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HomeMy WebLinkAbout0197 SHOOTFLYING HILL RD - Health 197�Shootfiysng''ifliII W. Barnstable` 1 1 � Wk I cAD t ,- �� 4f _ f� � a .. - �� a-. !� r _���.wMr�u..a— �.� T.,�..�.�,.-..-.n.s-.�..-.�...-'�,�--1.—..,r.-ra,,.....+.m, m.......�...,e.M...�. -- .. p � f J, _ f}} 1� {� 4 ;i + i; _ ._.....r.,�._�___-_�- i � f i} ;� `t �� ;i �, ti � � �� .. ' .§. ie. _ _ .. . � - 4 � F � k '�. }..� '• - - ;� t� _ _ _ � F �� � • � � �FTHE Tpy� Town of Barnstable �s Department of Health, Safety, and Environmental Services * BAxNsrABLE. Ass. Public Health Division �A i639. ' 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508 75-3344 Director of Public Health August 2,2006 Geraldo F.Defreitas 2177 Service Rd. W.Barnstable,MA 02668 NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE CODE,V60-20(1) The property owned by you located at 197 Shootflying Hill Road, West Barnstable, MA. was inspected on August 1, 2006 by Donald Desmarais, Health Inspector for the Town of Barnstable because of a complaint regarding overcrowding. The following violation of.the Town of Barnstable On-Site Sewage Disposal Systems Ordinance, §360-20. In addition this dwelling also violates §232-5. 4360-20 (1): Criteria for Determining System Repair or Replacement There were a total of six (6) bedrooms observed in this dwelling; three were upstairs, one on the main floor and two were within the basement. However, the existing septic system was not designed for six bedrooms. The septic system which was installed Dec 22 1992 was designed for three(3)bedrooms. 4232-5 (A): Maximum allowable wastewater discharge. On-site sewage disposal systems shall not exceed 330 gallons per acre per day. You are ordered to remove the bedrooms from the basement by removing entrance doors, by removing the beds, and by opening all door-way entrances (by partially removing walls) to each room in the basement and the bedroom on the first floor to a minimum of five feet wide within thirty days of your receipt of this letter. You are required to pull a building permit to accomplish these directives. You are allowed no more than 3 bedrooms. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in the issuance of non-criminal ticket citations of$100.00 each. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH ('�A4as A. McKean Director of Public Health Ilk f AsBuilt Page 1 of 1 i t�wtvur nruuv�t LC LOCATION 121-7 Mr P ,ter ��i SEWAGE H t� VILLAGE Ctn: ry,l� ASSESSOR'S MAP&LOT a- / -a L INSTALLER'S NAME&PHONE NO. 4 o l%2 SEPTIC TANK CAPACrrY LEACHING FACILrrY: (type) (size) CIti NO.OF BEDROOMS 3 BUILDER OR OWNER A L/5�bn PERMITDATE: COMPLLANCE 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 leachi g facility) Feet Furnished by .-r--11 j A A ' L ALi� t ;Li 13 a ! i4 D��k , c'Lal'o 13.6 3 3 3�. 5•Y http://issgl2/intranet/propdata/prebuilt.aspx?mappar=214020&seq=1 5/10/2017 14- C6`l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P7R ]ED TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 197 ShootflyinQ Hill Road _Centerville. MA 02632 Owner's Name: Luther Ausbon Owner's Address: Date of Inspection: August 4 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:214 Osterville,MA 02655-0049 Parcel: 020 Telephone Number: (508) 862-9400 Lot:8 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Nee Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: August 8 2003 The system inspector shall sub 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. 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 r Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 197 Shootllying Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: Au.Qust 1, 2003 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. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or 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: i The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain- 2 r Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 197 Shootllying Hill Road Centerville, AM Owner: Luther Ausbon Date of Inspection: August 1, 2003 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 ' 1 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 197 Shootflying Hill Road Centerville, AM Owner: Luther Ausbon Date of Inspection: August 1, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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 (YesfNo)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 197 Shootflying Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1, 2003 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 197 ShootflyinA Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1. 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x#of bedrooms): 330 Number of current residents:' 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Landry system inspected(yes or no): No Seasonal use(yes or no): Weekend use Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAVINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Bass of design flow(seats/persons/sqft,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: Never pumped-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approx. 1983-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 ShootflyinQ Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" 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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of cum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring 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.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 Shootflying Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (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 f Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 Shootflying Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits, number: 1 -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields, number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit was dry. There were no signs of failure. I used a video camera to conduct the inspection. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Iage 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 Shootflying Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1, 2003 Map:214 Parcel: 020 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot:8 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. A A a! 13 0 1 a j)`Gk , d a( 13.(o - - 3 Y y� ag y 10 i f Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 197 Shootflying Hill Road Centerville, MA Owner: Luther Ausbon Date of Inspection: August 1, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Wing the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPE T ONJ F0�4S+1"���/ Address of ro c/ S�I;;v�" �� � �� o UN 6 ert / P y l �5 Owner"s name Date of Inspection PART A CHECKLIST S Che.ck,.-if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks 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. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. L/The site was inspected for signs of breakout.J. z 11 system components, excluding the SAS, have been located on the site. :,--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. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of SSDS.' f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms -2- number of current residents No garbage grinder, yes or no' laundry connected to system, yes or no -*I seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: e yk.i2el r Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System pumped as art of inspection,Y P P P p ion, yes or no if es vol ume lame pumped Reason for pumping: Type f 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: (Z Sewage odors detected when arriving at the site, yes or no I 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:_z (locate on site plan) depth below grade: material of construction: concrete metal FRP other(explain) dimensions: l� 4 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 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: y (locate on site plan) r� © depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) t PUMP C BER: (locate o site tan) pum s n working order, yes or no Comments: (note condi o of pump chamber, condition of pumps and appurtenances, recommendat ons or maintenance or repairs,etc. ) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type- leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : number and��onfi�guration depth-top o" iquid to inlet invert depth of solids layer depth of scumflayer dimensions of/cesspool materials of construction indication gr undwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate 'on site plan) materials 'of construction dimensions\ depth -of soli*ds \ comments.: _s.: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) f ' 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L�SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 3q�zb Ci 6 y�Z �oF 31� DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation:pp ion• 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) G' Backup of sewage into facility? VD Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times o more in the last year? number of times pumped d Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? =s any portion of the SAS, cesspool or privy: K� below the high groundwater elevation? A O within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? U within 50 feet of a bordering vegetated wetland or salt marsh (Cesspools and privies only, not the SAS) ? A/b within 50 feet of a private water supply well" 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 analys__ . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address ) Sup . 12 ,'l��i?�.!'� Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consis nt with my training and experience in the proper function and man it nance of on-site sewage disposal systems. f7/k one: have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment.. as defined in 310 CMR 15. 303 . The basis for this determination is provided i the F LURE CRITERIA section of this form. Inspector' s Signatu_e Date J Original to system owner Copies to: ble) ppraving authors Ed I �t cI^ ( TOWN OF BARNSTABLE ;LCi��'.A7116N t C1 J 16tr C't1 ji4 14) 1 SEWAGE # W.:,LAGE G2'1'Ttryi I L ASSESSOR'S MAP & LOT a / ' NL INSTALLER'S NAME&PHONE NO. L U g SEPTIC TANK CAPACITY r t111i'7 LEACHING FACILITY: (type) (size) l NO.OF BEDROOMS 3 BUILDER OR OWNER Lis Gn PERMITDATE: 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 leaail, facility)--�-- r Feet Furnished by, n S,0 tWN J • t t��� P 1 A f a1 13 Q ^' DO , U F' SEPTIC SYSTEM MUST SS Asszaessor's officelst floor) ;= ` 1. IN COMP�IANC YNe T yAsse1 .ssor's ma and lot nrmher' ° �C � teISTAL �H TITLE �'� Board of Health,(3rd floor)., g RONIIAENTAt CODE t` Sewagg Rerrnitinu{nber. i. .. .{.. . 6il6 T60 L Basas4l►DLE n � n 3 floor• c n R�C'a1l.A E ineeun . De atme ( d:. m B. g. P � f, i �t Hoirs , nu nber� s ;,c !J• ///••?/•. _ 'Fa MAI a u 1 .•• • Y •t .,.•• .i o QFPLtCpTICNS PROCESSED, ,8 30 c� 30 A M and 1:00�•- 00 :P.M ;only i p i c r� _ 4 } a t + r f Oar {OF BRNSABLE r 1.-e. .{ .Eel. ' BaURDIHG INSPECTOR <.� APPLICATION FOR PERMIT TQ, t l.( .1 ''�1'4. � &D! :...fh�.°"cy' Z- ........ �..... TYPE. OF CONSTRUCTION j�De.°.o!y• ao v 9�c� Aw ca• .. ,. ..... {... .... .............. TO SHE INSPECTOR OF`BUILDINGS : The- up.dersi ned hgr yi applies for p permit according to the followm� mformatlon00 '_'G "sz 7�# iVNGL�. b�Et9L Location :.v1\.J�fPo� / c.4!- /r�4. . : ...... .... ::. PiWr94 , .. ....... Proposed Use 1f`� `S.� r.9'l�. ..... ........................................... ........... Zoning District .............. ....... ...............Fire District ...1�3/....... ,. , Name of-Owner sk�...�t` ?���c.tYa'i.........Address .... .el: �lsj:.7... �' �- ..... .... n ,tom Name .of Builder ... D/1/..?�.D.... ,0 .....:....Address ... �i / � �1� Name of Architect n"°.. ...�4...d ...............................Address ...........`. .... . �........ .� .......... ..... 4. Number of Rooms ...... Cam:..... �Cs.�t.�.r...........................Foundation ..,......... X.. ...� ;Exterior Roofing ......... .vicea.......................................`r'..�o� Floors C�ll.!��A Interior �.J.It��T . .rc. k.-Hating _�:. 4 :Cr!�.!o.. ..... . }... �....... .. .......P um ing ..:. y ..� .... ..... L..... .....................�........ ........................................Approximate Cost ...... a...................................................... Definitive Plan ;Approved ,by Planning :Board -----------_------_-----------19-------- Area ........ Diagram of-Lot:and :Building .With Dimensions Fee ............... ..... ............. SUBJECT _TO ,APPROVAL OF .BOARD OF HEALTH IS ro'4" -- - �- T� a 4 10 co 1 2 3` 5 22 ' � _ 1 2 12'c)"Ln ¢" N 5 �9 mur��•-.ca,sr-..� . c� 3.154 t"LOu r r 4.�rPt _c ..qur a -l�racla -►Y�t ► .- 0`arz-lcac._. .. M E\ - .. . 4 (4, ., I ' ----- ---f-- - --- - -�- - - - 14 2 3-5� 15'-5 1 Icoo - i I � A colac: - Is"x 8-- 14' r F•aR-: 2.xd t-ru o Wit"LL SYWMTJOC -mo.tZFrD.I ANy �o TO M J. st 1214 114 jer-, G-6 '3'011 J t -JL 7 PF-2F,-4FY 3:s- -f G," 4 W Jj I I i 1-* 7 0, o. i L? 0 lAq, __4_�__ : 1114:. 7-6 I F- T EU *01 LUJ 0-'4 0 r 4'7L� 4-'- o'A t 0 to 0 c 76 O.t TOWN OF BARNSTABLE L©t S LOCATION Sho&r SEWAGE # VILLAGE ASSESSOR'S MAP & LOT SIL4 1Q20 INSTALLER'S NAME & PHONE NO. 6,17 SEPTIC TANK CAPACITY 1600 LEACHING FACILITYAtype) �� ?C (fl it (size) x 6 l NO. OF BEDROOMS _PRIVATE WELL OR UBLIC WATER UILDER OR�O NER O � G S a� I DATE PERMIT ISSUED: 2- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No~� ova Lehr?�t�vl<. 8 . 2 1 o vf- - ID 3 9K ram, 2S 11 Q C 71 e, A. J'I +1 No......R.rg FBI ....5� s- THE COMMONWEALTH OF MASSACHUSETTS 9� G BOARD OF HEALTH ApplirFatiun for Disposal Works Tonutrurtiun Prrutit Application is hereby made for a Permit to Construct (4y or Repair ( ) an Individual Sewage Disposal System at: /� 7. -500 � .1.!�:c ton �� eSr- nsy. ............................' ... ••••. --- ..... '� A ess or Lo o. .......... ..:a .�a1. . .c. ' . - _�.._.--------------........ ..----s........a , �xt ... <�!1........2.. • • •• .-•Owner • �j � Installer �•• Address UType of Building Size Lot--_.f .t __.._.... q. feet Dwelling—No. of Bedrooms---_--__.3.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a —Type g .............................No---of persons::-----------•------------ Showers ( ) — Cafeteria ( ) Other fixtures . .. W Design Flow...................-�•�•..5.................gallons per person per daX. Total daily flow___...._3 3 O._.................._gallons. WSeptic Tank—Liquid capacitylO O.gallons Length. ...'_.,.. Width4._"h2.. Diameter- --_. Disposal'Trench—No..................... Width......... ........ Total Length-------- •--•--•-_ Total leaching area•-__-•------_-------s . ft. x 1210 � / � g q Seepage Pit No..._...._.1_-__-__-- Diameter-__....-........ Depth below inlet.j(a....P...... Total leaching area..klo?...sq. ft. Z Other Distribution box ( � Dosing tapk � ) /� _ 3 26—6 6 `" Percolation Test Results Performed by....... f�.�:.'.._f..... JL +Date........................................ �l V---- Test Pit No. I......�7....minutes per inch Depth of Test Pit...... 8� Depth to ground water....KQ. G14 Test Pit No. 2.......' .niinutes per inch Depth of Test Pit..../AA.... Depth to ground water-----A.14, 4L. .. - - -------•--- -- ---••.......p - � Description 30 TO _ ,cy- WA-0 . ...� .._ S ....._. 7--- ?.... /ate).--.`!.o-...":..�6.0------.H e S�----..4lr�.l��s'1.!_ -•------•------------•----------------•---•-•.....-----•-------------•---•-•••-------------•--•--••---••--•••-•--•-••---••-•----------•••••--•---••-••-----------•••-•--•-••-•--•--•--•--•---•--........ U Nature of. Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------------------------------•---••----------.................:---•--------------------------•---------...------•-----------------------------•----------•-•----. Agreement: The undersigned agrees to install the aforedescribed ndiv'dual ewage i sal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— he u gne f th ees not to place the system in operation until a Certificate of Compliance has be 'ssue o rd li g .. -•---•-- cfi A ---- Application Approved B --••-••---•-••-------•••-------------------- ---- ---- -------- -•----_.....��Date PP PP Y �.. Application Disapproved for the following reasons:_. ..-------•-------•----....--•-----------................................................................. ------------------------•-•--••--------•----•-------------••------• -Date.................... Permit No......7;L,._A..tll................ Issued........................................... Date I I w � '2+ g' Ste- No............... FE ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... to .t...:-:: .OF....... ..................................b 1 , .... --------------•-.........__...••••- Appliratinu .fur DinpnnFal Works Tonntrnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: t �/ Location Addrfss ( ( / f l� or Lot t . .. ..C}'Y`..... . I l........................................... .. l2........ ... ,........t.....1 ..... Owner . Address W Installer Address dType of 3uilding Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms............ }_______________ _____Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ___. No. of persons____________________________ Showers — Cafeteria Q' Other fixtures -------------------------------------------------------------- Design Flow...................::�__`_�________________gallons per person per day Total daily flow - gal WSeptic Tank—Liquid'capacity.� !?_2gallons Length..F._."�_ Width. _--.�P_ Diameter..._."~-____ Depth.... x Disposal Trench—No_____________________ Widths__._.___ ,. _r.. ....... Total Length.........7___�;___ Total leaching area....................sq. ft. Seepage Pit No___________ _________ Diameter. .::.Q.._. Depth below inlet__6a_____L .____ Total leaching area___ __ _ ..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by-__,____`4_t) 5..._____ !_�?? `.t b1C_ + `' -?� - -------.. ..?�-----••---- Date--- ----- •-------- •---•---. Test Pit No. 1_______________minutes per inch Depth of Test Pit_______��-,...„ Depth to ground water_____. Test Pit No. 2.........7~_minutes per inch Depth of Test Pit__-_. Depth to ground 0 �✓ t .?�, '� ter/ { %�/Jo'� / Description of Soils � r 5.(? , /�.'j &) .j ...... V ... . �.. -.- Y'f r .. ... 1t'w� /{ r�k. _.-_... t�fVia.... ._... '` ;ter--_'__-•.•.-��0 f2 z'._-�I------�... W ________________________________________________________________________________________________________________________________________________________________________________________________________ U Nature cf Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL2 5 of the State Sanitary 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. Signed.......... f r - Application Approved By.............................................. .. .. ------ ..............�JDat,­J-R6. Application Disapproved for the following reasons: -•----------•--------------•-----•------------------------•----------------------------...•----•.......... ---------•----•..............•--------....•----••--------••-------•-•-•---•------____.........-----•----•._...-•----------------•------•-•---•--•----•-•-----------------••-----•----•-••--•----••••----- Date PermitNo......................................................... Issued-....................................................... Date ..,.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... Trrfif irtt#r of Tnntph atta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (i) or Repaired ( ) by....................................................................... ... ..V---,.61<i!�.-'---•--'----'•---------------......---........_..._..----•----••' •-••-•---- �' Installer ( ` at............................................................CA..._-`S�-----•----`�s-�Q�� "�'��t_►_" `(_!_�:1_... ��t'.r---___6ew4,`*t-wi.AQ --------_-- has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code as described in the. application for Disposal Works Construction Permit No...........C?a_---- dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. .............................. Inspector �-1 ...................... THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH �j J . ! No._-____.__..... ., FE , /' Di#ns al.�nrb Tonot tan rrntit Permission is hereby gran'ted.............. .... l t �` -IPIr...................................................... to Construct or Repair, ) an Individual Sewage Disposal System at No.. �.. � .1 /q ._..... - tft '`�------�"-`------ ...... ree as shown or the application for Disposal Woks Construction Permit No.?6'_.S.___ Dated.... X.7-_-�_$�...... t f . - Boar ' II DATE................................---•--•-•--•-••--•---••-= FORM 1255 HOBBS & WARREN, INC.. ,PUBLISHERS'•' - 9/ Per . F-r— DEPTs4 X aa,sT B nl 'vC Ar. ri 4 t h�6 O � d 7s. 0,0 ILL VVe PO SAL s Q Do" A .LD CAPi�E� I CALF i"'�O' APR. I4- S , t 986 . C - -! �-7 I q4,5 H �O � � I 10 c 01 ST.BCK b6iol D 1gN1. . 85• 6Fr•Tan rcp+lc� 000 C-14. Cor". 63.5 0 0o GoNc.l.r=AcN�u� P,r. A o ea (G 85.5 Q 40 A AAA A d AA A. 3 �, { r1? O A AA 0A I L a k! 5jl c BOT• Pi T Eta v Gee°- r°p`' To P5ox, Soggo1L �Es Ic,J� DA.T'A : 64.5 30 RLP-coLc .—ruoN R.AT�,; 2 MjNllmCJ-J DRo P BeTC-JT -PC-tZf=ORMtj> We, 261 le)&G 83.0 48 3r BEDROOMS K ( l O C-4PD = 330C Pp LEACNIt4' ���bf Fl,Vc IV O GARBAcqE DISPO$AL `USE J.00O GAL.SEPric-TAuk S.4N v, 5MA« CAPAG I7'y �FZ,oV 1p E D ; 79 5 goo Ci p X S, '78.2 t3orror ion" MOTA f- CAPACITY 79 GPD . � C�eAv�` `�► oTE-- D lSPOSA�.. S`l�r� D�slc7NED f � A�c.oR�P.NCE w ► T� �RO�lIs1oNS o.F � TITLE Elv lRNJMEf drA i 73,0 No C.>;auu Q W�- i CA PPP-LLre-T-r I L-O-r 540or'Foovev dlu -PA P.h1STA'1-4Ll �-� i ;I I; ' L-oTg c, lot K 01 �Ay0 ' _sus oo .. ti 1��Ffae. w l S PO Sly LPLA, 1,..) Dot4 kLD CAPPE LLETT I ct,*R. A65oc, l Nc, 'RAv►� SCALE I -3© Ape. 14-, t 986 . P-57 7c f • I •O � t0 C O t st'.,g� c to.. 8 66 85• t 4 83.5. �oFr• Dts�ivl. loco C-.,4 tom, A 0 AQ Goi.1c.IEAcN►uGl Pir• Sep+tc. Tan le. 85.5 d 4A A AAA e o e 3 �`;-• 7'] O Q A BOT. P$T Raw i B1 OLD Genoao v D To P50lL, ' 84.5 30 2 M/N INc;j DRo P .. TEST �ER�'o�ED M��• 26, 19f3� 83.0 48 3 BP-PROOMS K ItO GPD = 33oCPp LEAcNINC, ��m,p FiNc GIAPencia DISP05AL 1JSE�.pp GAL.SEPT'ltT K S'RAJ D, SMAte. CAPAe iT y �FZ,oV 1 D D ; 79.5 90" oT-roll f.� Z i . v _ j 13 C p D ,7 8.2 t3o rr.Of— ToTA.L CA PA c. !T"j F o v/Dop 80N E7 ,A 1� 6!7kAVrL- K oTE- D IS PoSAL S%-IsT-om Dc.S 1cgN E D 1 1 T'cTLE S o T9E. !` A55 . ENV IR06MMEN-rA.t 1 1 (08 Q W�- Low g A`r d,L4 en No..-�•�---14--.. Fps....... ....._ 1 THE COMMONWEALTH OF MASSACHUSETTS EO R® F H EA ? H of ZI�( -................................. Appliratiaa>rt or 11hipatial Works Taµmt ndion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 01 x -. ...- _ Or L catio sIt on '��` — ....... .. i .-..... Owner •Address W .. L -- / lt. d----------------•-•-•--- Cl a. ilfa!: Installer Address ` UType of Building Size Lot.. 4.:___�"'r_'_c?...Sq. feet Dwelling—No. of Bedrooms____. •_________---------------- Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Buildin p (/ ) ( ) —Type g _r�_�!.___.:.?�ir�a%�IVo. of ersons._.�______________________ Showers — Cafeteria dOther fixtures ---"--------------------------------------------------. •--•-•--•-•--••--•••.....-----------••---••-••••-- W Design. glow..... ._.._�40..........gallons per person pgr day. Total daily flow.....�.3-=t:.........................gallons WSeptic Tank—Liquid caps c•},Y'Wl..'-_dgallons Length__ '___" _ Width..�_-ka. Diameter________________ Depth_- _''- x Disposal Trench—No.....? ...... Width... ._........... Total Length-----............. Total leaching area...:.-__;_._____sq. ft. Seepage Pit No.___,/-__________•- Diameter........./4 ..._ Depth below inlet.....e..__._..... Total leaching area..Z....' sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.................... Test Pit No. L.2,_G%...minutes per inch Depth of Test Pit...../Z........ Depth to ground water.. -_. P� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - • --------- = ---------- •--------------- •---------------------------••-•-------•-•--•-------•-•-•-••--•••--------------•--------•-------- 0 Description of Soil------�� - ------ . -'J..-•--•-----t----...-•-------------------------------------------------------- x W ----------•--- ------------------------------------------------------------ ------------•"----------------------•.....-----------------------------•-------------------------•-•••......•--•--•-------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------•-------------....----------------------------------•-......----------------•----------......-----"---------------"--------------------------------------...._..•-••---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.L 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has b issued by th and f heath. g in r D L� -------- Application Approved B __ __ e`er fe PP PP Y � �� -•�•-�� Date Application Disapproved gr t e following reasons:.................. ._.....-_..... ....................................................... -----•------------....----•-.....---•-•- Date PermitNo......................................................... Issued-....................................................... Date Cl C A T ICON 4so S E W A C'E E RNIT NO. dl.LLAGE I INS A a ER'S NAME A ADDRESS B U!LDE R AR OWNER r4l 0AA,ai� 4"&= CO DATE PERNIVT ISSUED {— . DATE CON PLIANCE ISSUED .� r �3 I i i No..... Fxs....... ..... r' THE COMMONWEALTH OF MASSACHUSETTS B ARD OF HEAL H /�ti.� o / - ------------- --- oF....., ./...?aN..�?[ e Ap iration or Bi_gpaa al Works Tomitrurtion Famit Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal System at: ....... ............ ...... •-•••••..... Q ....... catio - s �%d� yNo. ' x Address .. ..�--� Owner '-'~ W D C7/ �L ....h e_e..............^......•- /I�.�.t// . Installer Address VType of Building Size Lot. ` .....2..`t ....Sq. feet �., Dwelling—No. of Bedrooms...... -__.. _________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ,__l.e� o. of persons..2...................... Showers (/ ) — Cafeteria ( ) 0.1 Other fixtures ---------•----•-•-•-•-•----•---- - W Design Flow.......................�'�U_..........gallons per person aer day. Total daily flow-----3-•�A- .........................gallons., WSeptic Tank—Liquid capacjt ldla!gallons Length._ .......... Width..''_/4?.. Diameter................ Depth:'`. '..___. x Disposal Trench—No. ___..7% ....... Width.._ "'............ Total Length---.=............. Total leaching area----�.__.._.._..sq. ft. Seepage Pit No..../--_---_______- Diameter.........w---- Depth below inlet.... ........... Total leaching area... ._._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , aPercolation Test Rests Performed by Date U� Test: Pit No. L.Z.Q'.Q...minutes per inch Depth of Test Pit....Z Z........ Depth to ground water..--------------- (s, Test. Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o Description of Soil--- �" l-U Z:Z/). ... -------- w -------------- --------------------•---•--•---•--------------••--•-•-•---•-----•--•------•---•-•----------•-- -•-•-------••------------•-•------------------•------•------•----------------•-•.......-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------------------------------------------------------------------------------••--•-••---------•---------.•--------••----•--•-•-----•-------•-•---•------•---•---------•-••••.--•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Complian/h , issued b th , card f lth. lie �9� .�. ;Application Approved BY r --- ----- - ------------------ -•.....-..../Cs..._!!:G---•- G .................. Date Application Disapproved r t following reasons:-------•------------•---•---••-------------------------••------------•------•-•----•..._...-•--------••--.-- .............................•-----•---•----•-----••---•-----•-----------•••••••-----•••••...-----........-••--••........-----••-----------•-•••-------•••---------••------••--------•-•-•---•-•--•-•--. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... C�rdi 'rtt#ler1i�a�trr THE S O ER F t e ividual a isposal System constructed ( r Repaired ( ) by ,� �'�. .... -- ----- - - ------- - Installer at ........................... -• ........ ...............•------•--•----------••--------------•------•-----•---------------•--. has been installed in accordance wit i the ovisions of T 5 ofkt_-, ate Sanitary CQ in the application for Disposal Works Construction Permit No•_ dated_... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU A5 A CzUAR TEE THAT THE SYSTEM WILL l� X�TION SATISFACTORY. DATE... I ... ..�................................. Inspector... ....... THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH No... 3�'./. FEE....7 .....................................O F...................................................._................................ .................... Mops orks %0_1111notr iott rrmit Permission i� ereby g ed .. ........ ..... ----- ....................................................................... to Constru f i� tem-- at No . S eet 1� as shown on the application for Disposal Wor s truction Permit No-----_...... >ated. _............................ ------- --------------•- ....................................... oard of Healt DATE----�--�-•- ------------------------------------------------ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 7. NOTE.: %F E/TNjeT T"e SEPTIC• 7-.4,,V OR 20 FT:, M�IV- ig�gCil/n/G AN'/T ARE MORE TIS►A,Al /2"BOLOiV 5Ra0E� ,4 ?4.0/AMETEK CONC,?ETE Coslzle q•PY C P/PL' Sj/ALL 8.F BROuGMT TO GRAoE..�.+N EXTRA GCNGilL'T'C -. jiE,4Vy CAST /UPON CO✓ER Sf/AL L L3E USES M/N- P/7CN !FIN GR/VEyV.4 Y E L 10 o COYE/tS - '/B:'oER FT 2 M/N. CONCR� TE CO KER CLEAN SANG 77 a• 0,4C,rC�ILL q` 24AYER �:•-• IRON PIPE J/8 MIN:P/TCN WA StIFO S727NE SEPTIC TA NK • ► • • . . . • r : BOX a` .i • • •EFFECT/VC r • • i 3�4 - �2� o� WASNED STaNE OCPTH • 0 • • • • • • • • • • •- + � s ...• • • •. op a sp s• + • • • • • • . o ••• PRECAS T SEEPAGE 4-77.1 G��C7' . ' • o. • • • • • • r t o P/7 OR EOU/V lNV4wA-1! L•tEi/AT/ONSSOD • a EL= RS.o lNYERT:AT Ot/lLDING 10 o FT G D/AM. lit INLET'.,.SEpT/� Ti4NK 10 1,.8 FT rcAAgc�-r-r : . S4q .G./D C� FT 0%4M. CCSEE7AAVLATION�': "OUTLET SEP7l.0,TANK 0 : F7.' . /INLET DISTRI�LIT/GN 80X 101.4 FT. SECT/ON OF . GROuNO IiTER Ts�LE `. Ot/TLET'D/..STR/B�/T/ON BQX ►of•2 tr SEys/AGE OISP�SA L SYSTEM - • - lNL.FT'LEACHING PIT I OI •O' FT. TABULATION. 1.L EACHI"4rw PIT SCALE /_o"`. DIMENS/oIV A DES/GN CRI TEA 1A o��Fxsioiv 8 � FT- N41.4f8ER OF BEDRGOI`!S 3 DIMENSION C -FT. .(M Ih:1 GAR6A6EDISPOSAL !IN/T Noun SO/L. LOG SQ/L TEST TOTAL. -3Tl1-1X'Eo FLOrt/ 33y GAL.�DAY SO/L TEST A/ SOIL 71�ST#2 NUMBER. 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