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Home My WebLink About0298 WILLOW STREET - Health Willow Street West Barnstable R A=131-023 , V � n_ t ti a .. y e ' r n f r, N ,Fi4x i V. u, a „ _ m c r r ' - F _ - a apj�,jv� cl .421d 1/3 � LIJ ~/ 1. At a a t z-, ui=uu Town Boundary 12J-aSE: Parcels FY2017 131-021 Address Street Numbers #295 °`?•n! Buildings Decks/Patios 19[,W Above Ground Swimming Pools 131-020 � OEM In Ground Swimming Pools 307 Paved Walkways �(. Unpaved Walkways T.sw Paths - i 131.:d57 a� " Stairways iT Y 0 1 yyQQ bt.� Paved Roads C Z7:j Unpaved Roads ) :.� Paved Driveways /Driveways - Un aved / P S -^ Painted Lines / 0 . Paved Parking Lots Unpaved Parking Lots IM Bridges —4— Railroad -}- :h Fences —�— Guardrails —n— Retaining Walls 'i,x � cr�a Stone Walls - Other Walls $` 131-023 Hedges #298 ' :• Sorts Areas ... .-Golf Areas '01 \\ Docks/Piers s� el I.M.W'��.x \�- \ ® Boardwalks Jetties Streams w '• ��\ — - Drainage Ditches N / tom' Marsh Areas Water Bodies ••:•;,,.Wi:;''{••:. \� Y Spot Elevations(NAVD88) � �'��'•'.%'� ''•`,,:•�:'�.• Topo to ft Contours(NAVD88) Topo 2 ft Contours(NAVD88) . Wooded Areas ' < Street Trees Catchbasins '� k * Monuments Lamp Posts Satellite Dish mManholes 01M Fuel Tanks 131-026 Q Utility Poles V®Water Tanks #340 Signs Flagpoles Town of Barnstable. Data Source Human-made features, Disclaimer This map is for planning purposes only.It is 1 inch=60•feet N hydrography,topography,and vegetation were Parcel lines on this map are only graphic not adequate for legal boundary determination - - Feet Conservation Division interpreted from 2014&20o8 aerial photos representations of Assessor's tax parcels.They or regulatory interpretation.This map does no htto://www.town.barnstable.ma.us and may have been updated from more current are not true property boundaries and do not represent an on-the-ground survey. 0 15 30 60 90 120 W E r - s Commonwealth of Massachusetts Title 5 Official Inspection'; Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Willow Street `'' Property Address ML James Crockerh Owner Owner's Name -- information is required for every Baiytstable MA '02668 August 4, 2015 page. /Town -- State Zip Code Date of Inspection �1 r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, use only the tab 1. Inspector: J # key to move your cursor-do not Michael DeCosta Jr. use the return Name of Inspector —------ — key. P —.._-------- —----- Wind River Environmental Company Name — --- ---- 577 Main Street Suite 110 Company Address --=--------------- ——---- �^ Hudson MA _01749 City/Town ---- Zip Code 1-800-499-1682 State_ _ State Telephone Number License Number ---- B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further E aluation by the Lo al App ving Authority August 4, 2015 _ sp s Signature Date --The system in ector shall submit a c of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of mpleting this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection : Form Subsurface Sewage Disposal System Form -Not for Y Volunta ry Assessments M 298 Willow Street Property Address — James Crocker Owner Owner's Name information is required for every Barnstable MA 02668 August 4, 2015 page. Cityrrown State :Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inlet cover on riser to 2" below grade. Outlet cover T below grade under walkwa 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 Ofricial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 298 Willow Street Property Address — — James Crocker Owner Owner's Name information is required for every Barnstable MA '02668 _ August 4, 2015 _ page. CityTTown 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 FT 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Willow Street Property Address — James Crocker Owner Owner's Name - information is required:for every Barnstable MA 02668 August 4, 2015 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 ❑ ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection. Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Willow Street Property Address -- - ---- -- James Crocker Owner Owner's Name information is required for every Barnstable MA 02668 August 4, 2015 page. City/Town . State Zip Code Date of Inspection �.. B. Certification (cont.) Yes No El ® 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 its 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 janalysis, 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 nitrogensensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone IL 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Willow Street Property Address _ James Crocker Owner Owner's Name - information is required for every Barnstable MA 02668 August 4, 2015 page. City/Town State Zip Code Date of Inspection C. Checklist. Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms 3 (design): Number of bedrooms (actual): 3 --- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330�pd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Willow Street Property Address James Crocker Owner Owner's Name information is required for every Barnstable MA 02668 City/Town Au ust 4, 2015 _ page. State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Well — Detail: On well water. Sump pump? El Yes Yes ® No Last date of occupancy: currently _ Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) -- Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 298 Willow Street Property Address James Crocker Owner Owner's Name -- - information is required for every Barnstable MA 02668 August 4, 2015 _ 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: Wind River Environmental Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1,000 gallons — — How was quantity pumped determined? Previous pump records Reason for pumping: Check structural integrity of septic tank 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 w 298 Willow Street Property Address James Crocker Owner Owner's Name — information is required for every Barnstable MA _ 02668 August 4, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known)and source of information: Approximately 40 years old per owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 42 inches feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 175 feet _ feet --- Comments (on condition of joints, venting, evidence of leakage, etc.): All joints sealed. No leaks. Vent on roof. Septic Tank (locate on site plan): Depth below grade: 3 feet feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: _ years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x 5'x 4' Sludge depth: 6 inches t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 298 Willow Street Property Address James Crocker_ Owner Owner's Name _ information is required for every Barnstable MA 02668 August 4, 2015 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 32 inches— Scum thickness 4 inches Distance from top Of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 15 inches How were dimensions determined? tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover on riser to 2" below grade. Outlet cover 3'below grade under walkway. Tee's are in good condition. No filter installed. Liquid level normal. Moderate solids and sludge. Tank is structurally sound and not leaking. Recommend installing a riser on outlet with the use of a filter and to pump tank annually. Grease Trap(locate on site plan): Depth below grade: _ feet -------—- Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El 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 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Willow Street Property Address James Crocker Owner Owner's Name — information is required for every Barnstable MA 02668 August 4, 2015 page. Cltyfrown 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 El 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 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Willow Street Property Address -- James Crocker Owner Owner's Name information isequired or every very Barnstable MA 02668 _ August 4, 2015 page. City/Town State Zip Code Date of Inspection D. Systems 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.): Distribution box is 42" below grade. Box is 16'x 30". Distribution box has 2 outlets both accepting equal flow. Liquid level normal, minimal carryover. Distribution box is sound not leaking. 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 298 Willow Street Property Address — James Crocker Owner Owner's Name information is required for every Barnstable MA 02668 August 4, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 @ 6' x 6' ❑ 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.): Pit#1 has S of available space. Pit#2 has 40"of available space. Showing no signs of hydraulic failure. Vegetation is normal. 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 cf cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' H '< 298 Willow Street Property Address _ -- James Crocker Owner Owner's Name information is Barnstable MA 02668 August 4 2015 required for every _ � , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: - --- Dimensions Depth of solids - -- -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 298 Willow Street Property Address — --- James Crocker Owner Owner's Name -- information is Barnstable MA 02668 August 4, 2015 required for every _ g page. Cityrrown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•'•r 298 Willow Street Property Address James Crocker Owner Owner's Name -- information is s Barnstable MA 02668 Au ut 4, 2015 required for every _�_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 + feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Aproximately 10' to the bottom of stone in pit Pumped pit and observed no groundwater inflow. 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 298 Willow Street Property Address James Crocker Owner Owner's Name information is required for every Barnstable MA 02668 August 4, 2015 page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 m .�� ,x '' .. -� -. ._.... v ;` j 1 � �� .�' � ` � � �. ,�� `` ''� \ n t��' `�`� _, � - � . , .„�;,, t � ,:� .,,.. �""'�` - "? _. j TOWN OF BARNSTABLE �� ,[J UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS A e ASSESS ORS MAP NO. PARCEL NO. ADDRESS:,-� '�r&,Y&a,�e ST VILLAGE' 14AM Ell __ CONTACT PERSON PHONE NUMBER -- �� LOCATION OF TANKS: - : CAPACITY: TYPE- OF- FUEL. AGE: TYPE: LEAK OR CHEMICAL: DETECTION T(9��C�� `'h� /�`' T- f1 fI / s SYSTEM! DATE OF PURCHASE OF EACH: 1. 1122 - 2. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. &so }�l liCi+ �- �. s � �' jai` c �' , , r `YS c� No.....................�05 _ THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH ...................O F...... .. /ct/1.... ..... Appliratiun for Disposal Works Tonutrur#tun 1rrutit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: . .................. .... ._......--------....----- Laca'o -Aid ss or Lot No. W •- ..� .. r ---- Address._.......... •••• ....... ........ a . . ......... ................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet �-+ Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.--------------- Depth................ x Disposal Trench-No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.... •.....---•-----••-••••-••••••••••-•-••...--••••...................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.......... .......... Depth to ground water.... LT4 Test Pit No. 2................minutes per inch Depth of Test Pit----................ Depth to ground water....................--.. 9 .-••••---•-•----•--•---------•--•••••......••-•-...••-• ... .------- -.......... ••------- -------- ------------ ----•-•--------------••-------- 0 Description of Soil--------------------------------------------------------------------------- W W •-••••••••••-•-------•••----•----••---•-•••-•-•-•••••-•----•-•-••-••-•-••-------------•-••----•----•--------. --•----•----•-• =� U Nature of Repairs or Alterations—Answer i he a ll -��icab .A-8-�_ �•_----- � - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT:is 5 of the State Sanitary Code— The under ned further tl:er agrees not to place the system in operation until a Certificate of Compliance has b n issued by t and o iealth. Sig .d. _.. -• . -- -------- p 0. Dat f Application Approved By-•...-•-•--......••-•--. -•-• • .. ....... --................... Date Application Disapproved for the f ollowi reasons------------------------•-------•------------------------------••------------••....-•--•. . ..........._..... --- ----------------•---------•-----------------------•--------------- ._. Date PermitNo......................................................... Issued_........................................................ Date No.....0 6......... . FEB.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for YVispusal Works Tonstrurtiou Vrrmif Application is hereby made for a Permit to Construct ( ) or Repair (z-,)-an Individual Sewage Disposal System at: •- //' Locate° -Add sst �"r or Lot No. "'_. ...._ Zr. 1 :% :.•, _1?•. 7�,/.r•/.............................. ............................•-------.......----..............------........................-...... Address ........................... ............................................... ---- ..... ------------------------------- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a Other—Type g ____________________________ No. of persons......................... Showers ( ) — Cafeteria ( ) d Other fixtures -------•----------------=------------•-••••....•---..... W Design Flow.....................:......................gallons per person per day.f Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length.........../ /�_Vidth'............... Diameter......-------.-. Depth............ x Disposal Trench—No..................... Width.................... 7Fotal Length............_....... Total leaching area....................sq. ft. 3 Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit into. I................minutes per inch Depth of Test Pit..........0......... Depth to ground water....:.................. .. fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ... •----------------------------------------------------- •••-•-•-•-•o-••....---•---••-.................--••-------••-•----•••-•---•••---•-----•....•-•--.•-- 0 Description of Soil......................................................................................................................................................... U W U Nature of Repairs or Alterations—Answer when ap p licable....1!_4. _�: .- A i-2-.�.� a? s•,_••••••--_----: -----------------------------------•--••-••-•-------•--,t..&A:0-- -�!.. - ................................... Agreement: The undersigned„agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. Sign d. ...-. r' ,r3 = = 4 ---• - r y at .:' i Application Approved By........................ �/.� ... ..-. I.,}-� �. ---- -�•,-fit=,--...._..f,< 1� ----•------ - -- Ii ^ Date Application Disapproved for the followin / -e¢sons:........... ............. ......... / � ' 1. -•••-••......_•••--••--•r f_. -_•-•--•.......................•-•......--••-•••....•... .........•..... Date Permit No......................................................... Issued _ ...._ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .....OF...... ................a` ........................ (Irdif iratr of Tomptittnre THIS IS TO CERTIFY, That,,the Individual Sewage Disposal System constructed ( ) or Repaired by...................... ati .. - - `" —........ .... ` ...................... ...... .. at............... . ....... /. .t;. YT .* sea 1 .* ,2_ �C_G! a_.... •-•-•-...... ---• .......................................................... has been installed in accordance with the provisions of TIT T' ` of The State Sanitary Cod a des bed in the application for Disposal Works Construction Permit No.- ... dated..............f ..._. ... . . THE ISSUANCE OF,THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a0 //�" .... A •\:l---- FEE............... No......... ��15 ......... DisposalWorks TowArmtion frrmit Permission is hereby granted............ ': . =- = r--..+- == to Construct ( ) or Repair (I,-) an Individual Sewage Disposal System L� 1-- N o.. , at ` f t_ r fly?y�._...: t___�.------.... f� h�- / rtjr 8 p� '� .�` ..•y L�'(/�i�\,././ G�„%' � .`�1.. - LatC 1- ---- ---• ----`--•-�--0....... Strcct as shown onthe application for Disposal Works Construction Permit No ---•-f--•---._., -- _ ... --------- ------ - :............-- -------------------- DATE.....-----_---------I---- � �- Board of rf ilt .. - jY N .•� 1t Lv7'/y �, �. 717- / 3 � LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER S NAIVE $ ADDRESS 0UILDEIt OR OWNER s _ Wr DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 7— 9" �� . w ,« o � sT 07? No...................... YmB ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD ( = HE WLT a4 ............f*64-M. ...........OF..._. . . ...... ..... ............................... Applir4tion for Di-oposal Works Tontitrurtion ramit Application is hereby made for a Permit to Construct (X) or Repair an Individual Sewage Disposal System at: A/ dv�.w...�ael_p............................................................................................. ...........g Location-Address or It No. V...................................... .. .. .V . Owner Address ld�h,x iiyl,omp,i.......................................... .....eenm ......... ...................... .... ................. Installer Address U go q. !4 Type of Building R,�q/Z/C# Size Lot.3....,.9,pde?_�----S. f t Dwelling—No. of Bedrooms.__.....................................Expansion Attic Garbage Grinder Other—Type of Building ........................... No. of persons............................ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow...................... .........gallons per person per day. Total daily flow............ ....................gallons. 9 Septic Tank/—Liquid capacity.M.O.O..gallons Length_............. Width..._._.._._..... Diameter.............._. Depth............._.. Disposal Trench—No......../......... Width.................... Total Length.......... ........ Total leaching area—V7t.,f7sq. ft. Seepage Pit No....../............ Diameter......./-Y...... Depth below inlet..... ......... Total leaching area..jAnf..._sq. ft. Z Other Distribution box Dosing tank aJh A Percolation Test Results jerformed by._J5.7kkVA.R.D. ................. Date...4/0Z...2a,. . . Test Pit No. I_1_3?.......minutes perinch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit..__................ Depth to ground water......_............._... ................Ww..... irp,-----------/ 0 ....... r a Description of Soil...1—7 _11;:4........ ......�r ... .. . ... .............q...t.. 4—-------lr_ --------------------------------------------- . ..... .....*" .................................................................................................... ... ---- -----�_ .......... Nature of Repairs or Alterations—Answer when applicable_ —--- --- U X�4�. ��4" --------------- ----------- ....................... ............. ........... 1�1�..*.O".�e.............. ........... ---------*...... ------------------------- ------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'"LITiZ 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. Sig �d... .....*......*..................*'*'*----------------*-------------*----- ... -------- -- 2 's - �_ -'130tp, ApplicationApproved By..... ................ ............................ ........................I.............. Date Application Disapproved for the following reasons:............................................................................................................. ......................................................................................................................................................................................................... Date • PermitNo......................................................... Issued ........71.1.......13..!..................... Date _ . No....................... �, FE$..... THE COMMONWEALTF� OF MASSACHUSETTS : Y BOARD HE LT ...........t . . . ...........OF....... ........................... Appliration for Disposal Works Tonstrnrtinn Vamit Application is hereby made4or a Permit to Construct ` or Repair. an Individual Sewage Disposal '_• z System at: .. .... f f�' /f !; ...E .:.tali hr.l s ry.., .---------------•--------•---•------•- --• •-•-----------.-.----......:... Location-Address or Lot No. ................................. Owner address • -� ,f [._... ---•-•••..........................•••-----.......... •--•-••.(. p .... '.'. ..0: ... .... ..?: %.`=. ......... v Installer Address Type of Building l?,f tiles Size Lot.Z.I.f P ...Sq. fee U a Dwelling—No. of Bedrooms....... ------------•---•----•--•-_--_-•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..........._.Zd A................_..gallons. 111 WSeptic Tank 4L Liquid capacity.0.&la.gallons Length................ Width................ Diameter................ Depth................. x Disposal Trench—No........,/_.......... Width.................... Total Length....... Total leaching area.-f 7,.Z7_sq_ ft., Seepage Pit No......j......._.... Diameter........1�(..... Depth below inlet_.._..._....__ Total leaching area_..) .?:e..sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results " Pe'rformed by.._ u1 p21e'r _.. __11C. �. . .............. . f/0Z...� ,_.t.57,? 4 � ,AA4 Date Test Pit No. 1:.._.s '...._..minutes per inch Depth of Test Pit.................... Depth to ground water........__.............. fs, Test Pit No. 2.................minutes per inch 'Depth of Test Pit...............•_::_:Depth to ground water.....i.................. ,�) �- . �..... .... ••.: • 7 : O Description of SoiL...._--.... �!dt/ lt.�..i ...A v. 3r, ...r� 1..� 'f•�{tMl x _........... - • w q = ---- t ••••-•••---•-------------------•-----------••-•-•-----••-••-•--•-•-••••--••-••....-••••...........-• -- .... •, -------------------- V p — when,applicable .r , +. - ..... ... e ....................ature o -:e--airs otx�terat�ionsfl•_... nswer ...:.....-•---------•'- --•--•- -----•-- ----- ...-- Agreement., i -�^ + :x The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisionS'of TITL;,: 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. Sig d- '-••- __ �t �j e Application Approved BY.......'f •• t. d%"� ..... ................. .................... l............ Date Application Disapproved for the following reasons:................. -• -......--•••••---••-----••-------•••••-•-:.........---- •--•---•..........-- Date Permit No...... ... Tssued-... -••-•----x ------ --Date ••••................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT .................ION. ..........OF................... "........ �r�ifirtt#r ,af f��rnt�rli�anrr Aei IS. TO CE .TIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by........ 1,? .. ......... ••-•_-•-• .................................................. at ,-"V'4 a ... ns .. id�i'�j i u!I!��. •----- hastalled in accordance with the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. ...... .:$s............... dated-...,S--':-9'_-_7.�.,.._.._.............. THE ISSUANCE OF THIS CERTIFI,CATE':.SHALO NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY A/c:,'al DATE..------�......P....` ... ..................... Inspector...-•-• ................................ a£ „ THE COMMONWEALTH OF MASSACHUSETTS �- BOARD �s HEA-LT _ .... .........OF...... .... �...~. 1! �}......... ......... No.................. _._ f . > FEE.__... iA in tt 'g' rks T s#ra iaan rranit Permission is hereby granted__.--- - :----......-•-----------------•-•--- /,,�.-� _.. ---...... . to Constr 'LCV"4 � �`epai ( ) an In ' 1 Sewa a is System jj�} at No.. ...!!k, 1 ....... rTr:.. `......- ' a LLy'J ..... ' Y Street as shown on the application for Disposal Works Construction Perm' o.._._.. ..__ Dated.._._. f Boaid of Health DATE........................ •-•...•••-••......--••-----••-•-••-••-••••-- y --•--- /)�r �� /�•� .► / ..,��Vim.. ��C.L.(„� FORM 1255 HOBBS;& WARREN, INC.. PUBLISHERS Sf�E�T Z OF Z 3�/CC rs vio u; /9�'>zI�}cr � .. _ 75 aE ,4'rioVeD r*e A /7' g. .... rco H 7riE C� � r6 , TOP OF FOUNDATION oc 7�1/E- ZZ-4Cr/ P17- + , x&'7-4,4cev w/7-P CZ--A-X-' D CONCRETE COVER CONCRETE COVERS 1: 4' CAST IRON 12 �� RIPE (OR 12"Max. • '• ' 4��ORANGEBURG(OR EQUIV.) EQUIV.)— MIN. PIPE- MIN. • � PITCH I/4"PER. LEACH PITCH 1/4"PER.FT. PIT e � PRECAST INVERT a ;�+:: LEACHING +'0NEL.,�Q•!9••• INVERT INVERT > . a•;' PIT OR e'. SEPTIC TANK DIST. q8;/8. , ' EQUIV. EL.4��A .. EL... >x .•: INVERT BOX +o, •• .• GAL. INVERT INVERT �` v°' 3/4"TOI1/2' EL ,r>f a EL:476o w w w Lu WASHED i ,.. w STONE 6'DIA. —+'I .• •. ., �--- /4' DIA. PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED. BY : DATE Ya? ZZ/yI78 TIME.q:3o Ail. . v�- Mt�.e,2 BOARD OF HEALTH TEST HOLE .I TEST HOLE 2 Tfi��I7'�S . 4�444�>e. PE ENGIN EER ELEV. .sfZ, * . . . ELEV. .: �Go . . . • wooCLeAry DESIGN DATA : •..., ' s�a.e.� ,yN Lt" ? S�oSe.a NUMBER OF BEDROOMS 3 34 ' -TOTAL ESTIMATED FLOW - 33p . . . GALLONS/DAY +.� , •'. oBh�xrv¢t'' PEYC 7 swo BOTTOM LEACHING AREA !S35 •SQ.FT. /PIT / 7S%3 / L SIDE LEACHING AREA . . . . SQ.FT./ PIT ,yam,,,,, Ss►..o GARBAGE DISPOSAL .!MR1,!E:.(50% AREA INCREASE) Ss►.wa /�" • �; TOTAL LEACHING AREA .3Z�1-f? SQ.FT v 9 c PERCOLATION RATE MIN/INCH LEACHING AREA PER PERCOLATION RATE SQ.FT. ......WATER ENCOUNTERED NUMBER OF LEACHING PITS .I P/T W!>�/•�sv� �'�T o/�Si'n.uE-o.v R2 C Si pC-,S, z .2G./ Ta✓S# of APPROVED . .. . . . . . . . . . . BOARD OF HEALTH • • • • . . . . . 37a�E PE7r PiT THOt1AS E.KELLEY CO. DATrs . . . . . . . . . . . . . . . . . . . . . . . . . . ENGINEERS—SYJRtiYEYORS. . . . 346 LONG POND DRIVE AGENT OR INSPECTOR SOUTH YAR. LOUTH,r 0256.4 jl�OF MgSSq '► THO EDWARD A:j ,Ev `y 60 0 GISTS(' .' �cf IONAL PETITIONER E D •1�t/A��.F L � . . ASS �.v-::::�'' - ... - Al T Iviv wAy d o w 17' P/T 1 f _. All — ,qtL /rlpC2VioLos Hf,n- mot. cc of 1pC- ZEAc 4 PIT P S N ct�,ci� w•rr� A � �X a.'4`i8�r:� �A j pa• .` y o o SEC f ( � Ci t2�'Y.70iPP of I � - 1 S3.Do — -► "—' N os6v E. SU-1 ,�� ►y11• -a c ram" A CERTI EI ED PLOT PLAN LOCATION SCALE .�//=6o'. . . . DATE T�_?4/y79 PLAN REFERENCE .4 E Al �r z. ..... 1 - ¢G I CERTIFY THAT THE .: .,�.;, SHOWN ON THIS PLAN I�tL0 ]',��N THE GROUND AS SHOWN HEREON A?i.::,'f_ 'F If CONFORMS TO THE T Z SETBACK REU�R�hI OF THE TOWN OF 7— . . ' ' .. . . . . . . WHEN CONSTRUCTED. WiLCO� .STD-Et DATE . . . .. . . . . .. . PETITIONER;* yt/�Y'CCF'iE�J� ASS. REGISTERED LAND .SURVEYOR r,U TOWN OF"BARNS'rABLE J� LO(9,:A'TION, / SEWAGE # U� VILLAGE°! rZAP14,1 �`. ASSESSOR`S MAP 6a LO J. F. KENNEDY TRUCKING ^,� 3 INSTALLER'S NAME & PHONE NO. 5 WILE.C"W CTREET 6` ST BARNSTABL� MASS. 02668 SEPTIC: TANK CAPACITY LEACHING FACILITY-(type) �� (size) 1000 NO, OF BEDROOMS �j PRIVATE WELL OR PUBLIC �VATF�t }BUILDER OR OW�NER� ✓�(�'�� DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED__ _ VARIANCE GRANTED: Yes No (� f1e¢ Aq i VA ' e ASSESSORS MAP NO: t- PARCELNO. .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , TOWN OF BARNSTABLE App iration for Disposal Works Toustrnr#ion Frrulit Application is hereby made for a Permit to Construct .( )tor Repair ( ') an Individual Sewage Disposal Z system v�%- eez.-A � �= =1� .. Locatio Address or Lot No. 1 n _ y� f0I/ Address ,Wa •---•... . .. ................... .....--••-•......•• .....�------ __��"J� �t'/- � ......... -•--------------•---••--- � Installer i Address T of Building �, Size Lot............................Sq. feet U Dwelling No. of Bedrooms_._ ---------------------- -----Ex Expansion ` ttic g— _._____ p A, ( ) :a Garbage Grinder ( ) p`4 Other—Type of Building ............................. No. of persons.............................,showers ( ) — Cafeteria ( ) W Other fixtures ---------------------•---------- -----•. . -------- -----•--d W Design Flow............. .(f)-4..........gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------- _L�� Diameter.................... Depth below inlet_................. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------••--------------------_-------------------- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------•---------------------•------•-•--•-------------...._..------.................••.......---....••••-•••••....._.....----•-----.........-••-----•--- 0 Description of Soil..............................................•---••----...-----•----------•--•------------------------------•----------•-------------------------...--•--------------- x c, x ---- ----------- - ------ -------- --=------------ ---- f U Nature of Repairs or Alterations—Answer when applicable_.....__ _ . . _�.1, '---- ---------- ---------------------------------------------------•----------------------------_ •- ---- ------•-•-- ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environme—The and signed further agrees not to place the system in operation until a Certificate of Com4ft? s by t board of health. Signed Date Application Approved By .. .... Me F Application Disapproved for the following.reasons- -- ---- ------------------------------------- ---------_....................................................................... ------------------------------- --------------------------------------------------------------------------------------- --- ------------------------------------------------------------- -- -.... ....................------------I...... Date PermitNo. --------- _ --------------------------------------- Issued ----------------------------------------------------------- Date !� f No.... .��" �...... Fxs.•• ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - TOWN OF BARNSTABLE A v tra tun for Di-quiittl Worko Tonstrur#tun Vamit Application,is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal R System a�1 � t% i/l. ......... -_... ....... ..•--.. ......--•--- •: -----/-••--••-----•................ •----------........_....................__...... .---••---..Wig... . .. Location Address or Lot No. 1....................................................... ---------------------•---•------------------•--•----._.........--•---------------•--•---••------- W �� Own i' � < Address _ �a ..__._...---•--...-: ....------•........:...................................................�J......_... __._ ............................................................. �f Installer Address "� Q Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria QI Other fixtures -------------------------------------------•-------- ---- . -••------------------------------•---•------••--------------• •------------------_------ W Design Flow............�� ..............gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..___.__- (r.X'f Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( r Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit___________________ Depth to ground water........................ Gz, Test Pit No. 2........._......minutes per inch Depth of Test Pit.................... Dept,to ground water_-___________________-_- t P1 ----------------------------------------- ----------------------------------------........................--------------------------------------------- ODescription of Soil...............................------------------------------•-------•--...--=--------------------•--•-------------i'----•--•-----------•-•-------•--•----•--•--•--•- x U --•----•------------ ------------------•-•-------- UW ------------------------•---------------------=----------------------------------------------=----------------------^-------------------------- --•--______ Nature of Repairs or Alterations—Answer when applicable--- -��-•'-� �_.. _ .2 �'"�r" , � ••-- ---------------------------•.......---•--•-•-----•---•------- --•------ /l r.! - --------------------------------------------------- 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 Compliant�hLbeenoisssuueec(by the board of health. in d ��/ .fir( �S g e --------- A , ..................................-.. '- �ce-._-...--...Application Approved BY ..... ...• ��,_. ......._. ... ---..----r ------------------------ ------ -=-��--r Date Application Disapproved for the following reasons: --------------------------------------------- ----------...---------------------...-----------------------------...---- Dare Permit No. ..... ��/7, Issued r'--.... ----------------------- -.......................... ...... Date THE COMMONWEALTH OF MASSACHUSETTS JBOARD OF HEALTH TOWN OF BARNSTABLE Gertifi ate of (gontlatia nre _ THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ��:----------IAA.,�� Pew ................................. -.. 1 -------------------------------------..--...----------------.........----------------------------------------------.. -.-......4.---- Jr�Installer at ---..1:..<- _-----1,t -j< r.. 1�,�....-...% .==, -=- .-n ,r - 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. .(:74/- _��----. .... dated ---------------------------------------..._--_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI/QN SATISFACTORY.- DATE--------- --------f-. ----------------?........................ Inspecto ---/�%............ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f0 TOWN OF OF BARNSTABLE NOIA................... J FEE. . ........ Wapaoal Works Tonstrudion Nermit Permission is hereby granted---------...................................:.:..................•----•-•-----•---.......-•-------._....------.....----•-••--••-•---...... I to Construct ( ) or Repair an Individual Sewage Disposal System �+ -- / // .-r 7` w .. 1' >................•-----------•-•--..._••---•••••-- Street _ as shown on the application for Disposal Works Construction Permit No.....: ........... Dated.......................................... 1 Board of Health DATE ---'-�--."-��--------------•------•------._.....----- FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS