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Home My WebLink About0455 MISTIC DRIVE - Health 455 Mistic Drive, Marstons Mills LA= 061-029 _ I Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer, use 455 Mistic Drive-Marstons Mills, MA only the tab key Property Address to move your Theresa Balzotti cursor-do not Owner's Name use the return key. 455 Mistic Drive Owner's Address Marstons Mills MA 02648 City/Town State Zip Code July 1, 2005 Date of Inspection: Date _ 2. Inspector: r,' David D. Coughanowr, R.S. Name of Inspector ::' "- Eco-Tech Environmental < C;1 Company Name ! ` 43 Triangle Circle Company Address r_x> Sandwich MA 02645,---- r City/Town State Zip Code 508 364 0894 Telephone Number 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority O a. • �G S July 1, 2005 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2035.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Pagel of 16 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) F 455 Mistic Drive Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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: t5-2035.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2of16 a Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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: 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 t5-2035.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts a Title 5 Official Inspection Form Not for Voluntary Assessments ; Subsurface Sewage Disposal System Form A. Certification (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of 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: t5-2035.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 4 ` 1 w Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® 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.] 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. Title 5 Official Ins stem Inspection Form:Subsurface Sewage Disposal S t52035.doc• 11/2004 P 9 P Y Page 5 of 16 Commonwealth of Massachusetts a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4^M A. Certification (cont.) 455 Mistic Drive Property Address Marstons Mills MA -02648 Citylrown State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection 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 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 "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. t5-2035.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6of16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 455 Mistic Drive Property Address Marstons Mills MA 02646 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection 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 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: ® ❑ 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)] t5-2035.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7of16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Salzotti July 1, 2005 Owner's Name Date of Inspection Residential Flow Conditions: 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 gpd Number of current residents: 1 Does residence have a garbage gander? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 392 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: . Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No o the Title 5 s Non-sanitary waste discharged t stem? ❑ Yes ❑ No y Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2035.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® 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: Age: 9+years. Certificate of compliance issued 5116196(Board of Health permit#95-353) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2035.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form . Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.), 455 Mistic Drive Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other.(explain): 20+ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: . ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 5 inches Distance from top of sludge to bottom of outlet tee or baffle 29 inches 2 inch Scum thickness Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 13 inches How were dimensions determined? Design Plan t5-2035.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C�M C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2035.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts k� Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form P Y•GSM n C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day 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.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet inverts 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.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2035.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection 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: ® leaching pits number: 2 ❑ 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.): Soils above leaching pits appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into the leach pits t5-2035.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection Cesspools (cesspool must be pumped.as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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 failure, level of ponding, condition of vegetation, etc.): t5-2035.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts t-P Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M 5y0•ev . C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code Theresa Balzofiti July 1, 2005 Owner's Name Date of Inspection 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. OLEACH PT LOCATIONS A B S LEACH 1 13.5 f t 32 f t D-sox 9Q 2 21.5 Ft 38 Ft 2 3 24 Ft 34.5 ft SEPTIC 4 39.5 f t 50 f t TANK Q 5 40.5 f t 28 f t EXISTING DWELLING n B WATER LINE 455 m NOT TO SCALE t5-2035.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 455 Mistic Drive Property Address Marstons Mills MA 02648 City/Town State Zip Code '.Theresa Balzotti July 1, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 12 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: 3/10/95 Date Observed site (abutting property/observation hole within 150 feet of SAS) El 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: Approved design plan on rile with the Board of Health shows bottom of system to be 12 feet above 'the groundwater level observed in a test pit on December 1, 1994. t5-2035.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE v s � LGC ATION O?� /Yl/5 T/� �- SEWAGE#25 3L VILLAGE JVA&P®rl�� ,/3Il1LS ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J5 s LEACHING FACII.TTY: (size)AM O NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �` COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility If 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 leachin facility) _ Feet Furnished by X Tt,< 'A, W. 1A1C-.r- 0 a O i i 02 - ��-a No....!.�� ti /YEF...... ...... Ir THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diti-pnuul Wurkg Cfuntitrnrtiun ramit Application is hereby made for a Permit to Construct (L,,I/or Repair ( ) an Individual Sewage Disposal Systemat: .. ' iJ _ `� ..a .. .'._:4.._. _.....5 V. ...L.. ... .._ ............................................................. or Lot No to w r •. •-•. Address . a Installer Address './/� UType of Building Size Lot--- .. ....Sq. feet Dwelling—No. of Bedrooms ............ .. .. No. of .Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Buildin �/!/ ___✓ ersons............................ Showers p., yp g - p ( ) Cafeteria ( ) a' Other fixtures ...................................... aR W Design Flow........................;..........gallons per per day. Total daily flow-..-_---Y0..........................gallons. WSeptic Tank—Liquid capacity)_52)0_gallons Length________________ Width................ Diameter---.------------ 6;th................ x Disposal Trench— No. .................... Width.................... Total Length-------------------- Total leaching area.....:`.............sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t k ( ) � Percolation Test Results Performed by-----� !1• ----r-`��-.................. Date-----j-Z-�l-~-g--- .._.. ,a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water... . �rX inch _. Z..l:�_ , Test Pit No. 2________________mtnutes per inch Depth of Test Pit...__._._.______ .. Depth to ground water..____......._.._....__. a -- ---------------- ------- 0 Description of Soil........ .. ......_ a. ((�...................V ........-•-'---•----•---•-....-•................'----•--'-'•-----'•---•--•--•---'-'------•--......--------'•--......---•-•-••-'-•-------'•--"----------'----•-"----•---•-'-----...............--•---'- 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Comp Pias been issud by the oard of health. Signed .. - ------ - - -- --- - -------------------------- -----�. ..... .. Da Application.Approved By ---- ---- ....................................... ..... �...D......774 -----......................---- Dace Application Disapproved for the following reasons- --------------------------------------------------- .-............-..--------------------------------------------- ....-......_--------------------- . .-- - _ - �----------------- - ..............----------------------....-----------------..................-.-..-..-..---.-...-.....- -------- ........................................ Dace r Permit No. -----75.............J�-- .................... Issued ----------------13'...1( ......., ............. Dare ---------------------------------------- /Fim ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allpfiratinn for Dhi-Viiiial lVildw Towitrnrtion ramit Application is hereby made for a Permit to Construct (L/1/or Repair ( ) an Individual Sewage Disposal System at, 7 caVion-Address �` --•---or Lot No_____________'......._...---••---.._.....- f L ��.---- --�--------- ---------------------- ---- Otener ��._____Address � .. 7'G�7 -------------- Installer Address C J�' � UType of Building ,, Size Lot.......:....................Sq. feet Dwelling—No. of Bedrooms-------------/------------------------.__Expansion Attic ( ) Garbage Grinder ( ) p.I Other—Type of Building W! f No. of persons____________________________ Showers ( ) — Cafeteria ( ) aI Other fixtures ---------------------------- W "Design Flow................:�.�1 __............._._gallons per4p!erso.tz;per day. Total daily flow........'_1._-4 .......................gallons. WSeptic Tank—Liquid capacity)_SOL?'gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ~' Percolation Test Results Performed by-----........................................�/-....--------------------- Date-----,2'.......................... W Test Pit No. 1_ .a'_'_--minutes per inch Depth of Test Pit__________________- Depth to ground water...._:t_ - 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 .4 -- v---- ---•--•--•••----•-•--•••--•------------•-•---•---•-------•.......................•-----------•----------....--•--•------------ ODescription of Soil------.. '(4el....................................................................................................................... x W ------- ............................................................................................ .................................................................................--•----•------• V .Nature of Repairs or Alterations—Answer when applicable.......... ..................................................................................... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliamerhas been issued by the board of health. Signed ...� .......... . Application.Approved By .......... �-- .a,:c-. �^_.... ............................ . ..... ....... ..... ..- e .....-.�r. Application Disapproved for the following reasons: ............ .............. -- ..................................... . ............................... .......................................................................................... .............................................................................................................. ........................................ C Date Permit No. ........�-'..5...�� Issued ------------------- ' .............. Date .......-------.a..-- _— e...e s.o.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C11ertiftrttte of Compliance ' THIS IS--TO CERTIFY, T at the Indi i•ua1 wage Disposal System constructed ( +� ) or Repaired ( ) by ....'.�" �C'.�... .................... f�--..... .------------------------- ------- --------------------------.--_----------------------------------- -. - hstauet at ... _._r ... ...... � -.... ..��%7..... - .... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .........C�-._' .. ..... dated ......,Z)=. 0-------F .ti`"�....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �• - / �r DATE... ...."". �'"�:--.. .... Inspectar ...... ............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..... _..:. : FEE..... . )........ Biapniin1 Works Tunotrurtuam rr it Permission is hereby granted-- � � Y_ -<1?............................................... Construct ( �or Repair ( ) an Individual See Dispos System at No... -!tl :._.._ ...._.`?�!I A/1 -1�'! ` 1-------�'------- �/1------- Street as shown on the application for Disposal Works Construction Permit No-_--_--5 3--_ Dated........................................... ----------------------•-•--•--------•-•-•---------------------•---•---•---------------•--•.............. Board of Health DATE................................................................................ FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS ' */ A, J`t i � a K—OP — � WILLIAM g J Ev c, 76 • � ,�� ®✓i G•�� 5� .� t��Z(...I t1 C.� G(�1J F't,�M S Ra [E--C� j IN Y E j a / 2p.Q S ` CI iVu. i9?34 tt a- FG=� / �c ►�c CZ�v Y. , 4-c) �I Fw U ' o r G fol 1kD '`'•r svv +" TaP t� �U /So ". o 4'•Poe ~• to � ♦ :Y Q Poe •" S�h•3aIG 4'p,P6 atSt; Iw. Gat.. , �j L�0 �t7 OFF Rf, - - ? 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