HomeMy WebLinkAbout0011 JUBILATION WAY - Health 11 Jubilation Way Nwckonn5
s i 1.
A= 098-065-1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ulp ENVIRONMENTAL PROTECTION
FMAR
CEI `EED
2 3 2004
Ly CkNNSTABLETITLE 5A�Th DEFT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION MAP Q)91
Property Address: 11 Jubilation Way PARCEL. . 5
Osterville, MA 02655 LOT
a
Owner's Name: Lou Vinios
Owner's Address:
Date of Inspection: February 27, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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 Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: March 1, 2004
The system inspector shall subm' 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 conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Jubilation Way
Osterville, MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined", please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Jubilation Way
Osterville, AM
Owner: Lou Vinios
Date of Inspection: February 27, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Jubilation Way
Osterville, MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either`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 '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
'To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
.gpd.
You must indicate either`yes"or"no"to each of the following:
,(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered des to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 11 Jubilation Way
Osterville, MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the battles 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:
Yes 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: 11 Jubilation Way
Osterville, AM
Owner: Lou Vinios
Date of Inspection: February 27, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required]
.Laundry system inspected(yes or no_): No
,Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
.COMMERCIAL/INDUSTRL41
Type of establishment:
Design flow(based on 310 CMR 15.203): _______gpd
.Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed approximately 25 years a-zo-per owner
Were sewage odors detected when arriving at the site(yes or no): 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: 11 Jubilation Way
Osterville, MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 9'6"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gai.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. The inlet
cover was ]'below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of l 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Pro Address: 11 Jubilation Wa
y
av
Osterville. MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
'TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: Qallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 11 Jubilation Way
Osterville, MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 Qal.)
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.):
The pit was dry. There did not appear to be any signs offailure. The bottom to grade was 10'. The cover was T below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimension's:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, 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: 11 Jubilation Way
Osterville MA
Owner: Lou Vinios
Date of Inspection: February 27, 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.
PronT A
C3 B
i /S33 a
a ao 3a 3
3
10
Page 11 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 11 Jubilation Way
Osterville, MA
Owner: Lou Vinios
Date of Inspection: February 27, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40 +/- 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)
✓ Checked with local Board of Health-explain:topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
40'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed, written or implied, relating to the system, the inspection and/or this report.
11
l 1 ...
DATE: 1 1 /1 5/01
PROPERTY ADDRESS: 1 1- Jubilation_Way------
-- Osterville,Mass
02655
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1500 gallon septic tank.
2. 1 -1000 gallon leaching pit. 6 'X11 '
3 . 1 -Distribution box
Based on my Inspection, I certify the following conditions:
4 . This is a title five septic system. ( 78 Code_ )
5. The septic system is in proper working order
at the present time.
6 . 'Waste water in the leaching pit is 36" below the
invert pipe.
SIGNATURE:1
Name:—J . P . Macomber �Jr-____—_
Company: JosephP_ Macomber_& Son , Inc .
- - ----- - RECEIVED
Address: Box 66
-------------------- DEC 0 7 2001
Centerville , Ma . 02632-0066
------------ -——————
TOWN OF BARNSTABLE
HEALTH DEPT.
Phone: 508-775-3338
---------------------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC..
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
v�
t�
COMMONWEALTH OF MA.SSACHUStTTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 11 Jubilation Way
Osteryill_e,Magg_
Owner's Narne:Mrs, John (,ui cj1 PS_
Owner's Address: ,Same
Date of Inspection: 11715/01
Name of Inspector: (please print) J.P. Macomber Jr.
Company Name:Joseph P. Macomber & Son Inc
Mailing Address: P=O= Box66
spnteryi_l In Mn 0 2 6 3 2
Telephone Number: 508-775-3338
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 Section 15.340 of Title 5(310 CMR 15.000). The system:
/ Passes t
Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authoriry
Fails
Inspector's Signature�bmit
Date:
The system inspector shall 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 conditions of use at thatl� `
.will perform in the future under the same or different
time.This inspection does not address how the system ,
conditions of use.
Title 5 Inspection Form 6/I5/2000 page I
Page 2 of I 1 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Jubilation Way
Osterville,Mass.
Owner: Mrs. John Quigley
Date of Inspection: 11 /15/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
/)d I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
-The septic system is in proper working order at
the present time.
B. System Conditionally Passes:
�[1d One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
AID The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
A16� 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
obstruction is removed
distribution box is,leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I '
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address.11 Jubilation Way
Osterville Mass.
Owner: 02655 Mrs. John Quig ey
m Date of Inspection: 11 /1 5?01
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:
W49 Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated,wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
tW The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
WO The system has a septic tank and SAS and the SAS is less than IN feet
but W feet or more from)a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
I
,Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 11 Jubilation Wa
p rty Y
Osterville,Mass.
Owner:Mrs. John Quigley
Date of Inspection: 1 1 /1 5/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
ackup 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
-Z cesspool t— ejvxip 1'iT �&6`�
/Liquid depth in sesspeol is less than 6"below invert or available volume is less than '/2 day flow
P/ 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.
r/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
y portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.. A copy of the analysis must be attached to this forma
tid (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
;The following criteria apply to large systems in addition to the criteria above)
yes n .
_ !vim the system is within 400 feet of a surface drinking water supply
e system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
if you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
r
I +
J Page 5 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART B
CHECKLIST
Property Address: 11 Jubilation Way
Osterville,Mass.
Owner: Mrs. John Ouigley
Date of Inspection: 11 /15/01
Check if the following have been done. You must indicate`yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant,or Board of Health
�/ Were any of the system components pumped out in the previous two weeks?
v — Has the system received normal flows in the previous two week period?
— t/ 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)
I/ _ Was the facility or dwelling inspected for signs of sewage back up 9.
4/ Was the site inspected for signs of break out?
Were all system components, eluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
07 and occupants if different from owner
Was the facility owner( p )provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
A/Existing information. For example,a plan at the Board of Health.
Y _ 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 I 1 +
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 Jubilation Way
Ostervi e,Mass.
Owner: Mrs. John Quigley
Date of Inspection: 11 15 01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
f��
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 6
Does residence have a garbage grinder(yes or no): «`
Is laundry on a separate sewage system(yes or no):;ZD [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes v ����D���� py6•�/�
Water meter readings,
if if available(last 2 years usage(gpd)): >t/9�' f d 9•�/iP�
Sump pump(yes or no): A)O
Last date of occupancy: 1"""`
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.): IfM
Grease trap present(yes or no):"
Industrial waste holding tank present(yes or no):,,J?&
Non-sanitary waste discharged to the Title 5 system(yes or no):f
Water meter readings, if available:
Last date of occupancy/use: il.
OTHER(describe): �l¢
GENERAL INFORMATION
Pumping Records �
Source of information: <.• / d-'
Was system pumped as part,of.the inspection(yes or no):
If yes, volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
!/T 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)
/7j Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from systeR owner)
Ab Tight tank Attach a copy of the DEP approval
Other(describe): �1
Appr cimate age of al co pon ts, date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
a
1 Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 11 Jubilation Way
ostprviiie,mass.
OwnerMrs. John Qu i aley
Date of Inspection: 1 1 f 1 S f n 1
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construct—ion: cast iron /40 PVC4T other(explain): Af/¢
Distance from private water supply well or suction line: /&/t
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appPar tight Nn Pxridenne n1f lGakar-e.The system
is vented through the house vents.
SEPTIC TANK: r/ (locate on site plan) �iOd rf'19.1i�0�-s
r , .W
Depth below grade:
Material of construction: concrete.dD meta l,2bfibergl ass 4Z.6polyethylene
40 other(explain)
1 f tank.is metal list age: d Is age confirmed by a Certificate of Compliance (yes or no):Al(attach a copy of
certDimensions:Zd Yu ' '5"" /7 ld 0 a
Sludge depth:
Distance from top olf edge to bottom of outlet tee or baffle:L
Scum thickness: /
Distance from top of scum to top of outlet tee or baffle: �iv�—
Distance from bottom of scum to bolt of outlet tee or bathe:
How were dimensions determined:
Comments(on pumping recommendati�tnlet and outlet tee or baffle condition, structural integrity, liquid levels
as related_ to outlet invert, evidence of leakage;etc.): _.
Plimp cPnti + =r,tr =nn„= Garbage disposal is presPnt"'A1 cn tank
is over 8 ' below grade Mfill;t- hp maintained-Tho tank- ig
structurally sound and shows no evidence of leakage.
GREASE TRAP�B(locate on site plan)
Depth below grade:Wz/
Material of construction4—/Aconcrete,�Am eta l/ZJfi berg lassA�JpoIyethylenq&other
(explain):
Dimensions:
Scum thickness: AJA
Distance from top of scum to top of outlet tee or baffle: >0_
Distance from bottom of scum to bottom of outlet tee or baffle: tO
Date of last pumping: 111,4
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Grease trap is not DrPGPnt
7
,.� Page 8 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSUR
FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Jubilation Way
Osterville,Mass.
Owner: Mrs. John Ouiglev
Date of Inspection: 1 1 /1 5/o 1
TIGHT or HOLDING TANKgj�l/c (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: kll
Material of construction: concrete metal�tl�fiberglass,0/,4 polyethylene A/ other(explain):
Dimensions:
Capacity: allons
Design Flow: gallons/day
Alarm present(ye or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: N)
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX:Zif 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.):
Distribution box has one lateral _No evidence of solids
carry over.No evidence of leakage into or out of the hnx!
PUMP CHAMBEPA&Le,(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump Chamber is not =rem=nt
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Jubilation Way
Osterville,Mass.
Owner: Mrs. John Quigley
Date of Inspection:11 15 01
SOIL ABSORPTION SYSTEM (SAS): Z//(locate on site plan,excavation not required)
1 -1000 gallon precast leaching pit. 6 'X11 '
If SAS not located explain why:
Located; See pace 10
T�leaching pits, number:
leaching chambers, number. 17)
leaching galleries,number: a
!� leaching trenches,number, length: O
ileaching fields,number,dimensions:
overflow cesspool, number: 0 _ A,-Pe'
innovative/alternative system Type/name of technology:/i%�/ /ye
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to boney sand to fine sand.No signs of hydraulic
failure or ponding.Soils are dry.Vegetation is normal.
CESSPOOLV114cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 0
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):IVA
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present.
PRIVY4,�djQ(locate on site plan)
Materials of construction: /U/Q
Dimensions:
Depth of solids: lelln
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy is not present.
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Jubilation Way
P
Osterville,Mass.
Owner: Mrs. John Quigley
Date of Inspection: 1 1 1 5 01
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.
1 � w
vJ
1
t �
Z
0
// Jar ,a rev t1/Xr y Oxa-A-v C,
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: 11 Jubilation Way
s ervi e, ass.
Owner: Mrs. John uig ey
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
T
Please indicate (check)all methods used to determine the high ground water elevation:
r
r
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)
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:
Used; Gahrety & Miller Model. Ground water above sea level.
Usas Ground water level. 92-000-1 Plate # 2
USGS Observation well data ,dune 1992
Top of Ground
Leaching
Pit ;eet
Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the botto
of the leaching pit and the adjusted groundwater table is
feet.
11
� �.•nrnrw.-rt!Tsr-.Te-arn�Jrtr•ntrrtl�-nrtr.T m11r.7r+Tnnrr�IrnagR+t7i 1�l1Zn�q wT• •rRT►1+rn--...•,r-
'I'ONN OF Barnstable BOARD OF HEALTH
SUII,SURFACR SF,HAOE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
•••T!1�T".-::a—T.III.�.TTTIRITI'R.'f!It TIIrJ�'{'1flTT7:r!.'t--IIRR'\i'R1R-1TIR�tR�1.It1A'1�r7 T1fl ..�-rT'•I�•�. .�.
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 11 Jubilation Way Osterville,Mass.
ASSESSORS MAP , BLOCK AND PARCEL # '"��
OWNER' s NAME Mrs. Jihn Quigley
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME Joseph P. Macomber & San Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632
Strevt Town or City State L I F
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa`1 system at
this address and that the information reported is true , accurate , and
omplete as of the time of �inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
it System PASSE
The inspection which I have conducted
has
not found an
information
which indicates that the system fails to adequately protect s
public
healLh or the environment as defined in 310 CMR 151303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I hRve con 110ted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection .form .
Inspector Signature ( Date
.
ne copy of this t.ification must be provided to the OWNER, the BUYER
O
where applicable ) and the 130ARD OF HEALTiI.
* If the inspection FAILED, the owner or""operator shall u
pg he aye te
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 ChIR 16 . 305 ,
partd .doc
WTN GAzB&ClE &Z"ve-C
SE C. -VAA ►V- = 4r15 CtOa
u
t COO
�t S PoSAU P t? V�,E. 2 Sm►JE +. . ,% ,
i N ,
BoTTOAA
TOT
PE�Cot�T to�.l Pp,TC-. l oQ LEOf.
' T P2oP
.N PIT..
41
h� kiCtjAFtfJ ALANA.
WA-
V
i
y-
TeST
=33 -/
B 4 Wit• 3
LoAl 4 PP I90v
•� S +
��6ot t �' _ t ; •
rT�►�.1tL s
(loco qS g: �uV tWN ..' ! + { z.
GAL.
,V _ _(
Mom. F&T I t
- ,
wM • t
.. ....'/ � �.• �� � I' �' t- - ill
C�ZTtFtEa P.-o-r QLAi.I
.
IJn I�ATve.
l FY TµAT T"C-- s wow".1
htE�EC��1 Go�•cP�-YS W/TH T4iE. �l�Et..11.1�
AuD SEC'BACK iL6QUiY�.AAF —rJ5. OF T"66 S
Tdw" of `i.3Ae�JSTAGLu n' �.d►3D CO t' �L.�
DATE c„�G,`r.it.'.• B A X T E TZ $ 1.1`(� 1�.lC,.
Q t-STM uEQ, L.A r-1 ;L)ZVept4
T"K ?c-sN IS tJDT l6A56D OLI AtJ t644TWMF-"'r ' OST Stu►-6. MA.CPOS.
5ur-vc:-/ 4 Tu r► OFFSET; 5"Oo Lt,, WOTL u5 ej> _
APPLtG A w"r p
To -PC -Zmi►. L t-o-r UWS4. _ I'aALD; QI, ALT`� (fLJST
• t
LOCATION 6I SEWAGE PERMIT NO.
VILLAGE
INST A LLER'S NAME & ,,f44,1) DRESS
V
B U R DE R OR OWNER .
.DATE PERMIT ISSUED
OMPLIANCE ISSUED
DATE C _ �
l6 0177 V
`(b
No........
--------- Flmla.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
OF............`.. ` . .-----/4................
Appl ration for disposal arks Tonstrurtion VrrYnit,*-.
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
-.6 ------
........ -- ----------------- ...... . ..................
oca n ddre or Lot
Owner Address
a -��rc. --- .
-------------------------------------------
� Installer Address
UType of Building Size Lot_._.. -_. ,�� --Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( —
CL, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -------------------------------------------------- --
W Design Flow.................:.5� ..._.....____gallons per person per day. Total daily flow__.._..__ _ld__._____.__.___gallons.
WSeptic Tank—Liquid capacity ..gallons Length---------------- Width---------------- Diameter---------------- Depth_____________...
x Disposal Trench—No..................... Wid ___�_ ------- Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No iame Diameter... _ Depth belo inlej---- ---------- Total leach' area
Seepage ft.
z Other Distribution box ( ) Dosing tank ( � �— /" ��/�` >f +
Percolation Test Result Performed by...... i Date•__ .__=11�_`��''__....._---.
s
14
Test Pit No. 1_ ---.....minutes per inch Dep i of Test Pit_____________ Depth to ground water.____________________._.
tmq
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_---------------------
9 -----------------------------------------------------------------------------------------------------------------•---•-•-----------•--•----------------------
0 Description of Soil.........................................................................................................................._- ------------------------------------------
x
U ------------------------------------------------------------------------------•-------------------...--•-------------------•------------------------...------------------------------------------------
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 i ued by� oard h th. �
Sig ........ ----------------- ---------------------------------
> D e
Application Approved By. � .���'"� . .. �� `------------ 7.c-.
Date----•-........
Application Disapproved for the following reasons:___.._.
-•---•-•-•--------------•---•----•--•-----------------------....------------------•--•--------••-----------•-•----------•---•--•--------------•-----------------------•-------•---- -----------------
Date
Permit No......................................................... Q Issued--�
Date
-- ---------------- --� -
N ,` ... FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`71T�; .,,,.
Appliratinn for i a � rk Cnaa r�trtiun �e�n�i
Application is hereby made for a Permit to Construct (I.) o"" r Repair ( ) an Individual Sewage Disposal
System at 1 ✓$ F / � j C-
............................ f /
JI P . t / /J
'i"Location Address f } ......-or Lot 1Vo -
.................. J..'`r t.Gr;� .... `.`� i .r er f�-�v`^�..............................................
Owner Address`
Installer Address
U Type of Building Size Lot..... _--`07-�---Sq. feet
.•-I -' Dwelling—No of Bedrooms a_ .............. Expansion Attic ( )` -Garbage-Grinder
p, r, Other—Type of-Building ..................... No. of persons............................ Showers ( ) — Cafeteria ( )
a ,
Other fixtures ..
W Design Flow___________________�*"� r _gallons per person per day. Total daily flow......_ _ ..................gallons.
Septic Tank—Liquid c pacity_�_�G:_'_gallons Length..::-;_-_- ..... Width---------------- Diameter__-_-.-.---_ 1
� ---- Depth
, Dis oral Trench_—No. .....................Width.................... Total Length.................... Total leaching area....................sq. ft.
x ti,,.p
Seepage..Pit No..........!.............Diameter /�_�=.�_ Depth below inlet....... ....... Total leaching area..................sq. ft.
Z O*Kr Distribution box ( ) I Dosing tank
Percolation Test Results '-Performed by..._....._ f.___ �._. _._..._.. Date.....
Test Ptt No. 1___.. rf1, per •inch Depth f Test Pit-------------------- Depth to ground water
L>, Test Pits No. 2................minutesrr inch Depth of Test Pit.................... Depth to ground Water-_____-____-_________--.
a x
p
Description of Soil-------------------- - -----------
.................................. ................ ___......•----- ----•----------•"-.......-----•----.....----•-----------------..........................._.............---
U Nature of Repairs of`Alterations Answer when applicable______________________________________________________"-_--__---_ --.----.-_.-•-.-:___--------
------------------------------------------.......................................................-.....................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed pIndividual Sewage Disposal System in accordance with
the provisions,gf�Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Ce'rtificate'of Compliance has been issued by the.board of health 14,11,
Signe9 �, , bate -
,. �Date
Application Approved By......_ ..
• v� �iy� Date
Application Disapproved for the following reasons: •�
t
---•----• --^..--• ---•-s,......
--...... --•---'--•--•------------r-------------•----•-
Date
Permit No............
A ... .._ : Issued:
Date
' THE COMMONWEALTH OF-MASSACHUSETTS
BOARD 'O HE ►LTH x}
THIS S 0 E TIF at the Individual swage Disposal S stem constructe ,/�, or. Repaired
---- ----- -az.,
at ... --- -----K •---- l In +ems" d_±tf/_ �
has been installed in accordance with the pros of'Ar I f The State Sanitary Code as describein the
A pplication for Disposal Works ermit No._ __.. ___..�%__r .tZ-_...._ dated.-.. .Z_2:":.7................
i�
THE ISSUANCE OF THIS tCERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -q "- ----------- Inspector := 1. --•---
'
.. r
b
i THEICOMMONWEALTH OF'MASSACHUSETTS
BOARD OF HEALT
.. O�F.......... ��� ................ � A
No....... ..... FEE........................, ,....
Bigpolial Mbar I r#inn... antit
Permission is hereby gr nted- __.- _-,l`l'
to Construct � ��r Rep r ( ) n vidu S age Disposal ystem I.
at No._" s ... _` -- -- - -----
- - Street
,.�.;: -- f; 7/ ..
as shown on the application for Disposal Works Construction it No. f- ____ Dated ........................
���Ago-
.ram no H Board'of '
DATE-- _-f........................... .... ....................... ------ r
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
w-
TOWN OF BARNSTABLE
L OCATION SV�t ATi 0 n SEWAGE #
VILLAGE 0 Mf V l tk ASSESSOR'S MAP &LOTt % 6�5
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY SW
LEACHING FACILITY: (type) P•�r" �eX fp (size)
v NO.OF BEDROOMS
BUILDER OR OWNER L Q%J
PERMITDATE: 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 leachi ,facility) Feet
Furnished by Sp 4 t+ a rf� T Fe
�ronT A:
Q g
O a
33
a ad 3a 3
3 a°) 3-7
y
TOWN OF BARNSTABLE
LOCATION SEWAGE #
ASSESSOR'S MAP.&LOT 1,��`'
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY m
+
—'.LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS r
BUILDER OR OWNER
PE.RMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 aching Facility(If any wetlands exist
within 300 fe f o- 'a6wets"W
facilityFeetFurnished.b
r-
1