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HomeMy WebLinkAbout0724 MISTIC DRIVE - Health r 724 MisticDrive Marstons Mills P A = 079 074 I i I 8` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher - Owner Owner's Name information is Marston Mills MA 02648 6/26/13 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector. key to move your cursor-do not James Ford use the return Name of Inspector key. raA Company Name P.O. Box 49 Company Address Osterville MA 02655 City(Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth0Eva uation by the Local Approving Authority 7/08/13 Ins tor's Signature Date Th s tem inspe for shall submit a copy of this inspection report to the Approving Authority(Board of th 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. Yg. t5ins•3113 Title 5 Official Inspecti F r :Subsurface sposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official) Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is Marston Mills MA 02648 6/26/13 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 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. Check the box for"yes", "no or"not determined" (Y, N, ND)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 i6filtration 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. ❑ Y ❑ N ❑ ND(Explain below): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 x Commonwealth of Massaphusetts Title 5 Official Inspection Form IM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is Marston Mills MA 02648 6/26/13 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ Y ❑ N ❑ ND (Explain below): l ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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)fare replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins^3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 • k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is required for every Marston Mills MA 02648 6/26/13 page. City/Town State Zip Code Date of Inspection B. Certification (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. El 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i J D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" o.r."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 0 ® 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 1/2 day flow. 15ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is required for every Marston Mills MA 02648 6/26/13 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ z 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ®. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The systerp owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd.to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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"fo 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. 15ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official! Inspection Form Subsurface Sewage Disposal �ystem Form -Not for Voluntary Assessments GSM ,•'�y 724 Mistic Drive _ Property Address Donald Meagher t Owner Owner's Name information is Marston Mills MA 02648 6/26/13 required for every ' page. City/Town State Zip Code Date of Inspection C. Checklist 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 thelsystem 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? ® El 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 dotermined 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name requir al.ion is Marston Mills MA 02648 6/26/13 requires for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 1. Number of current residents: 0 Does residence have a garbpge grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d unknown 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date i 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 Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is required for every Marston Mills MA 02648 6/26/13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: t Source of information: 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 1 ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _{ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owners Name information is required for every Marston Mills MA 02648 6/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 - per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 5"feet Material of construction: 1 ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: 21' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name 1 information is required for every Marston Mills MA 02648 6/26/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 21 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There were no signs of leakage. 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is required.for every Marston Mills MA 02648 6/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to 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): 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/1; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is required for every Marston Mills MA 02648 6/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present.rr ust 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 normal. No solids were present Pump Chamber(locate on site plan): f Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): i If SAS not located, explain why: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts y ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owners Name information is Marston Mills required for v MA q eery 02648 6/26/13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits+ number: 6'x 6' - 1000 dal. ❑ 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 were no sign of failure. A camera was used for the inspection i 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 j Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 . P. Commonwealth of Massachusetts Title 5 Official: Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M "( 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is MA 02648 6/26/13 required for every Marston Mills page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f Privy(locate on site plan): Materials of construction: Dimensions Depth of solids lifailure, lev I f n in condition of vegetation, Comments (note condition of soil, signs of hydraulic e o po d g, g , etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i 1 Commonwealth of Massachusetts a Title 5 Official Inspection Form =' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is required for every Marston Mills MA 02648 6/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t J 30 Q 1 3 aq 30` 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r t Commonwealth of Massachusetts Title 5 Official' !nspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'w 724 Mistic Drive !. Property Address Donald Meagher Owner Owner's Name information is Marston Mills MA 02648 6/26/13 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15.1' +/- feet Please indicate all methods.used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of;design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo and water contour map. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: i You must describe how you established the high ground water elevation: Using Barnstable Topo and water contours maps. The groundwater level was app. 18' below grade. The high groundwater adjustment for this site SDW-253 zone B for march 2013 was 2.9' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 9 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 724 Mistic Drive Property Address Donald Meagher Owner Owner's Name information is Marston Mills MA 02648 6/26/13 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION � a� `y s�•� OCT 2 9 2002 TOWN OF BARNSTABLE HEALTH DEPT, TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A f (D CERTIFICATION Property Address: 9JV �� w Owner's Name: Owner's Address: � S/�? MAP PARCEL ®1 ' Date of Inspection: �� Q���,�, //��DO.� - �or : 13 Name of Inspec please print) Company Name Mailing Address: 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 t-aining 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: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: i Date: q/0, 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 c d 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:. Owner/_(R Date of Inspee ion: Inspection Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. S stem Passes: I have not found an informatio n on which indicates that any of the failure criteria described in 310 CMR -15,303 or in 310,CMR.15.304 exi.st..Anyfailure:criteria not evaluated-are.indicated below:-- Comments: c ­-W -System Conditionally Passes: One or more system components as descfibed 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,NNill 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.hieh static,water..leyel.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 r Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSUIUACE.SEWAGEDISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: ` Date of Inspec ' n: , 0a 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 10.0 feet of a. surface water supply or tributary to a surface water supply: _ The system has a septic an 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 nkrogen—and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are riggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A `CERTIFICATION(continued) Property Address: ILIA Owner- Date of Inspec ion: 00()I'.;> D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ (S/Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 1/ 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 clooraed SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow I�. Required.pumping more than 4 times in-the last year NOT due to clogged or obstructed pipe(s).Number ' / of times pumped i� 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. '/f. Any portion of a cesspool.or privy is within a Zone 1 of a.public well. ��nyny portion of a cesspool or privy is within 50 feet of a.private water supply well.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. E Large Systems: To be considered a large system the system.must serve a facility with a design flow of%109,000 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"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 l 1 OFFICIAL 11114SPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �c Owner: Date.of Inspe ion:_ / 0/; Check if the following have been done. You must indicate"yes"or"no" as to each of the following: "N/ J Yes No Pumping,infcrmation.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 syste.n 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? _6Z— Were as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the faciLty 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 _V/_ 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: 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 CNIR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C SYSTEM INFORMATION Property Address: Owner. A _ Date of Inspect on: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):- Number of bedrooms(actual):. DESIGN flow based on 310 CMR 15.203 (for example: 110 a x#of bedrooms): Number of current residents:_ Does residence,have a garbage grinder(yes or no): Is laundry on a separate sewage system ((yes:or.no�.[if yes separate inspection required] Laundry system inspected(yes or Seasonal use: (yes or no.)L-� Water meter readings, if available(last 2 years usage(gpd)): j9yo Sump pump(yes or io • Last date of occupancy:6� - COMMERCIALIINDUSTRIAL`_� Type of establishment: . Design flow(based on 310 CMR 15.203): gpd " Basis of design flow(seats/persons/sgft,ete.): _ 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: 1-j-&Ak­), Was system pumped as_p6rt of the inspection(yes or o`) If yes, volume pumped: gallons--How was quantity pumped determined? _ Reason for pumping: TYPFjOF SYSTEM eptic 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: ar Were sewage "odors detected when arriving at the site(yes or n 6 Page 7 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY"ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date o Inspect 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: Material of construction: it5oncrete_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: _�p Sludge depth: Distance from top of sludge to bottom of outlet tee.or baffle: Z-Z Scum thickness:er— Distance from top of scum to top of outlet tee or baffle: y �� Distance from bottom of scum to bottom of outlet tee or baffle: /r . How were dimensions determined; Comments(on pumping recommen ations, i let and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert:, evi' d nce of llwc" eakage,etc.): , GREASE TRAP�ocate 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: . i;:A99 Date of Inspecti TIGHT or HOLDING TANI�{.,"(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 BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: :",P11 Comments(note if box is level and distribution to ou ley equal, any evidence of solids carryover, any evidence of akage into or out of box, etc.): PUMP CHAMBER ocate 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 appurfenames,'6t:c.):' 1 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURIFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner Date of Inspe tion: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain'why: Tfpe / leaching pits,number:l 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, e .):z CESSPOOLS (cesspool must be pumped as part of inspec'tion)(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.):„ PRIV _(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 l0,of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM% FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of nspect.on: J, Qa 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 l00 feet.Locate where-public water supply enters the building. f v� o . 1 1 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �&IAN 11)VM'qAA_ Date o Inspec 'on: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water 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: hecked with.local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: /M i - -J_ Sri �° lr I o.ermi Cornple:ed by_____G/%� � !'� G O•Uf�iD `dVA:,_ L=V'EL C.OMPU i,4TION Site Location: Own er: Address-- Contractor: Note, �.:. ... 7. S.ER. 1 Measure de{?Til-It? W^cT'er iabiB ............ ._........... .gate S%=° 2 Using. -' .•�e 9 � i:R'ange Zone . and I id ix VVeib:'�z.p loci e si.te-an•d',dete-rm-'ne: A 'Ap{7fO.F7r{eLc.!nOEX W.ei'I..........._....__.._...:.................. UWa :: 6ev._. Sao ,ocre..._.........:_..-.._._ Sri , 2: USlrla•:illy:'ii:.rll•V. O.f:4: C•.l•lFreil.i ._. ..._ •.' .. _ ._ Water iesiclurcEs Conditions" 1 d'ciefmin2 CJrict:i dEpin•i'o 1�7 water• rEve1 for' nelcX wel"I ..._._ �/Ll I „J. month/year L_ S r•`• '_ Usin6. !aLAe.of Wa Te,i,�eV.?I Adj�s''men.zs . r Tor Ind'eX Well fS EP 2.^c)_curreni deptth- i• ' o waver 1svel far.i-ndex well ('STEP 3•);, and•wa:er-level zone (STD°-2B) t• 1 de ermi••ne•w.;-.L level -aadj,us•m-eat . ....................... STEP- o stima:E•cep�;, toNah water by subxractifia h.e.wa-.er• level ac}usman,'.(S:T cP 4`)- =rom measi<.red-.depth to water level-at siwe.(STEP' .^,11.^�. _ i 1`;ulv :3:'-^r1GJiw::'vv:Jl 'evil; i.):C<'i)OR IC{I: .. F r LW--13 TOWN OF BARNSTABLE LOCATION l /t��S SEWAGE # 72-yVILLAGE �/JJ�ZJN:Jo�%/�L L S ASSESSOR'S MAP�& LOOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) P27- (size) ��� j NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 Leaching Facility(If any wetlands exist within 300 feet of leachin facility) y Feet Furnished by 1-4eDAlj- 03 - 2 .j a � No...Tjr---'_3jW FIm.... ..1.0.0......Z/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABL.E Apphration for Difipwml Hlorkii Toulltrurtion rainit Application is hereby made for a Permit to Corist;•uct ( L-�or Repair ( ) an Individual Sewage Disposal System at* X 'A _Z ....1 . . ........................... La n-Add - ot No. ...... .. ........................ ..... .oCS.es _.._______.__ ._. ....................................................... wner� Address IustalIy� Address Type of Building /�J�n��^ S a� r ��C� Size Lot______S<_ 7 U yP g `� fP.� .e (� � ----�-----Sq. feet ., Dwelling—No. of Bedrooms�'�-_,�_._.._ _�_--_-_____--_-_-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building�liJ�a-___l�-:�t�_. No. of persons-_-._.-____________________ Showers ( ) — Cafeteria ( ) Other fixtures ----------------------------------•--- --...--•----• ---•---- W Design FlowC- ... gallons perpdtl Per day. Total daily flow.-. � ...... ••..............gallons. WSeptic Tank—Liquid capacity./6W�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 t k ( -) ./� . �, __ Date--- -!~--� s _L a Percolation Test Results Performed by.-.____ .' _�.__._.. Test Pit No. 1._ _ _._.minutes per inch Depth of Test Pit____________________ Depth to ground water_ 0t --. 0-4 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .................... ..... x Description of Soil........... . V ............................................-----••----•-••-•...--•-•-•--•--------••----•--••••-•-----•---------------•--•-•--...---------•-•---•---•----••-•-•••-•-•---••-••-•----•••--•-•-•------..._.- W VNature 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 /undersined further agrees not to place the system in operation until a Certificate of Com be issued bard of health. Signed ...... 1/.......... ........ Application,Approved By ................ ............................................................ -.-- DL - 5.- Application Disapproved for the following rea.ron.r- -------------------------------------------------------------------- ----------------- ---------------------.----.-.-- .................................. .. .. .... ..... ............................. ...................................................................................... ..... Permit No. ..................qO....-.....?.,.�.. -.......... Issued -------------- "...r.0...-.���j-.............. Dace CT r No.....1. ""- ✓ 9y �.;`_ Fss....... �T� 1...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirativit for Di-nVw3al Work,5 T.onstrurtion ramit Application is, hereby made for a Permit to Construct ( G. /or Repair ( ) an Individual Sewage Disposal System at• p � � �,.....--- .................... --.........,--------------------• --- ---• ----•-•---•--•---.......--•--•--...-•----•---- Lcfc�ct'Dn-:1dth e or Lot No .......... ...»:.... tZ�� ---------- •----------•------------ ..------------ 7. caner Address W / .............. ...•--•...! -1------ - ......................... .............. 1 fr Installer Address / Type of Building � � - ^�� reV Sr�� ' (� Size Lot.._'/._ ,.17 1...Sq. feet U 04 Dwelling— No. of Bedrooms.._---.- ,- .............__.------.----Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building 1W No. of persons---------------------------- Showers ( ) — Cafeteria a ( ) Other fixtures ---------------------- ------- W Desl n Flow. �`��- --------------•--•-_... •-lons. jgf U___________�______gallons per per-son per day. Total daily flow______________ _ gal 1:4 Se D sposal Trench Liquid capacity-/.- . Width Length Total Length Width .............. Total leaching area_- Depth--.....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 /. .�1------------- ---- Date...1_4 . r_�.....................�f ..... a Test Pit No. I__J._.S....minutes per Inch Depth of Test Pit._---_---____---_- Depth to ground water.. Lz. Test Pit No,,2'"7::" minutes per inch Depth of Test Pit.................... Depth to ground water........................ L�+ Descriptionof Soil.-------•---•-_) -- 1 �kk........................----------------------..........---------------- ...............................-............... U ------...... --•--------------•----� ---------- .... ------•----------------._........--------•----•-•--------------------------------....-----•......---•------------............--•----- W •-•---------------- -------------------------------------j---------''- ---------------------------0------------------------------------------------------------------------------------------ U Nature of Repairs or Alterationstt5Afiswer when applicable---------------------------------------...........................0........................... ... ------------------- ---------------------- -.......... `................................................................................................................................. Agreement: The undersigned a� ees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions'of TITL/f 5,'of the State Environmental Code—The unders�iPP.ned further agrees not to place the system in operation ntil a Certificate of Comp�'ti'arr be issued by the kard of health. Signed ----------- -- -- -----6'u----------- --"-- ------------------------ /.. /'� ....1�• i Application.Approved By ................. ^ -- ---- --------------------------------------------------- -� �_ 1.=...4:� Date Application/Disapproved for the following reasons- ------------------ --------- -------------------------- .. ................ . ........... ...... .._..........._..------------------------------------------------------------.----------------------------..._......-..--..-.-.-..---------------..------------------..._:.............. ... . -------------------------------------- Dare Permit.No. �r - .--3.�.-y........... Issued �� .-_-..�1� -�/ ................... Dace ��✓ F � '�,.�""" � `/���,6 THE COMMONWEALTH OF MASSACHUSETTS'.��i lqlq6 r it a BOARD OF HEALTH t� } TOWN OF BARNSTABLE Certifi ate of Complianre �- L �THl IS TO CERTIFY, hat the Indivi 1 Sew e isp l System constructed ( or Repaired ( ) by ---- .. . --- -------- i ' C 7� �,aide c at _................... ------------------..7 -----------...._..--...------ ---------------------.._.----------------------------------....._. .... has been installed in accordance with the provisions of TITLE 5,4 The State Environmental Code as described in the application for Disposal Works Construction Permit No. ---... .. .---3��.��.-.-__- dated Z� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-:...... Z f - 14----...---._........._---------------------- ---- Inspector ... ------.------------- -----------_...........---------.------------- __----—__.--__.————.» —— m—___——————THE COMMONWEALTH OF MASSACHUSETTS _��m��.«_�� BOARD OF HEALTH TOWN OF BARNSTABLE No.....c�.-2......5:�.�/ FEE..../eD ......... Permission * hereby granted7f ---.- _ -•-- .. � 1.. ). t to Constr/uct ( ) or Re air. ( ) an Individual Sewage Disposal System --------------------------------------------------------- Street as shown on t4apphation for Disposal Works Construction Perini No?? .:�_;___ Daxed-..._Z r ......v Board of Heatlth ✓DATE.------•---- .-- .. .--•------- ---••-•-- FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS i DEC-18-1996 07:46 FROM TO 7750155 P.01 T-)S516 N -PATa - - _'f_�I►:C-1_E FAMItY 3 8E8F°2- No &AZBA6E C910Z:)J:z -PAIL-( 1-LDw 3 1 r o -;I Sl�IC TAQY- -530 Also;", = � �iru� o►J �$ � F{pit�F 4 l�SE - I000 G�I�_ T -i-s /KIS'rIe- *-t) E D1SFj) AL ?IT,IT - uSE I01, Gam j 2 -->TbWE 51DEwd�.L A� 188 M A42 N 5 l8B SE.-A. Z•G .. Z' -00TTOM AQFA = r8 sF 16t,Fx t•o TOML IX416N S419 6fP, 7'orAt_ vA1c.Y FYI z. 33 ' I'm T%MP-OL-AT10N 2A7E,; 1"114 �{ru CLi6 E?j%k O � >� R A. L ;IVAN Rorie 29733 9 CIVIL.41 �I d 0L P 8 TF =6L V. rNv. SG. � w . °KT (14A(Au- I oop -rA N r; WIPt A. WA4We:;, SRuo STouE EL Aq.( PA?-Gr•4- -71 I o'- i. C�IFI© ?ice- PZ-4IJ Lo I rZ >�o �tIUL �1S MI�f;S� _ � Sr�I��L�- __ � -d n o cLo�t S yGQ Lam: � G6 'DATE-: 10. 1&•04 e, PLAN �ROJcrr ' 12 rg pi& 1 CQMFy 744Ji I- T �VWYATIWJ snow t� NE2EorJ c-0,vtP��YI`i l WITµ -NF 5f DEU+JE LOT -13 7bWN OF 4qr,> 15 fir.- Lo,:AT'C=D . I"II I ;E FLam �t-ell 1. PL- 3 BA XTBZ AYE INc W115 rJ 15 Nor 8a;,;I,D AN Q��SSlWAL LAVD Sopvsyorzs 1�S1�-cwtEU't' c�.i 1 L E�1Gr Nz.5 ``50''>y A►JD THE o 5 :=CS fl�� v ar Beu5c O S1�rz-v a c a MA,4 , ro EST��15N F?;�,o�E y ..�. APPLIC-4KIT, �j SIDS �Uic.r�►eJ6 �o he DEC-18-1996 08:24 FROM TO 7750155 P.01 ad V �zt• $�yS►os $v��+�� � ZorJE eF '4o Jr S 1�s AA l T 1G 10 For r 10 Aug 146 It _7ET � � `\1 10 S z � 4s,S"? I 1 � 1 I S-9 OF M o� ,.� PETER +.l r rA Qr.HARD SU a"-,MR j 1. o N0.2B?39 40 26M CIVIL � lsm i TOTAL P.01 f TDE516 N -2ATA 51,4c� FAMIL`( 3 $E�M r No l,=3AL-E GIzIIJDET� -PAIL-( FLOW 3 A 1Io - 33o GPI RrLaJ b►J txr✓DF '5EFFI C TANS 9 ISO /o= 4rIS GPa IZ 1'� Dl5PoSA LFIT - uSE I oUo GAL/z'STovic 5IDEW4LL AgeA ' 1138 SF M /2S,-ro Q S 189 2, =.'.4-io e-pp -0077oM AQ-A -1 x 1,o , :-Ia gyp, � TOTAL t>6516►J = sag 6fP, TOTAL DAILY F7 v z 330 GPD -•�� PECCMa AT1oN RATE.; t CIO MHARD PETEFI A. '� .:,.SULLIYAN rtn i a aeA24ER NO.K.133 vo �ae �a CIVIL . sr Pia =(oI rF =�2 ooc) wv. Sol GAL • vKT w�• •IG nV� 100o t�,�: �wvgtK %,;I � SE�1IC 5&8 T�•1- LEA} TA N r: w►il Z A3 - VZ WMFIFp Saco sTot1E EL=d�j.� /�Gf>E�J�S IU�p "lei I�Ar�LEL l�- 1 Cerzrlf:�IED PLOT Fa1J �vE1np� 'P�aF1 L.�-- t 45 SGA SD DAT1=; I o- I Co-g L ful S� llx PLAN V-a� rzoic - I CEXtI'FY 1- dT T4G- 5 v'A'-lATlVQ 'kcN,1j kpzeooj 4 �o/�M••'P�LJ� w1TA -cats 51PEUQF LOT "13 I � t- 'ZEQ, CT ,T1c- TDWN of A�tD IS Ian; L-o4A-f� It1lI T1I� 1 tao� pcnlc.l . �� K- Zo"', �� 53 Tr)4-rz— r� a.1/Z— �3d XT�z NYE INC. p2aFr--`i510QAL LAu"D SueVE%loL5 -[TIK FL<.►J IS Or T3AI;,© C3,J hN 6k�I L � 2Q(;I N E.EL5 urz, c-j AIJD 17NE oF5ET"S 44ou x, Our 'aE 0 >TErzvILLG MA/5.4 . u��cn T'o ESTQEL15N Rzo'PEizTy la Qe5 _ dPPLIc.AI.T ; �jA SIDti- F$Ui(-0046 � �1G k� ���- Spy id • �L • alL -F �o l�� I►� MAP 1q PGA AA I i4, i10 Rl 10 v¢�5sn� i I �(� i -74 54 (J dcP � \I � I I S z , 4S,r-)1 � � IIS•Q� I I ., OF AAA- VET OF im. gcre,nRnNo.°,-733 CIVIL �