HomeMy WebLinkAbout0133 MAIN ST./RTE 6A(W.BARN.) - Health 133 MAIN STREET, W. BARNSTABLE
A= 111 007 -
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments
133 Main Street -
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for west Barnstable MA 02668 July 3, 2012
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` A. General Information
When filling out
forms on the
computer,use 1. Inspector:only the tab key
to move your Patrick M. O'Connell
61
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
r� .189 Cammett Road
Company Address
Marstons Mills MA 02648
Cityrrown State Zip Code
508-428-1779 S1 12855
..Telephone Number.. License Number
- z —$
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 ❑ Faifs
❑ Needs Further Evaluation by the Local Approving Authority
July 3, 2012 Job# 12-102
In ector's ignature 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.
&,s o
t5ins•11110 Titl�50ffi on Form;Subsurface Sewage Di sal System•Page 1 of 17
Commonwealth & Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. Citylrown 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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank was not in need of pumping at time of inspection, leaching pit was half full with no signs of
surcharge.
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 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. CityTTown State Zip Code Date of Inspection
B. Certification (cont.)
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):
❑ 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) are replaced ❑ Y , ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
I
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main'Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. CityrTown 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.6'septic tank and SAS and the SAS is within a Zone i 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 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:
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
t5ins•11/10 Title 5 Official Inspection Form: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
wM 133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for West Barnstable MA 02668 July 3, 2012
every page. City/Town 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 pr rtion 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 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
El ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is 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.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for West Barnstable MA 02668 July 3, 2012
every page. Cityrrown 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 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
El
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
f
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
1
Number of current residents:
Does residence have a garbage grinder? ❑ 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
N/A Well Water
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Currently
Last date of occupancy: Occupied.
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? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for West Barnstable MA 02668 July 3, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
t
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) 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):
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Compliance date: 8/5/94
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'
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):
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 certificate) ❑ Yes ❑ No
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
2"
Sludge depth:
t5ins•11110 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
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. City/Town 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
28"
Trace
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
Measured
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert and tees were intact.
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-11l10 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
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for West Barnstable MA 02668 July 3, 2012
every page. Cityrrown 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
15ins•11/10 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
w 133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for West Barnstable MA 02668 July 3, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
No solids or high stains present.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
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:
,
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for West Barnstable MA 02668 July 3, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: One 6x6 pit
❑ 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.):
Liquid level was at 50% capacity with no definite sidewall stains and no evidence of surcharge.
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
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is required for west Barnstable MA 02668 July 3, 2012
every page. City/Town 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.):
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.):
15ins-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street ...-..-.....--..................
--— ------- ----------..—----
Property Address
Pamela Rhodes —
Owner Owner's Name
information is West Barnstable MA 02668 July 3 2012
required for
State Zip Code Date of Inspection
every page. CitylTown
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
3
2
36
57 3
Appro . location
of well 100'
+from pit \',','\r\;•. / ; . . , \ ♦ , \ . .
;,. ♦ \J+r r , r , , , /
Welil Line
Route 6A
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3, 2012
required for
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cone.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
15+
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Elevation of marsh on opposite side of road is considerably lower than SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wM 133 Main Street
Property Address
Pamela Rhodes
Owner Owner's Name
information is West Barnstable MA 02668 July 3 2012
required for
State Zip Code Date of Inspection
every page. City/Town
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
l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
C� TOWN OF Bt;RNSTABLE
LOCATIONnLR P i aUA SEWAGE #
VILLAGE Q y, ASSESSOR'S MAP & LOT `�� �
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /600 L-o
LEACHING FACILITY:(type) ?z (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BAR-0R K-fC
DATE PERMIT ISSUED: �✓ L _
DATE COMPLIANCE ISSUED: - �!
VARIANCE GRANTED: Yes No
1
J �� —.
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4 t,:� ���e��l
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P M
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativlt for Diripuual Works Tomitrurtiun 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
.o �Dq-
...1..3 . �... � �s °......_. L--- ------------••-----•--...---•-----•-------------•--•.....
...............................
....
...........
........................... ----- ...._ ....A...._ ..
Owner A flress
a 't � .t ` lam ill . -- 1� ? ................................�
,.
Installer Address
Q Type of Building Size ...Sq. feet
U Dwelling No. of Bedrooms.............................. . . E� ansion Attic Garbage Grinder
aOther—Type of Building _---------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
0.4 Other fixtures ------------------------------- - -
W Design Flow............5-,5_____-_--._ gallons per person er day, Total daily flow.......... ®..................gallons.
WSeptic Tank—Liquid capacit gallons Length_-_ /.: Width._:`) ... Diameter_.............. Depth................
x Disposal Trench—. o. .................... Width.................... Total Length----- ,-,__ Total leaching area..._...._...... sq. ft.
Seepage Pit No------/............ Diameter------�-.-.-.--. Depth below inlet..S�_! J.._... Total leaching area:r�?....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
.4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.....:1'--------
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Ix --•------------------------•----._....._..-•---•----------••---...-•------------........-----.---•--.................................
....
....................
ODescription of Soil...........................................................................................................................................-.............................
V ..................................•-•-•--•.....----....---••...--•••-••-�z-------••-•----•-•----.---.-----------------•-•----_--------•-•------------------------•-• f---•----------
.......... . �"���
U Nature of Re a'rs or Al rations—Answer whe ap livable _ Lvl�l.) �� � p
J
r m r.g ee n e
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 Si Compliance has been issued by the board of health. f Z nG�
g 0 Da 7
ApplicationApproved B ................ - ---- ��............................................................ �... .----- f
Dace
Application Disapproved for the following reasons: ...................................... .............................................................................................
...............................• ...... ........................................
Permit No. .... '......--...7.... ............... Issued ..............O�... ....:.. ......
Dare
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No. � �kdd ...........1�.......�.�...
• d
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEAL)TH
TOWN OF BARNSTABLE
Ap liration for Diripaiia1l Works C ontitrurtion Ilrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (4 a' n Individual Sewage Disposal
System at:
33.2.—...64-------w-------A _►. )�T 1_a=t ------------------ ........-----
L cation-Address or Lot No.
. ?°v c �f ! vv�.. 137.. /mil 6 4 t,_v l f . T .........r......... ......... __...._. ...._._._......._...... ._____•_..........--------- ----._-....
ow", Ass
a �_��2 t.►!-aiw` .f7: k-r t� -�VfE y' / -C' l �'-�'?'`{-----�.__pY ?^_D..�.c.lf......_..
Installer Address //�� L
Type of Building ' Size Lot_!_. 7.. ...Sq. feet
,., Dwelling— No. of Bedrooms._..................................__.__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures --------------------------------
W Design Flow.............^�1 `,,,,a._......................gallons per person er day. Total daily flow.......... .�.0...._............gallons.
9 Septic Tank—Liquid capacity/O gallons Length_..�!._�____ Width..rO___ Diameter________________ Depth................
W Disposal Trench—No_ ____________________ Width.................... Total Length............. Total leaching area....................sq. ft.
x
Seepage Pit No....__.........-_-___ Diameter------ .......... Depth below inlet_&��...... Total leaching area-5... ....sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date....................r..................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZq Test Pit No. 2................minutes per inch Depth of Test Pit-_-_____-...____.__- Depth to ground Water........................
-
0 Description of Soil........................................................................................................................................................................
x
U --------------------------------•-••--....------------------•----------------------••--•-••-•-•----------•--•---•---------•----•--------•---------------•--------•-••---...........--•-••---------•--...
w -------------------------- ................................................................ . . ----
CE"
U f Repairs or Alterations—Answer whenap livable. L�4C_ ._ /. .------C'' �'1y �UvL
Nature o
ee e gr m nt:
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 been issued by the board of health.
,Q.. z�..
Signed - ..:..................................... .....U.............. .........
- :<
. _
Application Approved BY -- '�� ------ .................................... -----------------
Application Disapproved for the following reasons: .. ............... ............... .........:.........................................................-.. ------------------
................................. ........................................
Q /� � Dare
Permit No. ...../... r...7...- ............... Issued .............. ////
.. .�.`7..........
Dare
-7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certtfirate of (fomlaItttnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ...... �..C... ......m
��" .............__ .._.............. ... ...................................... ........
at _ ... - .... .. ...._w ..._..... �..p .w.. ...�..X...►..�.a...�..1�.. -----------------------------------------------------.----------------------------
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. V1. --- _ dated ..- ��-'. c""C�_I
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
G
DATE------.................... ..-... .... )--- .. ............... Inspector ............................ ' - `"
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...... ,
.. -
FEE........................
Uispillsal ► orkq Tomitrudivit ranfit
Permission is hereby granted...--- .- .l. a- kr—S" 1"I ........
to Construct ) or Repair ( ) an Indi .irlual SP-wage DisposalvS,yste,�
Street
as shown on the application for Disposal Works Construction Permit r��'.� ated.�%-........ 7
----..............--
ZV
u -•-•-----•---•-•--•--;
Board of Health
DATE--.........[-a---.�........-�•------;-------------------------------•---
FORM 36508 HOBBS B WARREN.INC..PUBLISHERS
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 .John Septic
t
' D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD C15084Govemor
ARGEO PAUL CELLUCCI
Lt.GovemorSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART A
CERTIFICATIONProperty Address: 133 Rt.6A Main St.West Barnstable Address of Owner:Date of Inspection: 3/17198 (If different)Name of Inspector: John Graci Burke
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)Company Name,Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria defined InTRIe V
code 310 CMR 16.303.My findings are of how the system is
_ Condition ly P ses performing at the time of the Inspection.My Inspection does
_ Needs F the valuation By the Local Approving Authority not Imply any warranty or guarantee o►the longevity ofthe
Fells septic system and any of Its components userul life.
- q i
Inspector's Signature.. 9� Date: 3117198
The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:.
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not..
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Colhpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-, or.
the septic tank,whether or not metal;=is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 0412797)
One Winter Street • Boston,Massachusetts 021108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 733 RL 8A Main St.West Bamstable
Owner: Burke
Date of Inspection:3117199
_ Sewage backup or.hreakout or high.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four 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
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 the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersuppiy well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
— I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an 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
cesspool.
— SAS is in hydraulic failure.
(revised 6MV97)
' r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 133 RL GA Main SL West Barnstable
Owner: Burke
Date of Inspection:3117199
D]SYSTEM FAILS(continued)
Yes No
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.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04J27)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 133 RL GA Main SL West Barnstable
Owner: Burke
Date of Inspection:3117199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
X — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
—X_ The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any failure criteria related to Part C is at issue,,approximation of distance is
— — unacceptable)]15.302(3)(b)]
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 133 RL GA Main St.west Barnstable
Owner: Burke
Date of Inspection:3117198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 2w g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy: We
COMMERCIAL/INDLISTRIAL:
Type of establishment: n/a
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) Ne
Water meter readings,if available: nie
Last date of occupancy: We
OTHER:(Describe) roe
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection: (yes or no),-
If yes,volume pumped:` gallons
Reason for pumping:C°.7.='
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(if known)and source Information:
46 year
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04/27)97)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 133 RL GA Main St.West Barnstable
Owner: Burke
Date of Inspection:3117199
SEPTIC TANK: x
(locate on site plan)
1
Depth below grade: t'
Material of construction:x con create metal_FRP Polyethylene—other(explain)
If tank is metal, list age nie . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L816"H67"W4'10"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle:24"
Scum thickness:6"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 13"
How dimensions were determined: measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and ell components are structurally Bound and IUnctloning property.Recommend pumping every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_m eta l_FRP_Polyethylene_other(explain)
Dimensions: rya
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:We
Date of last pumping;d.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on srte plan)
Depth below grade: iv
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line9or from well
Diameter: 4"
qamments:(conditions of joints,venting,evidence of leakage, etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 133 RL 6A Main SL west Barnstable
Owner: Burke
Date of Inspection:3117199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rva
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Na
Capacity: rda gallons
Design flow: rda —gallons/day
Alarm level:-.Na Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_vea
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
III
(revlaad 04717)97)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 133 RL BA Main St.West Barnstable
Owner: Burke
Date of Inspection:3117199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-inirusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits,number: one 1PW gallon leach pit
leaching chambers, number:Na
leaching galleries,number: We
leaching trenches,number,length: n1a
leaching fields,number,dimensions:n1a
overflow cesspool,number:n1a
Alternate system: we Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all components are structurally sound and functioning property.Leach pit had 1'of water in iL
CESSPOOLS:
(locate on site plan)
Number and configuration:, We,
Depth-top of liquid to inlet invert: nra
Depth of solids layer: n1a
Depth of scum layer: Na
Dimensions of cesspool: nla
Materials of construction: n1a
Indication of groundwater: We
inflow(cesspool must be pumped as part of inspection)
nfa
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
rYa
PRIVY:
(locate on site plan)
Materials of construction: Na Dimensions: n1e
Depth of solids: rda
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
n1a
(revised 0427187)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
133 RL 8A Main 8L West Barnstable
Burke
3117198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
DA
C
�g 3oL
� 37
BC 3�
5
(revised04127197) Page t of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
133 Rt GA Main St.West Barnstable
Burke
3117199
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
(rev1sed04)27197) page 10 0[ 30
I
No.-W tt'--Y-2 Fee--�L ---------
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZipplitationArVell Begtruction Permit
Application i her by made for a permit to destruct an Individual Well at:
Location — Address Assessors Map and Parcel
Owner Address
Installer — Driller Address
Type of Building
Dwelling----- ----------------------------------------
Other - Type of Building--------------- - No. of Persons----------------------------------
�
Type of Well-- -�1-__�--- ------=----- Capacity----------------------------------__--_____
Agreement:
The undersigned agrees to destruct the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation.
Signed—A&Vrno"
— ------_ �
date
Application Approved By
date
Application Disapproved for the following reasons:----------- ----------- - --- —----
-----------__---date
Permit No.— -__ - �_—_ —_-___- Issued date
I
BOARD OF HEALTH
TOWS[ OF BARNSTABLE
Certificate Of (Compliance
THIS IS TO CERTIFY, That the Individual Well destructed by— h�`� � Installer
at . . �. . . . . . . . �'. . . .W. . . - �'� . . . . . r' v l . . . / .' . . . . . . . . .
? has been destructed in accordance with the provision's,of.the Town of Barnstable Board of Health as described in
W the application for Well Destruction Permit No.. . . .W.?-y . -y,7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . .
has been destructed in accordance with the the provisions of the Town of Barnstable Board of Health as described in the application
for Well Destruction Permit No. .. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . .
DATE-- ---__—------------ Inspector--------------------_�
Lj
No. �---1 t-�_-- --7 Fee-- �S
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*r Verl MOtruction hermit
Application i hereby made for a permit to destruct an Individual Well at:
Location — Address Assessors Map and Parcel
—.(a Ems, —_—_— --��3 j?--k 1L (0 1_^k Addressr Owner -
Installer — Driller Address
Type of Building
Dwelling--- ---—- —---
Other - Type of Building--------- No. of Persons----- —
p1�6 ;�_
Type of Well---� -- ------- Capacity------------_—__________ _
Agreement:
The undersigned agrees to destruct the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation.
Signed— /L ' � �l�{
date
Application Approved By ------------ ----- -
date
Application Disapproved for the following reasons: -- —- ------ ---
---------- q—� date
—,— ------------ --------------------------------�.—._.—_____.._._ —
Permit No.-- 1 L — — Issued
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
J-
THIS IS TO CERTIFY, That the Individual Well destructed by--rnY!_ !
_ . . . . . . t.n . . . . .lb !a�` !1!"� `In�t .r . .v .`. 5 at . . .�. . . . a W- Vj!� -' S . . . . . . . . . .
has been destructed in accordance with the provisions of the Town of Barnstable Board of Health as described in
the application for Well Destruction Permit No.. . . V?y . . . 7. . . . . . . . . . . . . . . . . ... . . . . . . . . ... . . ... . .
at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . .. .. .. .. . .. .. .
has been destructed in accordance with the the provisions of the Town of Barnstable Board of Health as described in the application
for Well Destruction Permit No. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . ... . . .. ..
DATE-----_----_------- Inspector--
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yell Botruction Permit
Fee--
Permission is hereby granted---- u — -�- `! ------ !L '�{ —v=--
to destruct an Individual Well at No.----/=L?--------- - ---�Q ----- -=------ = -S 4 R ��R
Street
as shown on the application for a Well Destruction Permit
No.--_— �__t" _7—� --- — — Dated- -------�=
rd of Health
DATE__:__------- _ -� ___--------____
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BACKHOE
SERVICE
413A ROUTE 6A
EAST SANDWICH, MA 02537
(508) 888-4875
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