HomeMy WebLinkAbout0059 LOCUST AVENUE - Health ol
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BOARD OF HEALTH
TOWNS OF BARNdSTABLE
ZippticationforWeli Conotruction Permit
Appl' 'on ' hereby rzjade .or a permit to Construct ( ), Alter ( ), or Repair "andividual Well at:
LL tin Address Assessors Map and Parcel —
r �3 dress t0 1 —
Installer — Driller — — —^ — — AddresscJ
Type of Building /
Dwelling ! --
Other - Type of Building-----------______ No. of Persons-------------.-_
Type of Well C ------ Capacity--�
Purpose of Well- ---------------- —
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well P t' Regulation — The undersigned further agrees not to
place the well in operation u a Ce 'cate a has been issued by the Board of Health.
Signed C7---
date
Application Approved By —_—_—____—___— --------_---
date
Application Disapproved for the following reasons:
date
2 00
Permit No. V V —� O I 1 --- Issued---C`� -f�- ��---- — ——_—_--
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifitate Of (Compliance
THIS IS TJOICERTAFY, Tbft the Individ}'al Well Constructed ( ), Altered ( ), or Repaired (4--)'
by ���%L° ��.L���o�d� -------------------------- ----------.—_---
T / Installer
atAlt
------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health 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 SATISFACTORY.
DATE--_ — Inspector-- ----- --- --- -------
No. o � �
---------------- ----------------
BOARD OF HEALTH Fee----
TOWN OF BARNSTABLE
Z.ppticat ion fforWell Con!gtructionVermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ("andividual Well at:
Location - Address Assessors Map and Parcel
O ner Address
Installer - Driller Address
Type of Building
Dwelling--- -------__—__
Other - Type of Building-=--__—__—_______ No. of Persons-----^----.__--_---_------
Type of Well� ------ Capacity— -5--- — ---__�_,_
Purpose of Well--
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well P ecti Regulation - The undersigned further agrees not to
place the well in operation until a Ce 'ficate o C �1' a has been issued by the Board of Health.
Signed -_C, - -
date
Application Approved BY _—_____—_______— -----------
date
Application Disapproved for the following reasons:
date
Ap j e
Permit No. v�0
_d o — Issued
date
-- --- . -- ------- ---. -.. >- --- -----.-- ---- -_-- --T- - - - -_
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of (Compliance
THIS IS TO-CE�IFY, Thai th,e Individual Well Constructed ( ), Altered ( ), or Repaired (C4-
by �/le _________--------------- -------- ----____—_ __----
In�stalller
at__- �Gfi_S /�� r � ✓L�{��_------------------
---------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health 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 SATISFACTORY.
!, DATE-----—— -- - Inspector-------- - - _
-- - ---- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
Well Con5truct ion 3permit
No. 6�0_q=o Fee_
Permission is hereby granted
to Construct ( ), Alter (/ ), or Repair ( q an Individual Well at:
Street
as shown on the application for a Well Construction Permit
No.- w Z ooi� - -- _ Dated- _ 0
--- ----- -------------------------
Board of Health
DATE `� _
�'
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`° A: � .: CERTIFICATE OF ANALYSIS Page: 1
x.1 Barnstable County Health Laboratory
3ysnct3�s" ,, Report Prepared For: Report Dated: 8/28/2008
Janice L. Hagberg Order No.: G0848947
59 Locust Ave.
West Barnstable, MA 02668
Laboratory ID#. 0848947-01 Description: Water-Drinking Water
Sample#: Sampling Location 59 Locust Ave.West Barnstable,MA Collected: 8/21/2008
Collected by: Customer Received: 8/21/2008
Routine
ITEM RESULT UNITS RL MCL Method# Tested
Nitrate as Nitrogen ND mgJL 0.10 10 EPA 300.0 8/21/2008
Copper 0.36 mg/L 0.10 1.3 SM 3111 B 8/26/2008
Iron 0.24 »g/L 0.10 0.3 SM 3111 B 8i26/2008
Sodium 13 mg/L 1.0 20 SM 3111 B 8/26/2008
Total Coliform Absent P/A 0 0 SM9223 8/21/2008
Conductance 150 umohs/cm 2.0 EPA 120.1 8/21/2008
PH 6.4 pH-units 0 SM 4500 H-B 8/21/2008
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By' --
(Lab ctor)
rM
vl
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
wk-
1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
David B.Mason,R.S,Certified Title V Inspector,508-833-2177
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
'PART A
CERTIFICATION A.
5Ot
S
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Owner's Address: Samezi
t ,
c�
Date of Inspection: August 10,2008
d
Name of Inspector: (please print)David B.Mason
Company Name: N.A. W
Mailing Address:4 Glacier Path
East Sandwich,MA 02537 ;
Telephone Number: 508-833-2177cc
;-
m
CERTIFICATION STATEMENT r`'
I certify that I have personally inspected the sewage disposal system at this address and that the inform '-on 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:
X Passes
_Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails,'�.
Inspector's Signature: Date: 8 1 Z Zb08
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments: System as inspected is operational. Increase in occupancy may result in failure. Tank needs
maintenance pumping.The information as identified represents only the condition of the system on August 10,2008
at 9:00 AM. Increase in occupancy may result in hydraulic failure.This inspection does not imply a warranty or
guarantee of the useful life of the septic system or its components.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I �� �`
• Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or i neven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced (THIS IS REQUIRED TO BE
COMPLETED)
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
Page 3 of I 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
T41A c r-„o,..:,,„ >~',,- r/1 C111nnn 3
Page 4 of 11
PART A
CERTIFICATION(continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than g g q 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 11 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.
'r:.I- c r_ _ .: _ c- cif c/onnn 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks '?
_X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up ?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site.
_X_ _ 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 ?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X _ Existing information.For example,a plan at the Board of Health.
_X_ 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(3)(b)]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3(per assessors records)Number of bedrooms(actual): 3 septic design
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (330 gpd capacity)
Number of current residents:_1
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system (yes or no):NO [if yes separate inspection required] Per owner
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): Property is serviced by Private Well.
Sump pump(yes or no):No
Last date of occupancy. current
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping: Maintenance pumping is recommended.
TYPE OF SYSTEM
_ Septic tank,distribution box, soil absorption system
Single cesspool
_X_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe): Primary cesspool used as septic tank with overflow pre-cast 4'pit with 2 feet stone.
Approximate age of all components,date installed(if known)and source of information: Leach pit 1990
Were sewage odors detected when arriving at the site(yes or no):no
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles G Tnenartinn Fnrm 411 VIOAn 6
Page 7 of 11
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
BUILDING SEWER(locate on site plan)
Depth below grade: Approximate; 24 Inches
Materials of construction:_X_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident
leakage.
SEPTIC TANK: N.A.(locate on site plan)
Depth below grade: cover at grade.
Material of construction: X_concrete_metal_fiberglass__polyethylene_other(explain)_
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 6'x 6'block cesspool
Sludge depth: II"
Distance from top of sludge to bottom of outlet tee or baffle: 14"
Scum thickness: 10 inches
Distance from top of scum to top of outlet tee or baffle: 15"
Distance from bottom of scum to bottom of outlet tee or baffle: 12.5"
How were dimensions determined: Actual measurements with tape and scour stick.
Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid
levels as related to outlet invert,evidence of leakage,etc.) PVC inlet tee in good condition,PVC outlet tee in good
condition,Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues.
GREASE TRAP: N.A.
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles S inenPrtinn Fnrm A/15,11nnn 7
Page 8 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10, 2008
TIGHT or HOLDING TANK:—N.A.—(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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level even with outlet invert: liquid level even with outlet pipe
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.):
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
TiAv r, Tnana 6— T:nrm An 51WI n 8
Page 9 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
—X_leaching pits,number 1 6'x 4'precast pit with 2' stone
_leaching chambers,number:
_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,
etch Leach pit is 24"below grade. 12"of effluent in the leach pit. No damp soil or excessive vegetative growth.
CESSPOOLS: (cesspool must be pumped as art of ins ection locate on site plan)
—( P P P P P )( P )
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 or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_N.A._(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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
TiNP G Tncnartinn Fnrm F/1 SOffln 9
+ Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
0- Well location
per property
owner.
Location as
indicated is
100' from SAS
POOL
A
Driveway
[13
Primary Cesspool
A-1 71'-8"
B-1 45'-4"
Leach Pit
A-2 78'
B-2 56'-8"
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title 1;Tnenvrtinn Fnrm All VIA00 10
Page 11 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Locust Ave,W.Barnstable,MA
Owner's:Jan Hagberg
Date of Inspection: August 10,2008
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_15_feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH
_X_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized the Town of Barnstable Groundwater Contour Map. Groundwater at approx.elevation 15 at this site. This
means that the leach pit is approx.9'above groundwater.
Title 1; Tnenartinn Pnrm A/1 si1000 11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 59 LOCUST AV.W. BARNSTABLE mAP 197 pAR 28 A
Name of Owner KENNETH HOWLAND
Address of Owner: SAME 1
Date of Inspection: 7/20/99 JUL
2P 1999 '
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) S OFflgpp� E )1
Company Name: n/a
Mailing Address: n/a ;.iO
Telephone Number: n/a £
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Eval ation By the Local Approving Authority performing at the time of the Inspection.My Inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:7/20/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
revised 9098 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 69 LOCUST AV.W.BARNSTABLE mAP 197 PAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7120199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
Wa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 LOCUST AV.W.BARNSTABLE mAP 197 PAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20199
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nLa_ (approximation not valid).
3) OTHER
Wa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 69 LOCUST AV.W.BARNSTABLE rnAP 197 pAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Healtn should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an_overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: 59 LOCUST AV.W.BARNSTABLE mAP 197 pAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected fo-signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 LOCUST AV.W.BARNSTABLE rnAP 197 PAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):$
Total DESIGN flow: =
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):JLO
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): B&
Sump Pump(yes or no): NO
Last date of occupancy: Wa
COMMERCIAL/INDUSTRIAL
Type of establishment: nla
Design flow: Wa gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):JSIQ
Industrial Waste Holding Tank present:(yes or no): flLQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):MO
Water meter readings.if available:n/a
Last date of occupancy: n(a
OTHER: (Describe)
n&
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Liza
System pumped as part of inspection:(yes or no):MO
If yes,volume pumped nla_ gallons
Reason for pumping: n[a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
NEW LEACH PIT INSTALLED IN 1990 BY BORTOLOTTI
Sewage odors detected when arriving at the site:(yes or no) NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 LOCUST AV.W.BARNSTABLE rnAP 197 PAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2
Material of construction:_ cast iron _ 40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: LEVEL
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n/A
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
n&
Dimensions: 6'X(i'BLOCK CESSPOOL
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: L"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17""
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n&
Dimensions: n&
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:-n&
Distance from bottom of scum to bottom of outlet tee or baffle nLa
Date of last pumping: nLa
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n&
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 LOCUST AV.W.BARNSTABLE rnAP 197 pAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7120199
TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nla
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nia
Dimensions: nla
Capacity: Wa gallons
Design flow: Wa gallons/day
Alarm present: NQ
Alarm level:jiLa- Alarm in working order:Yes_No_: XG
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
D&
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:Dla
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): MQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nla
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 LOCUST AV.W.BARNSTABLE rnAP 197 PAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20199
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nta
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: j3&
leaching galleries,number: jiLa
leaching trenches,number,length: Wa
leaching fields,number,dimensions: r:La
overflow cesspool,number: n&
Alternative system: n(a
Name of Technology: ji&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT WAS 1/2 FULL AT THE TIME OF THE INSPECTION.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n(a
Depth-top of liquid to inlet invert: n&
Depth of solids layer: n&
Depth of scum layer. n&
Dimensions of cesspool: Wa
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nia
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
1I&
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 LOCUST AV.W.BARNSTABLE rnAP 197 pAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
�rt,A �Sy
b�
V%.0I
v
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 LOCUST AV.W.BARNSTABLE mAP 197 pAR 28
Owner: KENNETH HOWLAND
Date of Inspection:7/20/99
NRCS Report name: nLa
Soil Type: Wit
Typical depth to groundwater: n(a
USGS Date website visited: n(a
Observation Wells checked: MQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
- Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS AND VISUAL-12+FEET
revised 9/2/98 Page 11 of 11
TOWN OC BARNS`T'ABLE
LOCATION C®CI.tS 2�� SEWAGE # -- `
VILLAGE ASSESSOR'S ASSESSOR'S MAP LOT^ ? GOB
INSTALLER'S NAME & PHONE
SEPTIC TANK CAPACITY��/�DF� �
LEACHING.FAC.ILITY:(type) (size)/f> sxr•
NO. OF BEDROOMS PRIVATE WELL PUBLIC W: TER
BUILDER OR OWNER Je
DATE PERMIT ISSUED:���i�/<
DATE COMPLIANCE ISSUED
V.ARIANCE GRANTED: Yes 140
1
I
0
No...92-'��--
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HEALTH
...............0 F..... . .... ----------------------------------------.
Applirafiun for DiupuuFal Wjarkp Tvun arnrfiun Ilermit
Application is hereby made for a Permit to Construct ( ,t or Rep�ir (AQ an Individual Sewage Disposal
System at:
- .... .. ......--
Location-Address or Lot No.
1t1� .1l1 ------------------------------
......_�_ lG�fkS?'_.. .......... .....
Owner o �1 Address
00 �'�1-.... F= .!�? ......................... 7. -01W--------- [S
Installer
Address
U Type of Building Size Lot. 0v'G=..Sq. feet
Dwelling—No. of Bedrooms................ .........--.........Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ...... i� ......... No. of persons-,......................... Showers ( ) — Cafeteria ( )
Otherfixtures .............................................`-------------------------------------------------------
•-------------------------
-•-------------------
WDesign Flow...................... ate_------------gallons per person per day. Total daily flow----....... ...................gallons.
WSeptic Tank—Liquid capacity/..gallons Length................ Width--......--.--... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter......--............ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit---........--....... Depth to ground water...............-----....
4o Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --••-•-••---------------------------------•-......---•----••---------- ------...-----..._...• ----.......-----......-----•---•---•---.......--------•---.
O Description of Soil..........4r/.....4:6 �_... _-540............. 'r�....4V...
x
W64Z------------------------------------------------------------------------------------------------------------------•--.......------------------------------------------------.
U Nature of Repairs or Alterations
/—Answer when applicable...-r1io.....,�f�1 ..
.�\`L'------------------• . 4.1j�-----0i(fJ,SIJPj �?..... &''1 �s
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Co fiance has en i s d the boar of 1 lth.
Y
Signe ••... --- _ .. ........... --- o,� / .
Date
Application Approved BY --------•-------- -•---- .............
D� ------
Applieation Disapproved for the following reasons---------------•------------------------------------------------------------------..............................
Date
PermitNo._ ._... ��----------------•-•----------_.... Issued-.......................................................
Date
No— Fmc.S_2 ...............
THE COMMONWEALTH OF MASSACHUSETTS
B0AR0,'P,F HEALTH
...............OF..................4.__;.,.-L.;;F
........................................
Appliratiou for Uispviial Works Tomitrurtijan Prrutit
Application is hereby made for a Permit to Construct (A,Q or Repair an Individual Sewage Disposal
System at:
-------------------*'*'**........- ---------------------------- -------or----Lot---No._'-----------------------------------*-------
Location,........... 'C6 /0 Z. I ........................................................................................
)...............................1... _5..'
Owner Address
........................ ..................................
Installer Address
41 Sq. feet
Type of Buildifig Size Lot4!9%,J24��=..
Dwelling—No. of Bedrooms................ .....................Expansion Attic Garbage Grinder
114 Other—Type of Building ........ ......... No. of persons............................ Showers Cafeteria
Other fixtures ..............................................
------------------------------------------------------------------**--------------------------
Design Flow.......................::��..........gallons per person per day. Total daily flow---------- 3LIC....................gallons.
9 Septic Tank—Liquid capacityZ4, ----_-gallons Length................ Width_............___ Diameter.--_--__--_---_. Depth...._..._...._..
Disposal Trench—No..................... Width............... .... Total Length_.....__..........._ Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter.................... Depth below inlet....._.............. Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit___.__..........___. Depth to ground water__-_--_--_--_-______-_-.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit............____.... Depth to ground water..._.__.___........._._.
Ix ............................................................................................................................................................
0 Description of Soil..........0::./......62.�. . —gL-?aA............ ./ . Z
..Zo ?4�.l V------6 -----;�... ....................
-----------------------*----------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------....................................................................................................................................................................................... ......
ra ------U Nature of Repairs or Altetions—Answer when applicable.._4e_94------Z_"�
S ...... ------
....... _ M�111......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of CorUp iance has been issped/,by the boar,4,of health.
Signe .. .....z... ..........
Date Application Approved By---
. ............................................................................................ ------------ ...........
L. D e
Application Disapproved for the following reasons:................................................................................................................
........................................................................................................................................................................................................
Date
Permit No..-Q.;f......C//
.......................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................... ................OF...../.........................................
... ........
Tntifirate of Tompliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or epaid
by............... ........(-:,.6... ........ .................................................................... ......................
Installer '��k
s7Ro
at..................f 9b
................................................................. .................................. ....................
has been installed in accordance with the provisions of TIF TILE 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 G ARANT* EE THAT THE
SYSTEM WILL FYNCTION SATISFACTORY.
DATE.......... .6te'17..................................... Inspector.J_
.... .......... --- ---- ----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
............. .................4......................................
N
FEE....
Z;;��.........
Bioposal Vorko TD11mitrudivit "puntit
Permission is hereby granted--------- .. ..........C/ ,
.....................................................................
to Construct or Repair (\) an Individual Sewage Disposal System
atNo................... -----------Z.% i .........
Street
as shown on the application for Disposal Works Construction Permit No?1341�'?-------q.,.1.1...... Dated..._. ................
......................... ........................ ....................................................
Board d of Health
DATE......... ........................................... ar
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
L