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HomeMy WebLinkAbout0033 HAZEL PATH - Health k 'Ire n 33 Hazel Path',..-;,`.,-', t�,y `Marston§,,Mills r t 4. s:=+ : J r d�3/Q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 Property Address Owner Owner's Name information is required for /// /fit /��/7A 7 every page. CityrFown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out LA forms on the computer,use 1. Inspector: only the tab key to move your _ ��`?� 3 cursor-do not Name of Ins ector use the return n ,m key. Company Name Company Address Cityrrown State Zip Code 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 15340 of Title 5(310 CMR 16.000).The system: Passes ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 7/07 Inspector's Signaftfre 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. t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Addresser Owner Owner's Name information isG✓G 19�P�B �`�710 7 required for every page. Cityrrown State Zip Code Date of Inspection. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Pell 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 explai ❑ The septic tank is metal d over 20 years d*or the septic tank(whether metal or not)is structurally unsound, exhi 'ts substantial irk Iltration or exfiltration or tank failure is imminent. System will pass inspection the existing/tank is replaced with a complying septic tank as approved by the Board of He h. / *A metal septic tank will pass ins�6ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the a is less than 20 years old is available. ND Explain: ❑ Observation of ewage 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 ❑ obstruction is removed t5insp.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 1� /gz;( Property Address Owner Owner's Name information is 024�.'fi Z�1/7h 7 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system requiredXp mor than 4 times a year due to broken or obstructed pipe(s).The system will pass insp (with a roval of the Board of Health): ❑ broken pip s) are if ❑ obstruction is removed ND Explain: 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 enviro/tank ❑ Cesspool or pithi'R 50 feet o a surface water ❑ Cesspool or pithin 5 fe of a bordering vegetated wetland or a salt marsh 2. System will fail ue Bo d o Health (and Public water Supplier, if any) determines that the is nctioni in a manner that protects the public health, safety and environm ❑ The.system htic tank and soil sorption system (SAS)and the SAS is within 100 feet of a ater supply or trib tary to.a surface water supply. ❑ The system htic tank and SAS an the SAS is within a Zone 1 of a public water supply. ❑. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 f Commonwealth of Massachusetts leiTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Addre� l�f Owner Owner's Name information isiiZ?Zc. 4 �-(PY� 1/17/d.7 required for . every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Ev luation is Required by the/Board of Health (cont.): ❑ The systXabsent ptic tank an�AS and the SAS is less than 100 feet but 50 feet or more froater sup ly well**. Method uine distance: **This systehe II water analysis, performed at a DEP certified laboratory, for coliform bacteria indic and th resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 p that no o I�er failure criteria are triggered.A copy of the analysis must be attached tons 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 ❑ Lam' 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 El a/ than%day flow ❑ L� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0— Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ tributary to a surface water supply. t5insp.doc•08/06 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 4 of 15 L c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Ad-dress Owner Owner's Name information is 7/U 7 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No [3"*' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 8,�` Any portion of a cesspool or privy is within 50 feet of a private water supply well. Ci EK Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ [ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑/ The system fails. I have determined thatone or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to.correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is ithin 400 fe of a surface drinking water supply ❑ ❑ the system is with) 0 feet of a tributary to a surface drinking water supply ❑ ❑ the systeXP ted in itrogen sensitive area(Interim Wellhead Protection Area—IWa mapped a II of a public water supply well If you have answered"yes"t ny question in Section E the system is considered a significant threat, or answered"yes" in Sectio 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. t5insp.doc•08106 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address— Owner Owner's Name information is /1i1 U24Yw /7A7 required for every page. CityfTown State Zip Code Date of Irispectlon C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No L" ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0� Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ Fr'_ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ O❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ©,-_ ❑ Was the facility or dwelling inspected for signs of sewage back up? 2 ❑ Was the site inspected for signs of break out? E ❑ Were all system components, excluding the SAS, located on site? 2 ❑ 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? El information 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: ❑ Ej--' Existing information. For example,a plan at the Board of Health. ❑/ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is `� required for2�yPi ��/7 �7 every page. City/Town State Zip Code Date of Inspection M'System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): yYd Number of current residents: o2 Does residence have a garbage grinder? ❑ Yes 9--No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 9--No Laundry system inspected? ❑ Yes [ —No Seasonal use? ❑ Yes [-No �d�/SBavc� Water meter readings, if available(last 2 years usage(gpd)): ,2oevs'/d2/S�dGU Sump pump? / ❑ Yes P—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/person sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title ystem? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc-08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 15 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address GS.��7 Owner Owners Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0--No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attachh-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): Approximate age of all components, date installed (if known) and source of information: 33 Y4d Were sewage odors detected when arriving at the site? ❑ Yes ZI-ITo t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is / �r��,,o /Iii�: Uo2 6-VR 1,17 0 required for 7 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 32 feet Material of construction: R cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: �a feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No . Dimensions: u��''`�� 9 �4 S w G Y Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 f . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 23 Property Address. Owner Owner's Name information is Al O-LCr�/� 7 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to tlet invert, evidence of leakage, etc.): A � Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ m I ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top o:ations, outletEinland Distance from bottom of scum to br baffle Date of last pumping: Date Comments(on pumping recommeutlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time ofinspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑.metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp.doc•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J3 Property AddressrL� iEil�p�-e Owner Owner's Name information is k. l�(o�/Pi 11117107 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: ns P ay . Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes E�`No 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2-3 � 4 Property AddressG�� Owner Owner's Name information is Q-Z(of/8 /1Z710 `7 - required for _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: �J leaching pits number: ❑ 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, etc.): O-K. t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Di/sppo�sal System Form-Not for Voluntary Assessments Property Ad ss C/ Owner Owner's Name y-- information is required for w`�✓ every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top liquid to inlet.invert Depth of solids I er Depth of scum layer Dimensions of ces ool Materials of co truction Indication of groundwater inflow ❑ Yes ❑ 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 c dition of sol signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ��1 !� Owner Owners Name information is required for s Od(S�P� //,//'7 Z,'7 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 1n1 l -e y, 31 >- �V of 3� I t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ZD Property Address Owner Owner's Name information is �/O required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water heck cellar ❑ Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: t5insp.doc-08106 Title 5 Official Inspection Foos:Subsurface,Sewage Disposal System-Page 15 of 15 1He Town of Barnstable ram, • y�� Regulatory Services BARNSTABLE ; Thomas F..Geiler,Director 9�'prE� °� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE LOCATION X. 44::W SEWAGE# VILLAGE/,�v� ASSESSOR'S MAP&PARCEL O`?3/6x r INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY Iv2;5"0 LEACHING FACILITY.(type) to ob Q o-y P/1—$ (size) 4e Y.9 NO.OF BEDROOMS OWNER 44 . PERMIT DATE: 7,/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY J 3 �� 'v2 ' �. i \ e � W `+ W �.[e ��� { r No.....I.: ............ Flmlm...le................ THE COMMONWEALTH OF MASSACHUSETTS BOARD ®F �-iE LTH r�r-......-----OF....... � . ....................•-"•""- Appliration for Disposal Works Tonstrur#tjan 1hrinit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Dispo System -.._.._. 6% .1 . .... . ... ' Locat_ re? o. . - .... . .......................... . - . .. _... ... ........ .=..... ..C.lt,. ......... O ner ress W .......................................... ------...- -- -......... ........................................................... �3 Installer Address d Type of Buildin% ze Lot............................Sq. feet U Dwelling JfNo. of Bedrooms............._.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -..._"-•"-_...."---.•_...... No. of persons............................ Showers ( ) — Cafeteria ( ) W Other fixtures Design Flow ......... 111ons per, person per day. Total daily flow-------. c ................w_...gallons. W Septic Tank; Liquid capacity y___-._.gallons Length_............. Width................ Diameter---------------- Depth---:............. x Disposal Trench—No..................... Width.._._._.. Tota .engt ....._. _ .Total leaching area...................sq. ft.' Seepage Pit No:..-._.-Z-- Diameter/_�'�__.___ ep elnle . ....... ...... Total leaching area.................. ft. z Other Distribution box ( ) Dosing tank ( ) ®�/ . a 1 %� 777 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................ o L..........1 . -•••••..-• •... .. .. ------ ---•---------•--""._ ----- ---•.....:.. .. ........... t Description of Soil ' ... -----•_... ..' -- _ ........... V -----------------••--•.... ......_...... ................ y W y ?. .- 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 be -is` ed y th of ealth. igned ..-•-•••-- . .•.. ...............••-.•-----` Date Application Approved By.......... •. ........ ------- 3/1- ., 7---- Date t t Application Disapproved for the following reasons:............................. ..... .... . .................................................................................................................................................................................................... ate _ ��.. Permit No._..... .. Issued - Date No... _. :. FEE..: ( ................ THE COMMONWEALTH OF MASSACHUSETTS E®ARD ®F HE f_ euA it..........OF. ppli ation for 473- hipmal Workfi Tongtrurtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Dispo System Locat' IreSe+ b ..... ......................... -.: ;c, %^ - . o. ........... .4..�-' w O ner Address t ..._.k........................ ...... ......... ............--•......................................••.. _ P Installer Address UType of�Buildip „ �$ize Lot............................Sq. feet Dwelling ff—��No. of Bedrooms..............;;::.............. Attic ( )" Garbage Grinder ( ) '� Other—T e of Building .......... No. of persons............................ Showers = Cafeteria Other fixtures . -- *� W Design Flow ,._ allons per person per day. Total daily flow - gallons. WSeptic Tank Liquid capacity gallons, . Length................ Width................. Diameter................ Depth................ x Disposal Trench No" .......... Width-.. T to engt Total leaching area...................sq. ft. Seepage Pit No. _:_ Diameter ______ ep el nle "� Total 1 aching rea.................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed.by_r- ............................. ...:...__ .....:. Date...................... aTest Pit No. .1..........:...minutes per inch Depth of Test Pit---..___.____._...... Depth to ground water.... �LI Test Pit No. 2................minutes per inch. Depth of Test Pit..._..............._ Depth to ground water........................ f Description of Sol l........... Q�- _' ...........:.NJ........... UNature of Repairs or Alterations—Answer when applicable._............:... ...:...:............:....................................................... • ............................................................ Agreement The undersigned agrees to install' the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 is ed y th of ealth. f ied . .............. .......... lm - - Date Application Approved B ....... . ✓_ :__. .: .. ; Date Application Disapproved for the following reasons--------------------_............... ---------------.....------------------------------------------------------ ..................•---------••------•------------•--------------•----------------....----•------•---•----'---------------------------------------•-----............ ................................... JDate Permit No........................................................ Issued....... -- ----- ... .----•� �t THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH .............OF....... . . .. . THIS IS 0 CE hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b } y ------------------- . ......--- ®r_�i' has been tailed in accordanc�rth the provisions'of I f T e State Sanitar Code de ribed in the P .�I Y application for Disposal Works Construction Permit No.___-__---t _'__ .:._._ dated__,S 71- :. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS Ao UARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. VDATE--------- ...................................... Inspector...•• -- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH400/ " I'. N :. ... FEE._ ........... i �rla 1 '5 n tit thrutit Permission ' hereb ranted............ . to ConstrUL4or Repair ( ) a -Individual. ewa _ Dis s: Syst _ at No._ reet as shown on the application for Disposal Works Construction kip No.. __. ....... ed ..._ .... ............... DATE..2 ....'"' lr ,Y< oa ea rL.. _. 1 FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - - ' r ., BARNSTA LEC®UN`7 Y larl-Ay���'�`]H DEPARTMENT BA J-.'qq T.''-.1:_-,3 L.aU-, M aN�:S. C��.�•l..'.T® TBI.HPHONES 36)-2 53.1. Date: March 1, 1974 To: Camille Houd.c 47A Farkway Place Hyannis, IMAss. 02001 On the basis of a sanitary survey and a laboratory examination on the sample of water taken from a _ 11 located can the premises of locate. at . ...., . .. ... . . . . , . . . d (p (Date) r Y. 19,7 , Place this supply is approved for domestic purposes at the time the examination was made. If you wish further information regarding this supply, please contact us at the County Court House, Barnstable, Massachusetts (Tel: 36.2-2511 Ext. 331), and we will be glad to assist you in any way possible. Signed: . Public Health Sanitarian I l + � �7.4*x I` .`� v' ,' f, _ r Tk: „ °F• x iFV;. y 4 #-' i� �'-t O; � T.`." r ;u j; � •.y � .. 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