill,Margaret&Karl Order Number: G0319809
Margaret B.Hill
P 0 Bcx 614
West Barnstable, MA 02668
Laboratory ID#: 0319809-01 Description: Water-Drinking Water
Sample#: 19809 SamOing Location: 68 Hilliards Hayway,West Barnstable Collected 5/19/2003
Collected by: Margaret B. Received 5/19/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB:IC Lab
Nitrates 1.6 mg/L 10 EPA 300.0 5/20/2003
LAB: Metals
Copper <0.1 mg/L 1.3 SM 3111B 5/27/2003
Iron <0.1 mg/L 0.3 SM 3111B 5/27/2003
Sodium 19 mg/L 20 SM 3111B 5/27/2003
LAB: Microbiology
Total Coliform Absent P/A Absent 307 5/19/2003
LAB: Physical Chemistry
Conductance 154 umohs/cm EPA 120.1 5/20/2003
pH 7.1 pH-units EPA 150.1 5/20/2003
Z
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
. 4 RECEIVED `6
i
t'.,1
11iyt,.j t V,u:'.
TOWN OF BARNSTABLE I
HEALTH DEPT. f
i
i
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
LO CAT IO � SEWAGE PERMIT NO.
® /1 s far /,��+�� �� 7
VILLAGE
4 All.
IN.STA LLER'S NAME & ADDRESS
B U It D E R OR OWNER
a
DA T E P E R M I T ISSUED.
' DATE COMPLIA :NC.E . ISSUED _2 ���-
� � e��3�
i `�
�� �
d` � ��"®
al
.�
�� ��/
,�
��
-_.1
. ..ter
1t ..............«.....« :_P r .. .........
THE COMMONWEALTH OF MASSACHUSE77S
BOAR® OF HEALTH
............. " _......--.----....OF.........................................................................................
Appliration for Biopoiia1 Works Tonstrnrtion rprmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
/� .. -,,y....__.... !IAA----------------------------------------------------------------------------------_-----
)Location-[Lddr ss
���./�(.�.4��' ....ff.:.. .7. ................................... or Lot No
/0
"............/ L:a Jl�r.•i-l°
Owner I \ Address
a ...
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder {
U
Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria
dOther fixtures .-�----------------•-.....-••-••••--••--•••---•••---------------------•--------------.............................................-..............
W Design Flow...._...—__...��---a.-..gallons per person per day. Total daily flow.._...'................X�0.........gallons.
W Septic Tank—Liquid capacity/_gallons Length_____________ _ Width................ Diameter----------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length....................Total leaching area......................sq. ft.
Seepage Pit No------/........... Diameter.......:�. Depth below i let..__ ........... Total leaching area..................sq: ft.
Z Other Distribution box ( ) Dosing t ( . ) O�0-/�� e, p -z 77
~' Percolation Test Results� Performed b r� l. --------------------------------------------- Date__/!_.-_�T' 7_.........
a Test Pit No. 1._.[r�'.....minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
s ..... ......, ...
O Description of Soil.._...•.Q.'_!Y 2r._."..'y1.� 6-------u•rc_�!.�_.• --- - --- _....
•---------------•--------
-••W --- -------------------- -------------------------------------------------------------------------- --•--•-••-•-----------••------••-•--•-•-•--------•-•---•---•-•--•••••-••-•-•------------..-------
VNature 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 iITI.L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en • sued b the board of health.
Sign % � '� �Da•-�
�r
e
Application Approved BY-- ------ • -•-•--.
_'� ?7....
Date ate
'11"17--------------------- -----
Application Disapproved for the following reasons----------------•--------------------------------------............__._._._..........._ ..............
------------------------------••----•------------------------...----------------•----•----.....---...----.............................................................._-.................................
« � .
PermitNo....................................................... Issued-D---..0.-----------------•-----... ------at<_.......
Date
t
No.. ...... Fps.... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.O.F.. .
............................................................
e'g
Applirattion for Bispliiial .Workii Tontratrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
--... .. .. - - " ..... ...................................................... ------------------------------
Location I ss or Lot o.
Owner Addrrsss
f
a 2 d . �. -'----•----•-- �'�''' !- + _sf.--....•----------------------
Y
Installer Address r
Type of Building Size Lot............................Sq. feet .
U Dwelling—No. of Bedrooms......... __________________________Expansion Attic ( ) Garbage Grinder
pa, Other—Type of .Building ............................ No. of persons............................ Showers (. ) Cafeteria ( )
Otherfixtu es --------------------------------------------------------- ------------------ ------=----- ------------
. ' _ _._gallons per person per day,:. Total daily flow ................... �',;,�'d_._....gallons.
w Design Flow..-_.. e --.: g P P
WSeptic Tank—Liquid cra" ity,l gallons Length................ Width Diameter................ Depth...............
x Disposal Trencli- 'Vo : Width .... Total Length ............... Total leaching area....................sq. ft.
Seepage Pit 1Vo: tf_,. Diameter. ' _ Depth below ii*t.._. .... Total leaching area..................sq. ft.
z Other.Distribution box ( ) Dosing t - (.;, ) '*" Lj,(}` • � ✓"
aPercolation Test,Res n Performed by. '�� 1 -----.- _•-- Date--j/`'a---_.
Test Pit No. 1___ ._•_-mmutes'per inch Depth of Test Pit.................... Depth to grburid water.......... __-_•--.
44 Test Pit No. 2................minutes per;inch Depth:of Test Pit.................... Depth to ground water.........................
O .� .
_ ' . ..- ... � .escrpt000 .............
. ....... ....... -•------••-----...-••••••••••. •...-••-•-•-•••--•---••-•..,....•.r-.
..-.w .{
UNature 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en sued b_y the board
�yof health
Signe . .....10 -- � r
f
OW
Application Approved By........... ... .._ --� y 't��� �
Date
Application Disapproved for the following reasons: ...---=---•--------------------------------------------•---------------------........-•----
.................•-•-•--•--.....................................---...••••••......---•••-•-••----•----•'
Date
PermitNo.......................................................... Issued....-----•... ....-----.....--•-•-•---
Date
r„
THE COMMONWEALTH OF1,'MASSACHUSETTS .:..;
BARD OF HEALTH
..... l " .............OF.;.... ... .:...:...........
TrrtifirFatr oaf ToutpliFanrr /
TH I T C TIFY, That the Individual Sewage Disposal System constructed (4 or Repaired { )
by .......... •-a:r ••.--• -•--.....--•---••------- ---------•--......_. ... ---•-•--•-......_... -.....
Installer
Qta
at......... .. ...... * y------
has been installed in accordance with the-, ovi . s of T 5 of The State Sanitary Codc.as described in the
application for Disposal Works Construction Permit No.. . ............................... dated------- .. �_... �`_�7_.__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE®AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... ..-------•---....................... Inspector....----..............--- ......................................................
t
THE COMMONWEALTH OF.MASSAC.HUSETTS
BOARD ® HEALTH
40
J. !' t --....-. .........
19
No........6721..��..._.. FEE..a.....................
...............•-•-----••-••••te,
iPermission is ereby granted.:.. - 1'... .._ ... -•....... .....••••-
to Constr t or Re air ; ,) a Indi ual Sewage Disposal ystqrnf
0.1
�t t� ,
� - Street
as shown on the application for Disposal Work Construction O. ......................................"
/ ated
`- ...---....._
Board of Health
DATE...................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
„