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HomeMy WebLinkAbout0063 MOCO ROAD - Health 63 Moco Road W. Barnstable P A = 215 005 ,. - .. _, ...� {/� { -*-- .. •- c+ .. a ... .._.. .w J v� • !. ^ . Commonwealth of Massachusetts . s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63 Moco Road ` Property Address . Michael Davidson Owner Owner's Name information is required for eve W Barristable Ma. 02668 12/16/13 ry; page. City/Town: State Zip Code Date of Inspection Inspection results must be submitted 4n this form. Inspection forms may not be altered in any way. Please see completeness.checklist at the tend.of the form. Important:When filling out forms A. General Information on the computer, use only the tab - 1. Inspector: key to move your cursor-do not .. RickyWright. Wri use the return: key. - Name of Inspector B&B Excavation reb Company Name 14 Teaberry Lane Company Address Sandwich Ma.:. 02644 City/Town State Zip Code (508)477-0653 S14595 Telephone Number License Number z3 q. z B. Certification certify that I have personally inspected the sewage disposal system at this address and that the inf was performed based on my training and experience in the proper function and maintenance a on-§it ion reportedPinspection. � of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15 340" f Title 5(310 CMR 15000). The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority 12/16/13 Inspector's Signature Date The system inspector shall submit.a:copy of this inspection report to the Approving Authority(Board of Health or:DEP)within 30 days of completing this inspection. If the system is a shared system or has a desigh.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. 1. -- I t5ins•3/1& Title 5 Official Inspection or :Subsurface Sewage Disposal System'•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town 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: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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): ❑ 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): 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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. ❑ 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 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 1h day flow l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 63 Moco Road Property Address:. Michael Davidson Owner: Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. ... : City/Town State Zip Code Date ofTnspection 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 El Z 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 ystem'obtained and examined?(If they were not ® available note as N/A) ® ❑ Was the.facility or dwelling inspected for signs of sewage back up? M El Was the site inspected for signs of break out? ® ❑. . Were all system components, excluding the SAS, located on site?. ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ... Was the facility owner(and occupants if different from owner) provided with ❑ ❑ information on the proper maintenance of subsurface sewage disposal.systems? The size and location of the Soil.Absorption System (SAS) on.the site has. been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to.Part C is at issue ® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System.Information Residential.Flow Conditions: Number of bedrooms (design):,, (actual): Number:of bedrooms actual. :: 3 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 220 t5ins•3713 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Moco Road M Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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 M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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: Tank and d-box installed in 2006,pit appears to be original. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 8"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: 1500 gal. Sludge depth: no sludge t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is W required for every Barnstable Ma. 02668 12/16/13 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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•3/13 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 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town 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.): At time of inspection d-box appears to in working order no sign of deteration, or carryover. 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.): * 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): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): At time of inspection leaching appears to in working order no sign of hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface S Sewage Disposal stem•Page 13 of 17 � ' Y Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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 C A 00 ® Al tot Al - I�' f3 2- A3 - 21° 83 - 35' A 4 - 25' cq - , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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: >20feet 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: abbutting lot drops over 20'within150' 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 I , Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Moco Road Property Address Michael Davidson Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � TOWN OF BARNSTABLE F,W� -, �� rn o r�C/1 SEWAGE# 6IO VILLAGE 40 BCZ% �= ASSESSOR'S MAP&PARCEL 9� /5 00 5 INSTALLERS NAME&PHONE NO. Pd-DIIt�►t SEPTIC TANK CAPACITY J S®® G 1Ihf1 Ile-O LEACHING FACILITY:(type) im, off �/�� (size) NO. OF BEDROOMS OWNER // 1I(°m 1 I1NIG� iOI� PERMIT DATE: 57-7"do COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(I.f 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 leaching facility) Feet FURNISHED BY AWO i 0 i i a?S- al 0 3 4000 No. Fee M 9THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Vle, application for Big oal 61)5tem Cowgtruction Vermtt Application for a Permit to Construct( ) Repair( ,n Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Addre s r'Lo 0. (03 mom �o- f' Owner's Name,Ad ress,and Tel.No. 6Lc.. M 1 c hc�ve� 'D owr'�Sor Assessor's Map/Parcel a.irej S t _5 CZ V-j `a W--A JVV'�� ` Installer's Name,Address,and Tel.No.. ��CA lDesigner's Name,Address and Tel.No. ��" To �)ox utp t,So�19�5 33�°6 &Y1yAAi-11Lg Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. kq)QD L-T Description of Soil Nature of Re airs or Alterations(Answer when applicable) o Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the#vironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thi rd f alth. Sign ® Date Application Approved by Date Aar Application Disapproved by: Date for the following reasons Permit No. Date Issued No.. F� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for 33iooza'Y,�§p.5tem Construction Permit Application for a Permit'to Construct l( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System Dl4ndividual Components r Location Addre s r Lo o. (p j }�+9 Owner's Name,Add¢ress,and Tel.No. CA)O k-,k ID ow,t�)9 h Assessor's Ma /Parcell � i° " d �� Installer's Name,Address,and Tel.No..) xylo m rr� � designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( )~ Other Fixtures iz Design Flow(min.required) gpd Design flow provided gpd ,c Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. kc)C,.o L? Description of Soil ' Nature of Repairs or Alterations(Answer when applicable) C t In C, t k I t—l-, r A ro a) e, oA 1) ' ,b��-,� ��t k 715 la x T Date last inspected: Agreement: Yft y The undersigned agrees to ensure the construction and maintenance.of th afore describe d/on site sewage disposal system in accordance with the provisions of Title 5 of the vironmental Code and not to place the system In operation until a Certificate of Compliance has been issued by,this-Board of eaIth. Sign�d� � �/ �/ 6GiiJ �'i 11 a Date -7 �n Application Approved by // -�.:rd i �.�1 Date t Date Application Disapproved by: - _. -.___,_.__for the followng,reasons..:._ .__-- �----T•---- / _._ _,.- ..�. _...:_ _. _ Permit No. c Date Issued - THE COMMONWEALTH OF MASSACHUSETTS C,13 BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site S wage Disposal`System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by at G:� n non VU _,_.)oy y'r --1 11 t ., 01(_1• , has been constructed in ccordance with the previsions of Title 5 and the for Disposal System Construction Permit No. .. dated Installer G)b4,1 l I n Designer In bedrooms Approved design flow gpd t'The issuance of this permit,shail not be construed as a guarantee that the system will function"as designe N d. Date ` Inspector `�` 44 ��----- No. l,�`! � — —————— Fee — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS j lwi!gpont *pztem Construction Vernut Permission is hereby granted to Construct ( ) Repair (X ) 1_Upgrade ( ) Abandon ( ) System located at (P3 \1 0 C10 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. t- Provided: Construction mtlst be completed within three years of the date of t,i;permR Date / Approved by / r COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.. i DEPARTMENT OF ENVIRONMENTAL PROTECTION. a TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SY TEREFO ED PART A CERTIFICATION JUN 14 2002 Property Address:. TOWN OF BARNSTABLE HEALTH DEPT. Owner's Name: T Owner's Address: Date of Inspection: r a Name of Inspec or please p int). ��'' f � MAP Company Name > PARCEL Mailing Address: -C3- 0 C/ LOT �. ..:.. Telephone Number: CERTIFICATION STATEMENT. I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. L am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR I5.000). The system: Passes Conditionally Passes Needs.Further Evaluation by the Local Approving Authority. / ails Inspector's Signature: / Date: Q 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 oftlm 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 i f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address' Date of Inspection: Inspection Summary: Check A;B,C,D or E!ALWAYS complete all of Section D A. System Passes: I-have.not found any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.,.,System-Conditional) Passes: One or-more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank.is replaced with a..complying septic tank as*approved by the Board of Health. *A metal septic tank will pass inspection.if itjs.structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will:pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or.replaced ND explain: Thesystem.required pumping more than 4 times a year due to broken or obstructed pipe(s).The systern will pass inspection if(with approval of the Board of Health):. broken.pipe(s)are replaced obstruction.is removed ND explain: 2 f Page 3 of l'l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued). Property Address: & 7.0 Njo Owner Date of Inspection: rr.;. QC1,;)— C. Further Evaluation is Required by the Board of Health: Conditions.exist which require further,evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment.. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which.will protect public health,safety and the environment: _ Cesspool,or privy is within 50 feet.of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a.manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has.a septic tank and SAS and the SAS.is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and.SAS and the.SAS.is less than 100.,feet but.50.feet or more from a private water supply well"..Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A,copy of the analysis must be attached to this form:. 3. Other: 3 Page 4 of l l OFFICIAL,INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: l Q4 Owner' l Date of Inspection: c�a A 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 d overloaded Qo q due to an o erloaded or clo ed SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow _ Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. / Any;portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone l of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of cesspool or.privy is less than T00 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 jare triggered.A copy of the analysis must be attached to this form.] (Yes/No)The systenrfails. 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 of10,000,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 _ 1 Page 5 of 1.1 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM ART B CHECKLIST Property Address: Owner: t. Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to.each of the following: Yes No AZ_ Pumping.•information was provided by the owner, occupant,or Board of Health, L/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? i,/,_ 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 1✓ _ 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 1✓ 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 _LZ Existing information.For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C.is at issue approximation of distance. is unacceptable) [310 CMR 15.302(3)(b)]. 5 . - Page 6 of 1 I OFFICIALINSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTI.ON FORM PART C - SYSTEM INFORMATION Property Address:Ce Owner Date of Inspection:lwak / _ FLOW CONDITIONS RESIDENTIAL 1/ Number of bed}rooms(:design): Number of.bedrooms(actual): DESIGN flow based on 310 CIv1R 15.203(far example: ]]:0 gpd 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 p if yes separate inspection required] Laundry system inspected (yes or no Seasonal use: (yes or no): Water meter readings, 1 a e(last 2 years,usage(gpd)): _AA ��(�✓r� Sump pump(yes or no Last date of occupancy /2 , COMMERCIAL/INDUSTRIAL /&— Type of establishment: Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats%persons/sgft,etc.): : . . Grease trap present(yes or no): Industrial waste.holding tank present(yes o-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 l� Source of information:®— Was system.pumped as part of the inspection(yes or no):, x�7e If yes, volume pumped: gallons--How was quantity pumped determined? Reason for,pumping: . TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool _:Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) . Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copyof the DER approval _-ZOther'(describe): A ximate age of all components,date-'installed(if known)and source of information: Were_sewage odors detected when arriving at the site(yes-or no): b Page 7 of I 1 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C s SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate.on site plant' Depth below grade: Materials of.construction:_cast iron 40 PVC_other(explain):- Distance from private water supply well or suction liner Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANKAliocate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a.copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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.): 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 11 OFFICIAL I.NSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: cp 11W Owner:, Date of Inspection: . t j TIGHT or HOLDING TAN 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 lastppmping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX- 4e&{if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): PUMP CHAMBER locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ✓t-!� Owner: -17 Date of Inspection: SOIL ABSORPTION.SYSTEM (SAS):. /(locate on site plan,excavation not required) If SAS not located explain why: Type _/leaching.pits,number: leaching chambers,number: leaching galleries,number: leaching,trenches,number, length: leaching fields,number,dimensions: overflow cesspool;number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, C�W o- r . r CESSPOOLS: i/ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 — `,zzx 7��s_ 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): Aimments(note condition of soil,signs of hydraulic failure, level of ponding,co dition of vegetation,etc.): J PRI)(I>. /( cate 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 l 0'of 11 OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address:6e dj+cm woeztel Owner: Date of Inspection: SKETCH OF SEWAGE DI8POSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. .60 � a Pei . 10 . Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Ca(S 1_/ Owner: %C;?7(- Date of Inspection: 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: Checked with local excavators, installers-(attach documentation) Accessed U.SGS database-explain: You must describe how you established the high ground water elevation:1® � , / x eo 11 Permit Number: Date: Completed by:. HIGH GROUND-WATER LEVEL COMPUTATION Site Location.: _�/ ✓ /��G`D � � /�l ,��f'�uc�j�� Lot Mo.. Owner:- Address: Contractor: Address: Notes:. STEP. 1 Measure depth.to water table to nearest.1./10:'t...... .... '............ .Date month/day/year STEP 2 Using.Water-Level.Range Zone . and Index We11::M:a.p:locate site anal determine: Appro.priate.index well......................... soy zz OWater-level range zone..........:.. Using•month y.repo.rt;•"Curren-t Water Resources Conditions" determine current depth-to water level for index wel-1 ............................ Month/year • I STEP. 4.. Using.Table.of.Water;levrel Adjustments for index well (STEP'2A:),..current depth' to water level fora index wel.l (STEP 3}, and water-level zone (STEP'2B) determine water-level adjustment ................. ........................................ STEP:, 5 stimate depth to:high water by subtracting the-water- level adjustment.(STEP 4) from measured.depth to.water level-at site.(ST_P 1)............. ................................. _............. ._.............. Ci J !v' i�171(LUL li i Irii I.II: 'TOt 100 ��T�x✓l�'�ii6'��� f Y ' jfr Y. TOWN OF BARNSTABLE M LOCA'!1(ON_ aj , SEWAGE # VILLAGE — - ASSESSOR'S MAP Sz LOT,4L � INSTALLER'S NAME 6i PHONE NO. ��p��,-1�( SEPTIC TANK CAPACITY LEACHING FACILITY:(type) r .(size)r ,, to NO. OF BEDROOMS RIVATE WE OR PUBLIC WATER BUILDER DATE PERMIT ISSUED: "- DATE COMPLIANCE ISSUED: Ag�,� vgq,-n VARIANCE GRANTED: Yes No 1 o P S - J THE COMMONWEALTH OF MASSACHUSETTS 3 C APPROVED BOARD OF HEALTH 8omWab1e CancorvCjjn ent TOWN OF BA R N STA B LE i �� nr K1iri vii al Wor1w Toustrur#iun amit sis ONO Application is hereby made for a Permit to Construct ( ) or Repair (>- an Individual Sewage Disposal System at: ........ e?26�V rJ ................... Coca ion-Address or Lot No. ......................_. `�-----------•------------- -----....... -- .........: D...........1 ..-...�%5.Z1W.... o,c cr Address aU��IOLU» �e;. � - G� eG' ice ... ........ -• •............... ............................................... Installer Address UType of Building Size Lot............................Sq. feet ,.. Dwelling—No, of Bedrooms................................._----------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -.----_-_-__--------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------------------------- Q ....................................................... - -•-•.....•........................ W Design Flow................. ..............gallons per person per day. Total daily flow..........` `. _�,................-..:__gallons. WSeptic Tank—Liquid capacity/4�.�__gallons Length................ Width__.-__-_-___-- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No----------/....... Diameter......lf_ ...._. Depth below inlet.... ........ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - Percolation Test Results Performed by..---------P-----------•---•---•••-•......-•---••-••-•......•-- •--•-- �te...•---•--------------•••••............ 0.4 Test Pit No. I.............. minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit._-__-__--____•-_. Depth to ground water........................ �+ ----•---•--------------------------•------------------------------..................y--•---••--•--•.....j......_......- ••-•.............-•••--••....•. 0 Description of Soil-----.••....® ......�f. Y►!4 .._ U _t_SQLL �-- -•-�-��...----- `^lp SP...@Pl /aUT U ......... a`.!..............as rU--•--•-----------• •--•-...--•.................. W -•--•••-••-••...................................•-----•--•------...----•-........_.....-------•---- ----------------------------------- -•--•--•---• ..................... ---------..... x Nature of Repairs or Alterations—Answer when applicable......... ..:... U P _ �- 1�- j QuU • ---• a` �T ._...__ `^?ld!�J -... `1� t�.. ��uGr.......J'4o'- .......................•--••-•--- Agreement-. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system In operation until a Certificate of Com N.a.n.L/ Signed ........ as be n is u b y t oa rd of he lth. .... .��...................... ... Dace Application Approved By ........ n�. ]..�.................... .............................................. ....4 j-^.Date .J. Application Disapproved for the following reasons: .... .......................... ................ ..................... .................................... ...................................................................... . ....................... ..................... . ...................................................................... . ................................... Dare Permit No. ------7..3..........a;i,2.?,, ........... Issued .............................................................. Dace ...... r. l �, ,.+e�,7�.-rs, ^:a.trJa++F e+v.irroet%+. pro ��fit:.' tti l+wwl�rY►+v +✓C 1.�do/.- �7-Srt.N:Fu7:r&rsatlZ4 f"S'.'.+L~ S.a.?'•'t�%.r!'�'2 ti�•a•LLL.,.)� +3,a,J~t,�.*•st,..�+'�lYr�.3..�:Yri'Tt NO...y! -... S' Fps...`36..... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ........6� r/?'?� C U f•lF .Q lAj . ��laa I1S7/34?1 --------------••. . --•-••• -- ..._...._ ��_ Location-Address ` or Lot No. ......................C'...'.1• /1 - /'°'�------------------•--.-�--`-3 s/1�0 ---.....1.-.C..ldl ........... 1= %lit lsi: owner Address ................. ... Installer Address UType of Building Size Lot............................Sq. feet 1--1 Dwelling— No. of Bedrooms.................... .................Ufa.___.--_--__._--_.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.-.-_------_-----_---.--_- Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------•.----------...------....---------- ---•---------- W Design Flow.................,`?._ _.___....______.gallons per person per day. Total daily flow............ `3.`....d..............._....gallons. Septic Tank—Liquid capacity/P _.gallons Length---------------- Width---------------- Diameter................ Depth................ W Disposal Trench--No. .................... Width.................... .Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No----------/....... Diameter------zQ........ Depth below inlet..... ........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1-" Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 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........................ a --•-••••••---•................•--•-•-----••---••-------------••--•-•------•-.........•--•---_-•---••-___.....••••--•--...-•---._........0.......•-•-....... 0 Description of Soil............. ----- _..---.. �` ... `� 7`��........................ V ........''%:..!..:`.........��...�_� ....---•---•--••-•-•-----------••-•. W V Nature of Repairs or Alterations—Answer when applicable.-------. ---------ZO'k)_n_4-�... t1.-,0) ..__._l-G_1 - Agreement: ` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued issuaied by the.board of health. Signed ...........�: f ......... 6�i ..... 9.-�... ... Dare Application Approved By .... ( .... ��`^..D,oe�.-../... 3 �„��,,, ....... Application Disapproved for the following reasons: ................................................................................................. ................................... ......................................................... . ... ..... ........................................................................................ .......... ............................ ......... Dare Dare Permit No. ------7-3---- �-...Z!>.,1............. Issued .._..---............................................... ............ _--_..___._— _..__—,_.___,_.______-- ________—_.___..--,._r.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fer#ifirate of N"Lloraylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by -- ------------------ ------ ---------------------------------'-'� ........... ..........-------------........... 7� ...................................................................................... Insraller 7 ��`� � at ........................................................................... 2 3.... ...... ?.OG............u.. L4(�--------- ,. ......................................4- :_.... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...f�"�...-_.�,. ...5.:..... dated ..... ....................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. I/ a JJ/f/JJ//J1 -DATE_..........._.. .._..........._....11)�.�f ../ ................ Inspector .............. �! � .....V.. ;....... ;........,....,......,.._.....__._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No._.l .'.. .5...... FEE....`-�.�...�..... Permission is hereby granted..................................../�c.,/L--f�CU�7-------L'lJ\f---� ----�'r/� to Construct ( ) or Repair (^�•)-an Individual Sewage Disposal System at No. C" !�7 a c' � ( - --------------------- L ----•------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No.YO3 -Z S-Dated.......................................... DATE.................. --�---�............................• Board of Health 3`-- -"--�'�- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS .i