HomeMy WebLinkAbout0051 MORGAN WAY - Health 51 :Morgan Way
W. Barnstable P
A = 174 001063
Y
� I
I
1
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
FART
CERTIFICATION oS
Property Address: 51 Morgan Way MAP
West Barnstable,MA 02"S PARCEL Z OO
Owner's Name: Dennis Metrick FQ
Date of Inspection: 1/21/04 LOT
FEB 1
Dame of Inspector.- Eric Lenardson r 3 ?004
Comp
Mailing
A dress: 2750 Harkne e: Statewide Environmental
Rti CoVenices,RIc.02816 0 y�A N of S?-A
g Y try, prkE
Telephone Number: (401)392-6906
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported below is trde,accurate and complete as of the time of the
inspection. The inspection was performed based on my training and.experience in the
proper faction—and maintenance of on site sewagedisposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).
The system:
x Passes
Conditionally Passes
Needs Further Evaluation.by the Local Approving-Authority
Fails
Inspector's Signature: Date:1f26104
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,ow.ner shall submit the report to the
appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to
the buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time.This inspection does not address how the system will perform in the future under the same
or different conditions of use.
PART A
CERTIFICATI0N(continued)
Property Address: 51 Morgan Way
West Barnstable,MA.02669
Owner's Name: Dennis Metrick
Date of Inspection: 1/21/04
Inspection Summary: Check A,B C,D or E/,ALWAYS complete all of Section D
A. 'System'Passes:
z_ l bove 001 fond any info atlon wbieb indicates,lint any of the failm criteria described in 310
CMR 1:5.303-or in:310 CMR 15,304 exist.Any failure criteria not evah a3ted,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 repiaGement 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 metai or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank Will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health): broken
pipe(s)are replaced
obstruction is removed
ND explain
.2
i
OFFICIAL INSPECTION FORM-;NOT FOR VOLUNTARY ASSESSMENTS
SUB.SI71 F1ACE SEWAGE DISPOSAL SI'S7 E1VI.INSPECTION FORM
PART A
CEATII~ICATON(continued)
Property Address: 51 Morgan Way
West B' s listable,MA 02b68
Owner's Name: Dennis Metriek
Date of Inspection: 1/21/04
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 ifthe
system`is failing to protect public health,safety or the environment.
9. System will pass unless Board of Health determines in accordance with'310 CMR-15.303(l)(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'feefof a bordering vegetated wetland'or a sakmarsh
2. System will fall unless the Board of Health(and Public Water Supplier,if any)determines
that the
syste'r�i is functioning in a`mannei�that protects the public health,`safety anti`envir`oiim"e"iifs
_ 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 anti 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,P'rovided that4 o other failure criteria a a`triggered.A copy of'the aiuilj%sis must be attached to
this farm.
3. 'Other:
3
I -
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
-SUBSURFACE SEWAGE DISPOSAL SYSTEM iNSPECTIONFORM
PART A
CERTIFICATIONS (continued)
Property Address: M Morgan Way
West.Barnstable,MA 02668
Ovvnerls Name: Dennis Metrick
Date of inspection: 1 f2.1/04
D. System Failure Criteria applicable to.all systems: ,
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_x_ Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
ac_ .Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
_x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
— _x Liquid depth in cesspool is Tess than 6"below invert or available volume is less than'VS day
flow
_x_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s),
Number of tunes pumped
x_ Any portion of the SAS,cesspool or privy is below high ground water elevation,
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply,
_x_ Any portion of a cesspool or_ privy is Within a Zone 1 of a.public well.
x^ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x Any portion of a.cesspool or privy is less than 100 feet.but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. [This system passes if the well
water analysis,performed at a DEP certified laboratory,for coliform bacteria and.
volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.],
No(Yes/No)The system fails.I have determined that one or more of the above failure criteria
exist as described in 310 CMR 15.303.therefore the system fails.The system owner should
contact the Board of health to determine what wilt 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
'8,600 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 11 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 3*10 CMR 15304.The system owner should contact the appropriate regional office of the
Department,
4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART B
CHECKLIST
Pro Address: 51,Morgan Way
West.Barnstable,.MA 02668
Owner's blame: Dennis iVMetiriek
Date oflnspeetlon: 1/21/04
Check if•the following have been done.You•nnust indicate"yes"or`ono"as to each of-the following:
Ycs No
x Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system Components pumped out in the previous two weeks?
x_ Has the system received normal flows in the previous two week period?
mx- Have large volumes of water been introduced to the system recently or as part of this inspection
_x _ Were.as,built plans of the system obtained and examined?.(tf they were not.availabk,note.as
_x_ — Was the facibity or dwelling in for signs of sewage back up
_x _ Was the site inspected for signs of break-out?
Were all system components,.excluding the SAS,.located on site?
_x _ Were.the septic tank manholes uncovered,opened,and the interior.of.the.tank inspected for.the
condition-of the baffles ortees;mateiial-offconstruction,dimensions;depth of liquid,depth of sludge and
depth.of scum?
—x— Was`the facility owner(and occupants if diiferent'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-die site,has:been determined
based on:
Yes no
Existing.information.For.example,.a.plan at the Board of Health.
_ _x_ Determined in the field(if of the failure criteria related to Fart C is at issue approximation
of distance is unacceptable)(310 CMR 15.302(3)(b)1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 51 Morgan Way
West Barnstable,MA'02668
Owner's Name: Dennis Metr-ick
Date of Inspection: 1/21/04
FLOW CONDITIONS
RESIDENTIAL
Number ofbedrooms(design): 3 Number ofbedrooms(actual):3
DESIGN.flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330
Number of current residents:4
Does residence have a garbage grinder(yes or no):no
Is laundry on a separate sewage system(yes or no): no jif yes separate inspection required)
Laundry system inspected(yes or no):n/a
Seasonal use:(yes or no):no
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):no
Last date of occupancy:current
COMMERCIAL/INDUSTRIAL
.-Type of,establishment:
Design flow(based on 310 CMR I5,203); gpd
.Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present„(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:02 Homeowner
Was system pumped as part of the inspection(yes or no):no
If yes,volume pumped:_Jgallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM,
x_Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
—_'Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to
be obtained from system owner)
—Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:6125198 asbuilt
Were sewage odors detected when arriving at the site(,yes or no):no
6
OFF'ICIAL.INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION l!OR1VI
PART C
SYSTEM INFORMATION(continued)
Property Address:_51 Morgan Way
West Barnstable,MA 02. 68
Owner's Name: Dennis Metriek
Date of Inspection.. .1/21/04
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron x_44 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition'of joints,venting,evidence of leakage,'etc.):Tight joints'no'evidence'of'leakage.
SEPTIC TANK:_(locate on site plan)
Depth below grade
Material o€construction: x concrete metal_fiberglass polyethylene
_otlier(exj�lain)
if tank is metal list age._ Is age confirmed bya Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Omens ons<lSOp gallows
''Sludge`depth 2"
Distance from top of sludge to bottom of outlet tee or baffle: 35"
Scum thickness:2"
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: 19"
How were dimensions determined:In the field.
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural,integrity,
liquid levels as'relaied to outlet invert,evidence of leakage,etc.)':lnlet/outlet are in'good condition and
functioning properly. Septic tank shows no evidence of.leakage and appears structurally sound.
CREASE TRAP:(locate on-site plan)
`Depth-.below.grade:—
Material of construction: concrete_metal—fiberglass_polyethylene^other
(explain): \
Dimensions:
,Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pu np�r g:
Comments(on pumping recommendations,inlet and outlet tee.or baffle condition,structural integrity,
liquid levels as related'to outlet invert;`eV deuce of leakage,etc.):
7
i
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
"SYSTEM INFORMATION(continued)
Property Address: 51 Morgan Way
Wewst'Barnstabie,MA-02668
Owner's Name: Dennis Metrick
Hate`of inspdaion: 1/21/04
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 poi yettylene other(explain):
Dimensions:
Cepacivy: . gallons
Design Flow: gallons/day
Alarm present(yes or no),
Alarm level: Alarm in working order(yes or no):
Date of last'pumping:
Comments{condition of alarm and float switches}etc.).
DISTRIBUTION BOX:_x_(if present must be opened)(tocate on site-plan)
Depth of liquid level above outlet invert: W
Comments(note if box'is level&id distribution"to outlets`equal,any evidence of'sol ds'carryover,`any
evidence of leakage into or out of box,etc.):D-box is level and distribution of flow equal. No evidence of
solid carryover or leakage intbor Wvof D=box.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or noy
Aiarms`in working order
Comments(note condition.of-pump chamber,.condition of pumps and appurtenances,etc.):
OFFICIAL INSrEqlON Fq NOT FOR VOLUNTARY ASSESSMENTS
_ 7."., .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'(continued)
Property Address: 51 Morgan Way
West Barnstable,MA'0260
Owner's Name: Dennis Metrick
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
x leaching chambers,number 2 50D gallon chambers
leaching galleries,number.
—leaching trenclies,number,length:
each�g`et ids,number,'dimensions:
—overflow cesspool,number:
innovative/alltmative,systern Type/name of technology:
COMMMIS 009 condition of 5oil,Signs Qf-bydrau(lic failure,Jcvd of ppaiding,dampspil.conditilo. _n of
vegetation,etc.): No signs of ponding or-hydraulic failure. System on the surface is functioningproperly.
After examining tank,D-box and surrounding area the system appears to be functioning properly.
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 laver:
Depth of scum layer:
Dimensions'df cesspool:
Materials of construction:
Indicationiof groundwater inflow{yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY:_(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids-:
l
Comments(note condition of soil,J,signs ofhydraulic failure,level of ponding,condition of vegetation,
-etc.):
I
QI4"fl ,ffPC
4W nON FIRM Nf'14 Vt3LUl 'ARY AS3
SO.IASURFA SEWA"OE"b 06AL 3Y 99 fb
PART C
i�Sf`�14L'R11�A9'Tf3fiT fCoi #nm�d
Pftperty AAr : 'Sorprn {►ay`
West Bgnu tab*MA OUM
t ier'§'r4AjWtr Denftis Mdrkk
'dInspection:'l -1
SXZTM OF SRWA.GE WSPOSAL S'YMM
Provide a sketch of the sewage disposal system including ties to pt lent two pwmenm refumm
landmarks sr l oft LOCM all welly wMin 100 feet_locate whem pMw water sM*ems
a
y
-Z Z5 .f4
3
Y n
€ MCIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM&SPECTIO FORM
PART C
r
SYSTEM INEflRMATION'(continued)
Property Address: 51 Morgan Way
West Barnstable,MA-02668
Owner's Name: Dennis Metrick
Bate`of Inspection: 1/21/(l4
SITE EXAM
Slope
:Surface rv$ter
Cheek.cellar
Shallow wells
Estimated depth to groundwater 10 feet
Please indicate(check)all methods used to determine the high ground water elevation:
x Obtained from system design plans on record;If-checked,date of design plan revievved:97'
Observed site(abutting'Property/observation hole within'l50'feet`of SAS)
Checked wath.local Board ofHcalth-explain.
Checked with local-excavators,installers-.(attach.d9cumentation)
Accessed USES database-explain:
You must describe how you established the high ground water elevation;Plans on Rec'd
5 TOWN OF BARNSTABLE
LOCATION
��S S� O 2 w E #a� 1M �h � SE AG
VILLAGE ASSESSOR'S MAP & LOT I Wit__9��,
INSTALLER'S'NAME&PHONE NO.�- S- C> 30��
SEPTIC TANK CAPACITY 1,560 � L
LEACHING FACM=: (type)(2) 5bo ` A(- Ch^M&nS(size)
NO.OF BEDROOMS
BUILDER OR OWNER 2"1 G4
PERMITDATE: -- 6 COMPLIANCE DATE: /®
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
3 6 vto
� � y S
i 3�
2 zs u1
Le 3�
TOWN OF/BAMSTABLE 0P 11/191
LOCATION 5(q MO RG AN Y If 4 t1 SEWAGE #
VILLAGE VII�i RARN5 gt-e ASSESSOR'S MAP & LOT 175
INSTALLER'S NAME&PHONE NO. '2 EXCA VA 7-101V '-'?S-3�454�C
SEPTIC TANK CAPACITY / —b 0.
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER F R F,® tQ#S 2P16P 191L;6E /.116Ma
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A A v l v�'S~ 13 ,4 ': � 1
13.E
,13 � �
A ® _ 36 .5
A e - 'je
1� = SI
919- �57
No.. , Fr�s........ .......
THE COMMONWEALTH OF MASSACHUSETTS
7 BOAR® OF HEALTH
TOWN OF BARNSTABLE
Allpfiration for Biinpooaf Workii Tomitrurtion Frrmit
Application is hereby made for a.Permit to Construct ( dor Repair ( ) an Individual Sewage Disposal
Sy aq
stem a
..-__-- -•------ -
-- -"o ; �ss No.
.................................................
c�n w Address
------.--_ ---•--•• •• -- ...--• •--.. ..-------•-•-•-•-•••--••-- -•--•-•-•-••--------------•••-•-•-•---•---•--••---
Installer• � /� y�� � Address ,
Type of Building Size Lot_._�1�. .....Sq. feet
Dwelling— No. of Bedrooms_______________ _______________----.-_Expansion Attic ( ) Garbage Grinder ( )
111 Other—Type of BuildiiigW .-F No. of persons____________________________ Showers ( ) — Cafeteria ( )
a Other fixtures ------------------ ----------- -
/, .....__.
W Design Flow.....................///)-_-_-_-_____--gallons per per day. Total daily flow........t_-�0........................gallons.
_ _L/
WSeptic Tank—Liquid capacity/_' ..gallons Length--------------_ Width------------ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No--------_----------- Diameter-----------......... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing to ( ) 44t~' Percolation Test Results Performed b ?/ Date �/ y ... .....
minutes per inch Depth of Test Pit.................... Depth to ground water----
_Test Pit No. 1....�_:s----
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water... .....
x --
0 Description of Soil...... _
� -----------------•.....•-••...----••-----•-•-------••--------------••---------------•-----•-•-•-•--•-••••-----.....••-•-••--•---•----------•.......
w
UNature of Repairs or Alterations—Answer when applicable.....................:......._...._.............._._......._....................._..............
----------------------------•-----------------------------------------•------•--....._...------------------------------------------------------........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The ndersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee is u y the board of health.
Signed ------ ..... . ................... .................................
Application.Approved BY ...... -x^^-ram------------------------------------- ---....... ---- ._....
�-_e�--
Application Disapproved for the following-reasons: .. ............. .....:....... .............................. ...... ........... . . ................
-------------- ---------------------- ---------------------------:-------------------------------------- -------------------------------------......------------------------------------------------ ........................................
Dare
PermitNo. ...... ---- - -...... Issued .............................. ..............................
// Dare
_ /
-------------
Ivy
q 9- 3s 7 �,_, -��t
�.� C4 i.4i
No_.= I - t .. Fns........���
s_ THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF HEALTa--I._ _µ -
r
TOWN OF BARNSTABLE `
Appliration for Diapn ial Worbi Tomitrurtion Vantit
Application is hereby made for a Permit to Constructor Repair ( ) an Individual Sewage Disposal
System at.:
.... -
.....................................................
,W � Lo^ c•dr•ss �?��.Jam—/rL/ No
77 Address
.
Installer / y ,l Address /
Type of Building (/ Size Lot---11. L?.....Sq. feet
t-t - Dwelling= No. of Bedrooms---------------- ---
----------.-_--_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building U) fLe. u-No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures ---------- ---------------------------
Design - ----
Flow...................../16.______.___._gallons per er da Total dail flow------..t/�
W - ,_ g P P P Y• Y l-----U------------------------gallons.
WSeptic Tank—Liquid capacitv��UO__galIons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation'Test Results -Performed by. C Vxe Date.._ . �� y
--- =......
Test Pit No. I.... -_--minutes per inch Depth of Test Pit-------------------- Depth to ground water_.--__,. _ _' _ _..
f=t -- 'Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water.._N.0
/< O .
Description of Soil.___.__ !/J____I/.�- !� riv--------------
U -----------------------------------------------------------------------------------------W �j -------------- ----------- -------------------------------------------------------...---------------------- --------------------•--------------------------------------------------------...__.:....._.
UNature of Repairs or Alterations—Answer when applicable............................_._.................._.-_.........._......_._......_.__________....
---------------•-_...•••-----------......_•--•----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
! the provisions of TITLE 5 of the State Environmental Code —Th�endersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee issu�erby the board of health. fA
Signed -------- ------ ...... . ..................... ...._............ . ...... .. ire
Application,Approved BY --- .cam - :....... ............
Date
Application Disapproved for the following reasons: . ... ....................................... ........ .. ................ . ....... .
-------------------------------------------------------------------------------------------------------------------------- ------- -------------------------------------------------- ........................................
Date
Permit No. ............ :>l .' -^` ......... Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tex#tf irate of Tomplianre
41isrls . 0 CERTIF Thalthe Indivi' Se age Dis os 1 System constructed ( ✓ ) or Repaired ( )
P
iby -= - _....... -��--------- // .. _
/ Instauer ` '!
at ....... 57� a/----- 4-----_l,(JCu ... L c(, 1/l... ........ .. - --------------------------- ------ - ------ -- -
has been installed in accordance with the provisions of TITLE 5 of The Stat�jEnvironmental Code as described in
the application for Disposal Works Construction Permit No. ........�C��.-. .��.C�............ dated _..- - ..�i1..-...% r.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ?'8 - 3s
DATE.... lr�..'.. :�� --7- ....... ........... .......... Inspector - r ............_.._......._........ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
FEE...... ................
Disp apal Workii To trur! "Ppr, it
Permission i thereby granted____._..J__.__.. _......�___ —U C�"
to Constructs 9( ) or Repair ( ) an Individual Sewage Dis osal System
at No...Y! '(_: l`?�r� ' �1 _.�/�l._... _.e..._.. sc�/c
as shown on the application for Disposal Works Construction Permit No._L_r:3y.�. Dated...........................................
Board of Health
DATE................................................................................
FORM 38508-MOBBS Q WARREN.INC..PUBLISHERS w'
E; PL.A I-3- ON 'BAGS uEs
Gorr/r1L r
,7M L`1 PLOW = 3 x 110
S�tG -ANC )(,ZOO
U 1500 GAL- ,}� e� �QurvaL.saT' d'PvG PrP�
�ESV0N - - - --- - - -- N
L AG L}l t.1G 5`( �
L —
7j Cu �G Z {��jCl1JMIBLS14:sTvUE DIST•
33 GPD SF`ATA&S zs
A¢ v�SlbN pLbN Vi�u/ - LF}INw G{4AM8EIz5
Sltaa-wacL A2F—=4
�j x�x2=Igsbsl"
tinTToM
3 tis�ax ,
�- sMIv/,NcN
-( '4 00 0r
gTEPHLN
wit-SON r —�
WrFR
Vm A04sl r� t
'r•
'L' 21 9 e,
r'vc' i U�11
G0— ao i qI
Lnu„ SUB, I►K
plr,� lint Iw qo 5 s i
- , ;- PLC 1 E11Lil CKAMBL izS quc.o 90-
FIDE SMD
F-Ioe SANS ._
w�S STDO
Lr r.�n.�f
'3 '�IE�GPG� �pFIL
to
�v FSnuD
. .� VZALfm-
CE "Tl
56AL-E-- 1''= SATE 'L
v c.,u 5i�oyuN 12LA1.1 1Z> 4�r�1C�
`
WIT" -.As st DEL%W9 A� LoT I SS
��N roHptyS
AIL zwvlzmmGWT 01✓ T14r. 'T V./m of MAF V-74
$��uJt7Ti}E�C r= A►-* t 5 Nb'r LAC1,T 11J l Tll I N $A CC { Nye I NG
J 41. mrop �A'Z�3� -ENE• L{�I.1D SU¢v6 CZ4 • =I'l sEv4 .
c, cy DSTIQ�ZVI�1,�. MdSS•
oFF 5eT'`� �M $u I C.D►N!� �,t � NOT" DB6ii DC
QppU GAN T:
----
I,
Zo+Jiu� - 30 �'i5 /tS
MAP 174
5Z
94 '
wMk�f p �
r _
M T
4~
94 �ZO 5�PI1G
—
.e
♦tom \ � —� 9G
�, JF
nh' 011.1 4.;:�r1f, i s •� \ ��.?,w,
3TEF��Pi tiy�
�I�E�T ► ter-
F +��`f 3 ®accwt r E PL.A 1.t oN u
o ,-Aa 3ALQ lwa.t��. LOT «S /��e,L ►J � Y
'DA4 L_`1 PI-O w - :,-?, x I 10 =`33�GPI
51�T1G TANL ` �30 x ZOO s a'PvG PrP�
UZ 1 -00 (At...• . 1�k cj7- �rrurvaL�uT'
A4&SF
USE � CuL,-rEG �+I,�eLt<�33L�Ci�•Awt8�S�45Tr:Ur: MKT• -
,d,�t.l GAT10N A�4 � D. �.---19•�1
DPP UG1�.:T ON AV.EA U�5lb N
PLaIJ Vl�1u - L�G�IhY, G�AM8Ee5
Sit�1/1L►LL At�A� �1 x�x2�14�SF
a
�
oT'foM A F�NrsN G
coLATt -r� L s'uIv�INudy Gz.� ,c S�c2� 2
51"o►1E
Cul_Tr-G _�'�, 11f�
e�41.
,,,....,.,' ,;r';•'" a
330 0
STEPHEN r41OF
�`:, ✓ I
1 ALLYN
fK
A ,n Nn 3�?1b
«�1 MXTERa .p� r�, lyvv � ^ C,2055-SE C9AMpj;r7 ____
�► z-7 11
17. z� 9� F�=q3
�r 4-�OLF C--'- C Ao 'n 91
-PL"nG LF.dLII C1dAM 4e d- 40 6= l� e
z
r-14E s +�
I=1uE �4N� .�•
\��� r� �C.-ir �,��� •mac•=_
CL7.`(
�� - ._ Q 4t�
�1i irl� F
IX
�D FtoT
C
-PA.TE 'Z Z'1 1E�
I GF 1�Y TKA-r 114 E
ccwtP�-y5 wiz'A T>4E slvE.uN� A� ��,T I SS �� �� � S� IS
� N o f �Tv s V wN of �'P l
,�'iBA.GIC. p�u126.M6d�'T �d-
F A,ud%rW_17- A►-* l 5' H07 LGIGATrD WJ l T'I I N A BAD— A NYM I hiG
5pG;e�.JAL FLrcv ►4AZAZZ;. E. LAQv 5u2v cz6 • GdJG1►Jbps
:tom 21, Ic U--o—k�. rJ o 5'f eV l�.t.& Md�S�i•
oFFS�T's 1t:TzcM BV Il�D1 NHS 41 toLXr:P NOT" B>s QPP(�G4NT:- S,D �',��►�� INC_
rrS�b � l�-rx��u�N PROP�'t`� LrIJE�S. I ---
f w
M
ZL�IlJ(, — 3D ��ir� llr�I
ALI
`1Z
� 9p
MT'
Lo
D TMJ Y. n —
�14
'r 1.[ -+'ej. rW� i' i��,�.��% gJ����yj. �....•..
TOWN OF BARNSTABLEfU
LOCATION Lo`S E S more more", w A SEWAGE #
VILLAGE_�'''�5'f �PnrC'Ct��1L2 ASSESSOR'S MAP & LOT _
96,3
INSTALLER'S NAME&PHONE NO.�L
SEPTIC TANIK CAPACM _ 1 S�1G� civ+ L
LEACHING FACILITY: (type)� L--size)
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: /o . .�,"-,95? _
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by_,
6
2 6 �
Q y
2 Z5 N�
3 �13
3Lp
5
b b9 Z 1