HomeMy WebLinkAbout0625 MISTIC DRIVE - Health x �. 625MISTICIVE ;
079-065 MARSTOP MILLS'
COMMONWEALTH OF MASS ACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
�) DEPARTMENT'OF ENVIRONMENTAL PROTECTION
�i
MAP ®7 �
PARCEL k 5-
LOT
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
tCERTIFI{CATION
Property Address: a
Owner's Name,
Owner's Address: C / '� l J- C:,
Date of Inspection:
—v
Name of Inspector- (please print)
Company Name yx<rO&oe—&075co
Mailing Address:�� L � co r—
� rn
Telephone Number: C
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the.information reponefi
.below is true, accurate and complete as of the time of the inspection. The inspection was performed based tin ntv
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
/-AInspector's Signature: � Date: V V
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healfli 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. y
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 ho.w the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Paoe 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT A
CERTIFICATION (continued)
Property ert Address: �-
Owner:
Date of Inspection:
Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. ystem Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
153031 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 exfiltratior 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 Heath.
*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 du&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
1
Pace 3 of I'l
OFFICIAL.INSPECTION FOR' - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: f ,
Date of Inspections
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 I of public water supply.
_ The system has aseptic 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 I 1
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PAIN A
CERTIFICATION(continued)
Property Address:
Owner ),_
Date of Inspection: Q
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 %day flow
Requited 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
J water supply.
_ V Any portion of a cesspool or privy is within a Zone I 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. ['Phis 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
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 no
the system is within 400 feet of a surface drinking
_ y rmking water
ater 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.
4
Page 5 of I 1
OFFICIAL INSPECTION FOIUIVI—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE 'DISPOSAL SYSTEM INSPECTION FORM
I'A:R' B
CHECKLIST
A
Property Address: f XA0
Owner:
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 ?
L _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
CZ_ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for suns 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
Veb 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 Sao
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) [3 i 0 CMR 15.302(3)(b)]
5 .
Page 6 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTAR.�:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PANT C
SYSTEM INFORMATION
Y
Property Address:
Owner:
A -
Date of Inspection: t / -
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 C10 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:_
Does residence.have.a garbage grinder(yes or.no): A) `
Is laundry on a separate sewage system (yes or no):;UD.[if yes separate inspection required]
Laundry system inspected(yes or no): )o
Seasonal use: (yes or no): f� J
Water meter readings; if available(last 2 years usage (gpd)):
Sump pump.(yea.or no):VV
Last date of occupancy: ✓lC.. �
L 11.i r�
COMMERCIAL/INDUSTRIAL
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: J `
Was system.pumped as part of th6 ins,pection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined? j
Reason'for pumping-
TYPE OF SYSTEM
t,�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):
qrx�imaZte age of all components, date installed (if known)and source of information:
Were sewage odors'detected when arriving.at the site(yes or no): )
6
Page 7 of 1 I
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ti
Owner:
Date of Inspection.
BUILDING SEWER(locate on site plan)/X7-
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: Zlocate on site plan)
Depth below grade:
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: i-CO k yC,
Sludge depth: -�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: —G —
Distance from top of scum to top of outlet tee or baffle: ^—
Distance from bottom of scum to bottom ofoutlet tee or baffle:_
How were dimensions determined: �u'LC
Comments(on pumping recommen ations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert, evidence of leakage, etc.): of
l
i3
-
a
GREASE TRAP:/J�)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
Pace 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '9 � 2_
Owner:
z
Date of Inspection:
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):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
.Alarm level`. Alarm in working order(yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOY:Z(if present must be opened)(locate on site plan)
)
Depth of liquid level above outlet invert: �Q/� &ItAd
Comments (note if box is level and distribution to.outYEts equal; any evidence of solids carryover, any evidence of
akaoe intg ou of box etc.):
PUMP CHAMBER(locate on site plan)
Pumps in working order(eyes or no):
Alarms in.working order(yes or no):
Comments(note.condition of pump chamber,condition of pumps and appurtenances, etc.)
8
Pa_e 9 of 1 1
OFFICIAL INSPECTION FOIR24—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE'��I�, DISPOSAL: SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 025 A I
Owner: 0,4 J At 17 (l
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): 7n.
cate on site plan, excavation not required)
If SAS not located explain why:
Type
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,
etch):
40-664
CESSPOOLS: cess ool must be pumped
(�( p p mp as part of inspect ion)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver:
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:A 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.)`.
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOB.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORIMATION(continued).
Property Address:
Owner.
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.
t�L
`D
a
allon.
10
Page I I of 1 l
OFFICIAL INSPECTION 1r 01kM1, -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address:
Owner: (�
Date of Inspection: / T
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water U feet
Please indicate(check) all methods used to determine the high around 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:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the nigh ground water elevation:
05,
11
,
Number:
D
cl $ . ate.
r
r �h. Completed by
�], ✓' s
..... .
'` i x: ' i'" �'I(;i- r C?;^,f I�I j�.'IiU.C,'.•�,!f�...�..�t .. -I-R LEVEL COMPUTATION � ...
Site Location:
Lot No.
Owner: Address:
Contractor: C� -'Address: ,J� C
.� Stt j ,'(Totes:
L
.0 W
STEP 1 Measure depth tc ,n;ater:able 20
,..
nearest 5.ft
. ........................................................................... .. .Dot
month/day/year l
sw STEP 2 Using Water-Level Range Zone
and Index Well Map locabs
- d d s:te an .terrine:
i
,::.;.... O Appropriate ir:de;:we!L..........................
Water-level range zone ..........
S T EP 3 Using monthly report "%urr em I
Water Resources Conditions"
determine current depth i:o �
I
water level for index ':irvel .....: ' I—
I/�j..................... mon'ih/year
1
STEP 4 Using Table of Water-level Adjustments
for inde;c well (STEP 2.A), current death
to water level for index well (STEP-3),
and water level zone (STEP 28)
determine water-leve! adiust Cn'.. .............. .
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4i
from measured depth to water
level at site o T EP 11 .... l/
.......................................................................................................... '
i=ioure 13.--Reproducible compucaLion form,
6,�
i
_......._.....:.r.,. _._.,_...._ ai rfP
1
i
i
TOWN OF BARNSTABLE - --------------
LOCATION ZaS 7- '15? M'�S T' �� SEWAGE #,.:�'^ `
VILLAGEclr�. �` ASSESSOR'S MAP LOT
i.
INSTALLER'S NAME S& PHONE NO.
SEPTIC TANK CAPACITY /)
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �i �ber-
DATE PERMIT ISSUED: - 10
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ,/
,.,:
j.�
�� � ��
�8 . �� r
�:
�.��.,
..�� ;;. �
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c� �.,
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No..... FEB......... ..b......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Applirativit for BioVo!3a1 Work.6 Tonotrnrtion ramit
Application is hereby made for a Permit to Construct ( 1/f or Repair ( ) an Individual Sewage Disposal
System at:
63
c on \ddress r
4 �J //� Lot No.
._..
--------9 ------
W / •-----•.... - 0.... . 4
� . ._.....
v r`/�
Installer Address
Type of Building l Size Lot--- .Sq. feet
.� Dwelling— No. of Bedrooms.......__�_`^1__._______ _..___E�pansion Attic ( ) Garbage Grinder ( )
p`4 Other—Type yp of Building No. of persons____________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- - -
-----------• -- --- ---------------- - -
W Design Flow.....................t.[`.0...............gallons per per-sen per day. Total daily flow.._-...... �-----------------------gallons.
WSeptic Tank—Liquid capacitv.!�_�..._gal Ions 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 ( ) Dosin�n� � _a�
~' Percolation Test Results Performed b- p-- - --------- --r......___......__.........._._ Date................__..._____---_-•--•_-.
W
Test Pit No. I................minutes per inch Depth of Test - it Depth to ground water_.-.-„�-/�.
(T4 Test Pit No. 2...� ..nimutes per inch Depth of Test Pit.................... Depth to ground water......_.................
a ------
O Description of Soil... ....... ..........
;;�
('r'!--•------------------------------------------------------------------------------------------------------------------
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 Compliance ha issued b Y.11151oard of health.
Signed ( v-------------------- .................................. ...................... . ............................
Date
Application,Approved By --------------- -u-- ... 2s -...�6....
Application Disapproved for the following reafonf: .............. ............ ............................... ..... . ..._........................
................ . .....
Date
Permit No. ..w.. ..... Issued ............ Jp...-�----------------
. ............---- Dare
J)C�-y ti
No.----•-,"5.:���r Fes$....... //5. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
i
Apphration for Diiipnittl Works Towitrnrtiun rnmit
Application is hereby made for a Permit to Construct ( (/f or Repair ( � ) an Individual Sewage Disposal
System at:
_..11XV!of/ .... ------... �p
•--• ---- -•-3-------- -------------- ....----•••-
Loc tion .Address g or Lot No, J
......--
_ d _
1 Installer Address
U Type of Building ,/ ` Size Lot...`7`" �Sq. feet
`7
Dwelling— No. of Bedroon}s.,,________________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___�?'n.... c- No. of persons.........................__ Showers ( ) — Cafeteria ( )
Other fixtures --------------------------------------
K/�----------------------------------------
W Design Flow...................../..d...............gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic. Tank—Liquid capa6tvJ.��__.J.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 b / �a a y....-------- - ----�----------=•e----------•------------------ Date..----------------...------------------
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--.
No.
re--a•i
.. r�
G>. Test Pit O. 2....a`�"__minutes per Inch Depth of Test Pit.................... Depth to ground water.....
a n ---------- ^-------------------------------------------------------•--------.----------
------------
----------------
=.............
...............
D Description of Soil---( � A-'f-4 A wY('' n--- =
U --------------------------------------
-------------- ��---------------------•---------.-------------------------------
-•-----•-------•.---
W
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 TITLE 5 of the State Environmental Code�The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has.bee issued by thfe board of health.
Signed ......1/.! ................. � .-..� --
Dace
Application.Approved By C/.................Q `�.. <�,., ,��._ - ---------------------------..........------------------------------ -----
Dace
Application Disapproved for the following reasonr- ----------------- ------------------ .-------------------------------------------------------------------------------
4
Dale
Permit�No. .................,y Lw'+ LA).C,..P........... Issued ------------>7!5-------l 9--'.��-------------
Dare
��..�e_�•a r-..����oea.c-- --...----om—a—e_--ab+o_m.._e_a —._.--- --t_sG---ems..w-- -----.—+—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
TErlifi ate of TomplianCP
THIS-IS - 0 CERTIFY, That the Individual Sewage Disposal System constructed ( �or Repaired ( )
by ..._�_ \J..... . - ...................•------------------------------------------------------------------------------------------------------- -------------------------.................
mscau�r--�„
....... ... - �_Iflfe ................./j.------ ............................................................ .............
at ..........,... ...... .. .........
has been installed in accordance with the provisions of TITLE 5 of he State Environmental Code as described in
the application for Disposal Works Construction Permit No. .a ..,... dated ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..._...---.. ................ .,.._..`.. ..�_t ..= - Inspector -- -----------............--------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No......L ') _..._ -l FEE...Z !.�...-•-•---•a
11e_ nrk� �un�trnrtirrn �rrntit
Permission is hereby granted.. !_..._ t --.Q�P�. -------------_---------- ------ ..................................................
to Construct ( ) or Repair ( _) an Individual Sewage Disposal System
atNo....... ....-/w_....... = •-r� ? --------------------•...------------------•-•-------------------•---•--•--...........
iA 3 Street
as shown on the application for Disposal Works Construction Permit No._�►r_._0__. Dated.......... �,t�_........
•----------------••------•--•----...-•-..... ------•-------•----------•-•-----•••--•--
DATE ..... �- -------------------------------------------
6 Boa Health
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
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Design Data •1
Single Family - 4 bedroom
No disposal, Daily Flow =
r
4x110=440 GPD. Septic tank =
440xl.5=660 gal. Use 1500 gallon
septic .tank. f
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DisposaL Use 2-6x6 leach pits
w/1' of stone. Bottoms. = 100 sf @
1.0 G/s.f. = 100 G/D. Sides = 301
s.f. @ 2.5 G/s.f = 754 G/D. <�
I certify the proposed dwelling �`�✓ u"`< q,
conforms to the sideline and setback o� wILLIAM
requirements of the Town of Barnstabl N Y E Al
and is, not located in the floodplain. `' No- 19334 A/ ILL SI MA
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Prof essional:..Land Su -veyor Date
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