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HomeMy WebLinkAbout0037 RIDGE ROAD - Health 37 Ridge Road West Barnstable A=216-064 'h Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name Information is West Barnstable MA 02668 4/30/2011 required for every page. City/Town 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. ImpoWhen filling A. General Information When filling out Joe Martins forms the ACCu Se h computer,use 1. Inspector: pC eCIC � I only the tab key 17 Northside Dr,' - to move your S. Dennis, MA 02660 cursor-do not Name of Inspector use the return key. Company Name Company Address City/Town 0� State Zip Code 5 • 3 8s • �$9l Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 4/30/2011 required for every page. Cfty/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) ;71 mPasses: ave 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: Z)k Y W PL L /IV �2v/V T A02 SC=/077,�, �►- ,� Zvi GEC 7T / S 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(whet al or not) is structurally unsound, exhibits substantial infiltration or exfiftratio nk failure is imminent. System will pass inspection if the existing tank is replaced with a ying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectio . it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan less than 20 years old is available. ❑ Y ❑ N ND (Explain below): "ins•09/08 Title 5 Official Inspection dorm:Subsurface Sewage Disposal System-Page 2 of 1T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 4/30/2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 lev d or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to roken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of alth): ❑ broken pipe(s) are replaced ❑ ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Y c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name Information is West Barnstable MA 02668 4/30/2011 required for every page. Cityfrown 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 vate water supply well. ❑ The system has a septic tank and SAS and the SAS is less than eet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well wXanae at a DEP certified laboratory, for coliform bacteria indicates absent and the pogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no riggered. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA w PropertyAddress Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information Is West Bamstable MA 02668 4/30/2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ❑/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ d Any portion of cesspool or privy is within 100 feet of a surface water supply or / tributary to a surface water supply. ❑ �—Q/ 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. ❑ C� 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.] ❑ T/ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ y� 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 of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit ' 400 feet of a surface drinking water supply ❑ ❑ the syst is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ t ystem is located in a nitrogen sensitive area (Interim Wellhead Protection rea— IWPA)or a mapped Zone II of a public water supply well If you have a ered "yes"to any question in Section E the system is considered a significant threat, or answer "yes" in Section D above the large system has failed. The owner or operator of any large system nsidered 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner owner's Name information Is West Bamstable MA 02668 4/30/2011 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no' as to each of the following: Yes No ❑ 02/ 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? [ r ❑ Has the system received normal flows in the previous two week period? ❑ U/ 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? a ❑ Was the site inspected for signs of break out? Kj ❑ Were all system components, excluding the SAS, located on site? [Q' ❑ 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? Q/ ❑ 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: El ❑ Existing ' ffrmgio? foroexllple, a plan at the Board of Health. 10�. ❑ 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): Number of bedrooms (actual): 2 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms)) `� 3 t5ins•09/08 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owners Name information is West Barnstable MA 02668 4/30/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: PIO Number of current residents: Does residence have a garbage grinder? ❑ Yes Q( No Is laundry on a separate sewage system? [f yes separate inspection required] Yes ❑ No Laundry system inspected? /1 y oC✓1d N J r! Yes No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: WR 11 Sump pump? ❑ Yes No Last date of occupancy: 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. tc.): Grease trap present? ❑ Yes ❑ No Industrial waste hol ' tank present? ❑ Yes ❑ No Non-sanit waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•0901 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address _ Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 4/30/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: �UMAO/d Otle AFk Awll- Source of information: Was system pumped as part of the inspection? ❑ Yes x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: � s/3/�� ��/g �v � �0 a d Type of System: V 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-09/08 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 w 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information Is West Barnstable MA 02668 4/30/2011 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all portents, date installed (if known) and source of information: L -4 4p /Z /vy Psi 37 P4/fs• J HIP ,8#h Go C. -2 o 1"rs Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: � �J cast iron ❑ 40 PVC ❑ other(explain): I Distance from private water supply well or suction line: > feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): / Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑l No Dimensions: //�� b x v f Sludge depth: Q1 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owners Name information is West Barnstable MA 02668 4/30/2011 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle ON Scum thickness J1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Gd t/ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): CA le ozA 4A" P APtaals olvrewlaoll T e Cdy Cw4e aI dd C�rna�i Li w d 1-,oveleqt 0,jh(el 14 Vek. Ny "O yI de✓J re O 9'00,& 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA ' M Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable 'MA 02668 4/30/2011 required for every page. CitylTown 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 ped at time of inspection) (locate on site plan): Depth below grade: Material of constructio . ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Di nsions: Capacity: gallons Design Flow: Zgallonsay Alarm present: ❑ No Alarm level: armnorking order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of ala Zt1oat s, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner owner's Name information is West Barnstable MA 02668 4/30/2011 required for State Zip Code Date of Inspection every page. Cityfrown 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.): o d t Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamb , condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 4/30/2011 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) G R-ade � �jj- A01— IType: leaching pits number. / -s A-4z— A ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 tern-Pa e13of17 t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage DisposalSys 9 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetati , etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•09108 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 R i dRe Road Owner Owner's Name information is West Barnstable _�A n? 68—�1�9/��l 1 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public-water supply enters the building. Check one of the boxes below: (hand-sketch in the area below ❑ drawing attached separately Well F R ' 0 lv t J 01 2o I �► Well > I00 3a • Bt ; l�•s� 3V" -= 4s-; B� �7s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 t5ins•09/08 f Commonwealth of Massachusetts Title 5 Official Inspection Form -Not for Voluntary Assessments e Disp osal System Form rY Subsurface Sewage Y i; Subsu 9 p 37 Ridge Road West Barnstable MA w Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 413012011 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: 02�Check Slope [Surface water (Check cellar [Shallow wells �/7 Estimated depth to high ground water: feet �j Please indicate all me thods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) (� Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: �. S,1-e vs 9o ' 4. 5 . t 2 . 6:-AaV WAZe,- Cdh-1-rvir 15 SY ' . S. L 3 Jul/TX Roe- d 6e ve 114 4-10 Y 6-'2aolz, 70 ipk�- ttAWNlr�o� at a Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 t5ins•09/08 r - S Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 Ridge Road West Barnstable MA Property Address Guest c/o Mark Guest 37 Ridge Road Owner Owner's Name information is West Barnstable MA 02668 4/30/2011 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist eInspection Summary: A, B, C, D, or E checked inspection Summary D (System Failure Criteria Applicable to All Systems)completed [System Information—Estimated depth to high groundwater (Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 00 .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH88r TOWN OF BARNSTAB AStdb1E:� A a Q cow 0 ppliration for Disposal Works Tons o &W4 0 Application is hereby made for a Permit to Construct ( ) or Repair (�an Indivi Sewage osal System at: 0 ..............R�� �...�°o. . ._. /��.�.,� �� Uvf f��r� s �� - ------ -e .. __� .... - "------------ ----- Q f Location-Address or Lot No. ... ............................................................. ....--""..............-•----. - ..... ^ ------- .8...----- .----- ----- Owner Address i�. -------------------------------'-"--'--- ......1 9.---.L o ?:a_._... R�szl�' .............a.s:. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T �of Building .............. No. of persons_....____._____......__.__.. Showers — Cafeteria a' Other fixtures ----------------------------------------------------------- w Design Flow..............M2.........::-...._---gallons per person per day. Total daily flow....................M-...............gallons. WSeptic Tank—Liquid capacity_lacic__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........................................ aTest Pit No. 1................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........................ ---------------------------------------------- •.... .---------------------------------------- -----------..-...-------------------------------•-----•--------- ODescription of Soil---------•-------------•----•-•-•----•------------------•---------------------------------------------------------•----------------------------=........................ x U -••••----•-•----•-•-•-•--•-••-•-••-••••----•••---•----••-•-•----•-•••••-•••••••••---•---••----•-----.....•••--•-•---•••••-••-----•••--•---•---•-•-•---•-•••--••-•-•-••-•-•••-•..................•••-•••. W •••-••••---•-•-----------------------------------•----•---••----••------------------•-••-•-•-•••--••---••--•--•----••••-••-•••-•----•-•••---•••••............••-••-••.................................. UNaturF of Repairs or Alterations—/ Answer when applicable ZAst ®F__,d....jc!�E.k1.....AVW...6CN- � t4�Y.�►7�l>.ee L ---- a._;44 — sl y 7 p�sl.....�1 ---------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued byyythe bo d of health. / / Signed ------- . ------. -d - ---------------- ------r{--���/ v--------- y �yce Application Approved BY ------ ------`------ :.. ------------------------ ---------------- -----g L'sa�%''Z�f Dace Application Disapproved for the following reasons- -------------------------------- ........................................................... ---------------------------------------- ------------------------ - -----------------------------------.....---------- ---- --------------------- .--------------------------....---------------------------------------- ------------------- ------------........................... Permit No. - : - 9- ,*,4f... Issued ............................------- r'r I if MAP o o Fims.. o ! THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE P, lutt#iaan fur i� lasat 'Works Tnnsum tt� exuti fi p � Application is hereby made for a Permit to Construct ( ) or Repair (V)�an Individual Sewage Disposal System at: t Location-Address or Lot No. r i A CvCSr Owner Address W 13 C �� ... s T' IlA.t o.4,o Installer ( Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............`3..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers - Cafeteria dOther fixtures ...................................................•......--------•----------•-------------------............---------------------------------... 1 W Design Flow..............//d.........._.0....._..gallons per person per day. Total daily flow__.._.._.___..____.-?J e?._........._._gallons. WSeptic Tank—Liquid capacity__!?Q .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...........0......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by--------------------------------•--.....------............................ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-___--_--____-__--_-_--- + (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' ...................................................-......................................................................................................... 0 Description of Soil...............................................................................-------------•----------------------•...........-----------------------•--•------...---- V ........................................................--------------•----------•----------------------------------------------------------------------------------..........0............------...---- W -- -- . ------------------------------------------------------------------------•-----.. . ......�---------------------------------.........._......---•--------------- U Nature of Repairs or Alterations—Answer when applicable_._. �?sT,4 fi!............... _._........ ... .....±vim ?....:� -*-.��- ZCE*/f oY-QJc-,c �q, 1_•_..........................................r / , A Jr �-s .... �r #!. --- Agreement: - The undersigned agrees to install the aforedescribed-Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed �.-A �e 1... ...:.. �J. c�. Pf11.1 !............. ------- ----------- ......I.....---- Date Application Approved By-,-._....................................... '--. .. .f;.....'... .........................:............ ----I''e--- ---------------- Date Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------.......................................................................................... ------------ ....................... Date Permit No. ------`�1. � , �� ...................... Issued '-f. "T.l�� e v ---'Date THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE (f.extifirate of C�urttylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ti)" by-----------------------------------------------------------------!A AA.... ... :----..k.�5a( )....... ............................. --------------------.........------------------------....-----.......................... Installejr at --------------------------------------------------3. ...... '.1"t", P,,, L��......, 1. .e4 , 1 5 r �Ao: ---- has been installed in accordance with t$e provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... i..............�............... dated .. -...../..,rl.�- `..-44,/- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ``i ;, r!.%n.. !>�. ------------------- Inspector ------ ......�. . r DATE----------• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE . pO No.. ......^?....... FEE..3o............... Disposal Vorks Tonstrnr#inn "verntit Permission is hereby granted.......... a 1.......c..:.! a f ,:.) ......................... to Construct ( ) or Repair (j,.-) an Individual Sewage Disposal System at No. '''1 rR i l(� .Arl l�ac?a l 7. 1 p Street A9 " y../,7 as shown on the application for Disposal Works Construction Permit N .j�...✓.......... Dated.._ ` .f...................................... r� r /ice DATE..... Board of Health r -----••-----•-----.....................................••-- / FORM 36508 HOBBS&WARREN.INC..PUBLISHERS 1 TOWN OF BARNSTABLE LOCATION _�� 2�r�a 4.,fj SEWAGE # 9/ ~ 36 7 VILLAGE tV,574 bl e- ASSESSOR'S MAP & LOT-QUO— 9 INSTALLER'S NAME & PHONE NO. R . C. k Q08, 0 41 Y 4( SEPTIC TANK CAPACITY /0 0 0 6 s Ir LEACHING FACILITY:(type� E c,4sT (size) op G-41 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER' WC-tL BUILDER OR OWNER _ ro i&A DATE PERMIT ISSUED: ,.DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No !S.9 oeraJ 9/di65iaa i o, 4� No.... - ----------- F$$ ...�.... THE COMMONWEALTH OF MASSACHUSETTS BOARD / _�-�4LL� ® H EA T af , �Ll F........... ....... ........................ , pphratinn for Disposal Vorkfi Toro rnr#inn runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: lit Location,Address or t No. .4 .� 4.!2s£.. SS.:........................................................... ....i!J7;/V/®v 5 ...... �i '..7.�1./..�Ql!�............---- Owner .. Address W Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building No. of persons............................ Showers 0.� YP g ----••....................•- P ( ) — Cafeteria ( ) 0.' Other fixtures ................................................ Design Flow................�s?......................gallons per person per day. Total daily flow.........ado.........................gallons. Disposal Trench tic Tank—Liquid do capacity............. gallons LengthTotal Lengthidth.........---_.Total leaching area Depth................t. Seepage Pit No._lpQa........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed b Date........................... Test Pit No. 1.......X....minutes per inch Depth of Test Pit.................... Depth to ground water_.l_dff... f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-___-___-______---_____. 9 ...--------•----------------•---••-•-••----•-•--••---•-.............••-•--......---.......................................................................... O Description of Soil-----:&lut'..A.C��t�l .......................................................................................................... W -----------------------------------------------------------------------------------------------------------------------------------------•----------- ................................................. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ... ... ....... .............................. ..fZV7..�....•••-- Date Application Approved By__.__�g .... ....... � ..... ate Application Disapproved for the following reasons_____________ __ _______________ _______ ______ __ ............................................. Date Permit No................................................... Issued.-------•-•-•------. ...... Date............................... 4-, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,< `q .......-.OF........ .......... . .. Appliratitttt for Disposal Works Tomi#rttditttt Phrutit Application is hereby made for a Kermit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: b � 1 x ......... .............. G ............................................................... C Location Address or Lot No ,.p... .............. a .d�M -w...._.- .............•....-- .... Owner �Address W Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.........................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type e of Building No. of,persons ersons............................ Showers 0.1 YP g ------•-----•-------------•- P ( ) — Cafeteria ( ) P4 11, Other fixtures Design Flow................:.: gallons per person per day. Total daily flow....._...4a.0..... gallons. W g ,�...--•----•--•-••--•--g� P P P Y Y P� Septic Tank—Liquid capacity............gallons Length................ Width..........._.... Diameter................ Depth................ xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..w:!_ t ........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................ Test Pit No. 1....... ....minutes per inch Depth of Test Pit.................... Depth to ground water..%. r._.'Q_,�: _ f14 Test Pit No. 2.......:.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----•---••--•-•-•••••-•••-•-•-•-•••••-•--...••••.......•••....._..•-•---......•..........................••-••----••-•-••••••--••........--•-------.....--•-- Description of Soil --------------�r......... U •••-••-••••-•-•----•-----•---••••••-••---•--•••-•...........-•••••--•-•-•......---••-----•--•••-----•-... W -----------------------------------------------------•••---......_..-•..._..-----------•••--••-•••--...--•--••----------_._..........•------•-••••••-••-••--•••-••••--•-•-----•-•----••-----------..... V Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------•--------------------------------------------••---•------------....--------...................-•---•----------------._....---- .................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Ic ` .fr..Y f-. ✓ k t ate < Application Approved By_ Application Disapproved for the following reasons:------ ....... .......... ....._.______....__.__._......................__............._.............. ................................................................•-------------...........----••-•_._.......---•-•-----•••-••••••••-•••-•••-•--••--•-....-•---•-•-•---•-•---•------•----•-•--.......••.... Date PermitNo.•---•............•--••••-•.......................... Issued ........................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .,:..t.:,,.,,jq............OF..... .......................... f�rr�i�ir���e of ��aitt�litittrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by r ...-•--•.••- /<i -�•. ° } }r Instant a't.. :� {:-,;' .'�f--•-• x.f- P_r� -- £Sf-- •. .............4. Alt% � f ,.s P...,,, :Ci•✓., - ..._..-•---•-•--•---•-•-------•--------- "v has been installed in accordance wii the provisions of`Artic� The State Sanitary Code as described in the application for Disposal Works Construction Permit No............... ._... dated-----------; :f ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................•------............................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD Q,.f HEALTH, .......... tr<4(. .:..........OF....... J �F._: ,................ �.:':.•./' - r No....;; - ........ FEE .e:•••-• .......... Dispaml Workii Tanotrttr#itttt rani# Permission lis ereby granted....---•--. -•-- -•..............................•-•--•-••-----••--•...............--•-•••.............................................. to Construe �ror; epair ( ),.an r ndividu)1- 'e 'age Disposal System r x atNo.;v. •. ... ...,t�� .9 a ;a :.zf: . �f...._.....r ............................................•.< ......... L< t Street as shown on the application for Disposal Works Construction P it No.. .... ... .:jibated.......... ............ u . , Euard of Fiealtla f DATE................................................................................ tjA,f FORA 1255 H0813S & WARREN, INC.. PUBLISHERS