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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
�e
JUN 2 9 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
C TION
Property Address: ace Lane,Marston Mills,MA 02648
PARCEL
Owner's Name:Robert F.Rooney LOT
Owner's Address:c/o Christine L.Spencer,6 Sassafras Lane,Harwich,MA ---
Date of Inspection:June 24,2004
Name of Inspector: REED C.ELLIS
Company Name: ELLIS BROTHERS CONST.CO.
Mailing Address: 23 ENTERPRISE ROAD,
P.O.BOX 59,YARMOUTH PORT,MA 02675
Telephone Number: 508-362-6237
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 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 tion 15.340 of Title 5(310 CMR 15.000). The system:
j;
1 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: e•t/L7�`� Date: Gam'
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
****This report only describes conditions at the time of inspection and under the condition 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.
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Page 2 of i l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1681 Race Lane,Marston Mills,MA.02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: qtd
-An 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: I
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 c r 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 th septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or ta ik failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as apj iroved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally ound,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 tatic water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven di ibution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are repliced
obstruction is removed
distribution box is leveed or replaced
ND explain:
The system required pumping more than 4 times a y ar due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are repla
obstruction is removed
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1681 Race Lane,Marston Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
C. Further Evaluation is Required by the Board of H the
Conditions exist which require further evaluation by he 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 determin s in accordance with 310 CAM 15.303(1)(b)that the
system is not functioning in a manner which will rotect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface i vater
Cesspool or privy is within 50 feet of a borderin o,vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and P iblic Water Supplier,if any)determines that the
system is functioning in a manner that protects the pu blic 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 s pply.
The system has a septic tank and SAS and the S S is within a Zone I of a public water supply.
The system has a septic tank and SAS and the S S is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the Sj LS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determh a distance
"This system passes if the well water analysis,perf ed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates th the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitroger is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis m ist be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1681 Race Lane,Marstons Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ V ischarge 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
r I spool
iquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
R uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
f times pumped
_ y portion of the SAS,cesspool or privy is below high ground water elevation.
l portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
_ y portion of a cesspool or privy is within a Zone 1 of a public well.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
y 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 tacility 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.]
A _ (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: N
To be considered a large system the system must erve a facility with a design flow of 10,000 gpd to 15,000
t`Pd•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in adc'tion to the criteria above)
yes no
— the system is within 400 feet of a surface inking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitiv area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 1I of a public water supply well
If you have answered"yes"to any question in Secti 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 S ion D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1681 Race Lane,Marstons Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes N
mping information was provided by the owner,occupant,or Board of Health
ere any of the system components pumped out in the previous two weeks?
as the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,@ccluding the SAS, located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of th baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
/ The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Ye$ no
Existing information.For example,a plan at the Board of Health.
Determined in;the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1681 Race Lane,Marstons Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.20J(for example: 110 gpd x#of bedrooms): 6;2�z>
Number of current residents: 40
Does residence have a garbage grinder(yes or no): IVO
Is laundry on a separate sewage system(ye r n� [if yes separate inspection required]
Laundry system inspected(yes or no):,(//,4
Seasonal use:(yes or no):IVO .�J A old
Water meter readings,if available(last 2 years usage(gpd)) 6D a �K— p`oo.
Sump pump(yes or no): &I Last date of occupancy:_ �" / /.CZ d�z
COMMERCIALIMUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gj id
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 o):
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): �✓
If yes,volume pumped:�gallons_ How as q ti„ pumped determined?
Reason for pumping: IJ
E OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the currant operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
01
A roximate e f 1_com on ts,date in lied if o ,','Apan so formation:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1681 Race Lane,Marston Mitts,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
BUILDING DING SEWER(locate on site plan)
Depth below grade: 4
Materials of construction:_cast iron Z40VC_other( p;ain):
Distance from private water supply well or suction line: &j
Comments(on-coRdition of join mg,eviden f leakage tc.):
1N N ti t/Lu N
r if
SEPTIC TA:gradr/�//h7jr,-
locate on site plan)
N
Depth below
aterial of construction: ncrete_metal_fiberglass_polyethylene
�other(explain)
rif tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) I ,
Dimensions: g 5 )
Sludge depth: /s<i D,y
Distance from top of sludge to bottom of outlet tee or baffle: �7
Scum thickness: U
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffled ,
How were dimensions determined: d/--
Comments(on pumping recommendati s,inlet and outlet tee o•battle ndiittiioo�c/mil integrity,liquid levels
as re Wed to o t invert,svi4per,of leakag�e��:`'/l7�it/
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_iberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or ba e:
Distance from bottom of scum to bottom of outlet t e or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet an( outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.)
7
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1681 Race Lane,Marston Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
TIGHT or HOLDING TANK: (tank must be pumpec 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: V"(if present must be opened)(locate on site plan)
Depth of liquid level abov 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 o box, ): A� �' ®� `a /n- /
G K [�'/✓
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 1 umps and appurtenances,etc.):
8
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1681 Race Lane,Marston Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
SOIL ABSORPTION SYSTEM(SAS): ? locate on site plan,excavation not required)
If SAS not located explain why:
/'
leaching pits,number: 0 [N A UV-Ai T&e-" S(f`
T e
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativelaltemative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
hwy
CESSPOOLS: (cesspool must be pumped as part of' xlocate on site plan)
J AA
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: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failur ,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1681 Race Lane,Marston Mills,MA 02648 N
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
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.
3
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10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1681 Race Lane,Marstons Mills,MA 02648
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
SITE EXAM
Slope
Surface water NV71��
Check cellar D
Shallow wells
Estimated depth to ground water/y feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
C ecked with local Board of Health-explain:
Necked with local excavators,installers-fpttach doc}WK
io ,�G
Accessed USGS database-explain: C GfilQ 1A, S ` 'f
You must describe how you established the high ground water elevation:
1;&-1-74, GC �eA i'a-w, o t
44�, LAC.& ss 42
l 1
,age 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
I
Property Address: 1681 Race Lane,Marston Mills,MA 02648 6
Owner:Robert F.Rooney
Date of Inspection:June 24,2004
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.
3
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�J TOWN/OF BARNSTABLE
C(vkdt r,,f la 4er/�c e
LOCATION Lq SEWAGE #
VILLAGE kl-i4,5�/) AS BSSOR'S MAP 6 LOT y
INSTALLER'S NAME & PHONE NO. 1 n SpYC'
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER `'^ 4 �-r1- 2Ga�1
DATE PERMIT ISSUED: /Jro /f
DATE COMPLIANCE ISSUED:
t`
VARIANCE GRANTED: Yes No
D y �
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y g v 33'
A . 3 27V V
10
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LOCAT 40N (,� r SEWAGE PERMIT NO.
0III jpyl'ekLcI � rra� � '7 ? zip
VILLAGE /
INSTALLER'S NAME & ADDRESS
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B U R D E R OR OWNER_
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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......................... Fps...... 5�. .�.d.....
,J4, THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.. _.,Town ...........0F......Barnstable..
I kiratinaa -fur Uhi oiittl Works C owtitraartion Vrruift
fog
sip
Application is hereby'made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at:
LQJb-- (Ass_essor..Map-147... --Lat..#9.7)-----------------------•------
Location-Address or Lot No.
Cinderella Builders, I ...... .........•-------------- --Bc►x--93$� SandeQl ,._M�•_02563---------------•------•--••----
O er Address
� r
,�4 -OKA
M nstaller Address
Type of Building , Size Lot........3Qi-7.34.....Sq. feet
1 Dwelling O. of Bedrooms......2------------------------------------Expansion Attic ( ) Garbage Grinder (j/)
aOther—Type of Building ____________________________ No. of persons_______-.-_________-____.__ Showers ( ) — Cafeteria ( )
Q' Other fixtures __-____________________ _
W Design Flow____ ____________ mil)__:_.._____gallons per person per day. Total daily flow--------- ____.®---._-._-gallons.
WSeptic Tank—Liquid capacityAN/. _ allons Length---------------- Width_-------------- Diameter---------------- Depth-----.---------.
x Disposal Trench—No. ________________ ___
Width_ _____ tal Length.................... Total leaching area-_- .---__-----_-_-_sq. ft.
Seepage Pit No....J Diameter__ l�. `R below inlet___________________ Total leaching area----.---_....._...sq. ft.
Z Other Distribution box ( ) Dosing tank -7-
~" Percolation Test Results Performed by -' Date a
a Test Pit No. 1----------------minutes per inch Depth of est Pit-------------------- Depth to ground water..---____-_...___---
�i, Test Pit No. 2________________minutes per inch Depth of Test Pit_.................. Depth to ground water........................
------- --
------- - --
O Description f 4----- - / ..' �! l
x ' `-Y - - - ------------------------------------z-- -
W
UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------
------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------z--------------------------
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 be issued by the bo ffilealth.
Si .: ------ -------- ---------------•- ----------•----------••---------
Date
Application Approved B ¢'___ _ _____________
Date
Application Disapproved for the following reasons________________________________________________________..........................•-------.. ---------•----
.....................-..................................................................................................................._._•-------•-----••-----------------------------•---------
Date
PermitNo......................................................... Issued........................................................
Date
ti
I 2 r5__
•. ..._...: F>cs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town.............OF......Bar ..nstable
.. ......... . ........................................
Appliratiun -for I -4posal Works Tonstrnrtinn Vrrniit
Application is hereby'made for a Permit to Construct (X ) or Repair ( } an Individual Sewage Disposal
System at:
L0t--#5__Cin,dere1.la.. arrace.,__ -mamma....Mi.11s_ ..............................
Location-Address or Lot No.
�i>adn. 1 _Bu�ildx�, I B .-938_,_-Sandwich.,:--MA-02563
lnsl�aller
Address
Address
UType of Building Size Lot--------N 734.._•_Sq. fe t
-, Dwelling�o. of Bedrooms------2....................................Expansion Attic ( ) Garbage Grinder
aOther
—Type of Building ...._...................... No. of persons_-_____---_____________--__ Showers ( ) — Cafeteria ( )
d Other fixtures �!'!I - ------------•---•-------
W Design Flow... _ (.__,._____. allons per person per day. Total daily flow___....______--___-_-- .-_.._-gallons.
W Septic Tank Liquid capacity gallons Length
q 1 g" g Width................ Diameter Depth
x Disposal Trench—No_____________________ Width.............._ ____ tal Length___-____--________-- Total leaching area....................sq. ft.
Seepage.Pit No f_______________ Diameter_./rrlli_j._ ti below inlet...... _________ Total leaching area__-__-.-____--_.__sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) U,6- 77
aPercolation Test Results Performed by------- ------- ..................................................... Date--___----------------------------------
,a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water...-------_-----_._....-
�Zq Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__.____--_-------_-----.
- /�
D Description of / i /_ 2 / r - Gt� ..��,wr `S ........`- "-
r
P 4--"--- ----�-- •-.•=- \Jsc _` . ....
-- --------------------------
x
--
x ------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee, issued by the board of ealth.
Sig
Date
Application Approved By......... --__ - ! - - / l!l ------------------------------
i
-
" Date
Application Disapproved for the following reasons:---------------s...--..........................................................................................
--•-•---•-•--•-----•----..-•_._..---•-••--•••-••--•••-•-------•-------•---•-----•--------•---••------•-•-•--•---•----------•---------•-----•-----------•••----------•-------------------•------------•--
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Irrtifirate of f�umphatt le
THE IS T CEJ'TIFY, That/We r 1.vidual Sewage Disposal System constructed ( ) or Repaired ( )
s ,
by--•--•.i ..A_�
---------------------------•••-----•----
---• ---..__. _ _. -ram-- -' -
�r�/ Installer
at----• -------- .. --•-,LP '1� '- .-=--
has been installed in accordance with the provisions of Ar • 1 I of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ _.__ ....................... dated-..._-.— I...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATEl/-----��-- .._.....--•---------------- Inspector-------• = ll._.---- .................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 ...........OF............... •---•--•----
N ---------- FEE........................
Biripnlitt n nnntr r " trrntit
Permission is he y granted { _---------- -- -.. .
to Construct or R it ( ) an n vidual ewage Disposal m
v =
at No..•. . .. `� e f:�:.zC may(: t-2. Street -j _ /s 7 7
as shown on the application for Disposal Works Construction Permit-,No----- .___/.___. ated..........................................
DATE- —ZZ-----• ........................................ Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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FXI.,iI A\D R,lNio!-I SixEXI_ N V)AS N wnT..h DATE:_
SERVICE. REMOVE AND RELOCATE OUTDOOR SHOWER
TtIE SOLE PROPERTY AND
OF
7NE DESIGNER AND CAN NOT
_ RENOVE EXISTING SIDING 0� THE RIGHT SIDE CO'=4TEt Y. i BE COPIED,REPRODUCED i
- APPLY WATER AND ICE BARRIER WEER'--Ic ROOE AND/OR ALTERED WITHOUT
... .. ..
INTERSECTS T-E W \.I A:L N. 36 - APPLY NEW G_ASETNG THE EXPRESS WRITTEN �AS RECU REiO APPLY TYPAR ',(J��_V'RAP AND-CEDAR CONSENT OF THE DESIGNER , I
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LEGEND !'
—--1 EXISTING WALL CON5TRUCTION TO REMAIN
NEW WALL CON5TRUCTION I w
EXI5TING WALL CON5TRUCTION TO BE REMOVED
47
SMOKE DETECTOR C
CARBON MO CTOR MONOXIDE DETE C'
" AL_EXiER Oa NA S SHALL DE 2X6: Di !
16' NLESS C v 5E NOTED 2. !
tiO'IC E 2
(4 16t! INTERIOR
SS Oli C WALLS IWSE AIL NO-EO
ALL IN NI_>O'vNS ARf_ .O GI-' 3. CONiRACIOR SHALL V RI Y WINDOW ali Q,
ROUGH OPENINGS Pr2 O.i-0 RDr.ING WINOGwS.
NDCRS (v 400 SERIES
CO\RA TOR SHALL VERIFY DWNI111 S i
' �V/ AFP1 ILC GRILLES aa!oa cousrR u N oN R16 F SCALE
A SS.:VrS SE_`N5 T FOR ANY MISSING Oil _--
NIS f C N D CUTSDE N oRRF T nlrnso NOT r,o ,I;to i/4 = 1. - THE- Aa LNIION OF rig L_.,L,NER. .
I (VEINII_Y J�!/ OwNFl4) II DWG.NO.: !!
THIS ADDITION IS DESIGNED IN ACCORDANCE WITH `HE
j: NASSACHJSETTS STA(E BUILDING CODE 8n ED!TLCti.
:THIS 'INCLUDES L7F WIND I OAD FOR EXPOSURE B AND 11.0 rnptlAll
l �hOOD FRAME CONSTUCTiON MAN A.L (V;F'lM') j
:
THE
PLAN5 SHOWN ARETHE 50LE PROPERTY OF
REV.NO :4 j
. .. .. - - THE DESIGNER AND CAN NOT
BE COPIED,REPRODUCED 1RI O1
THE EYPRF5NR(TTEN
- CONSENT OF P DE51GNER
I
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P QF NrV FCL'ND ATICN - � - - .
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. - - - EXISTING-Ej3FLC04'VER FY I\- LpIF
N
N01 N LR INREQUIRED%
EASE CJNDA \WALLS A R OLIRE
— _———
— ————— 1 .. VERTFY IN,FIELD —— — —— —— ——— --
i
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DRILL IN l Y r N arION————————————
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— ---------------------- —J — ——————————————— ---J I i .
No--:JN rPln
CXST
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VERIFY M
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WALL CONSTRUCTION TO REMAIN
L I ^ i
NEW WALL CONSTRUCTION 4^-d
EXISTING WALL CONSTRUCTION TO BE.REMOVED I
[=SASE IvI.Y \� �^IFS
-.y. .'J4h CUN'`A ION WAI 5 TO 1. :'JUr 0 'N C. W/2CC.45 BARS
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- =ROMP 30v5 H(J 17 B RS^OI N�OUS IN 'F(OO-.EN",'
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. - .: N S O 0 IN PROVIDE 6
& "I11 I3 f EXTEND
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DOUBLE FLOUR JO'S IS UNDER ALL PAI ALL -'4.'01 IOuS
CONCRETE SLAB TO BE fi' POURIED CON( ON ,JMPA.. F)RU_.
C:J'T JOIN.$ALONG WA__S AND_EAW,COLUMN LINES.
_ s CONTRA TOR .l P OYr'ens Uf NT`lI:N"_ATnN As SCALE
R;'OI.IR-D BY COOF WIN CVS OR MECHANI n) 7 -
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. ,- MINIMUM COVER.
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0 ALL STRUCTURAL- )UM.1S. ♦ r\
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