HomeMy WebLinkAbout0011 CAPTAIN MURPHYS WAY UNIT BLDG 1 UNIT 1 - Health Way
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TOWN OF BARNSTABLE °
LOCATION l-oro`t- AU�194La U',A,/ SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT - '9B
INSTALLER'S NAME & PHONE NO. 4 w4 V-
SEPTIC TANK CAPACITY ! anv�j
LEACHING FACILITY:(type) Q'g-G.44S1- &T- (size) Clr6 jd34
NO. OF BEDROOMS PRIVATE WELL OP -IC WAS
BUILDER OR OWNER ,b FQ f1(22-2
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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L4 X
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA 'LTH.
0 LA.:I.��........ F ..:...&Z,.
.. ............... ..0 .................. .............................
Appliration fot lhiipaoal Works 6uskrurtiou'prrmit
Application is hereby made for a Permit to Construct or Repair 4+-a�i-Individual Sewage Disposal
System at:
. .........................
e s.Location--Addrf.�Y
r or Lot No.
.)r.........T...............................
........... ...................
.....
----------***"*---------------------
0-n
.................. . ... .... ..W. Address
.......... .......7. b......
$4 .......?...........4C...........................
Installer Address
Type of Building Size Lot............................Sq. feet,
U
Dwelling—No. of Bedrooms....Q_jT!C-5....................:.Expansion Attic, Garbage Grinder
Other—Type of Building ............................. No. of persons............................ Showers —Cafeteria
Otherfix es ......................................................................................................................................................
Design Flow........:.15L?X
...........................gallons per personpFr day. Total-daily flow............•.................................gallons.
Septic Tank—Liquid capacityN.rM..gallons Length.: ......... Width._....1..0..... Diameter................ Depth................
Disposal Trench—No..................... Width.....(............• Total Length---........._..... Total leaching area....................sq. ft.
Seep4e Pit No...... .............. Diameter.....I..a....... Depth below inlet_.....q.......:Total leaching,area..................sq. ft.
Z Otho Distribution box ( L.}- Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit............_.....__ Depth to ground water.....................--.
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit........__.._...._.. Depth to ground water............_...........
C4 .............................................................................................................................................................
0 Description of Soil......................................................I...................................................................................................................
..................
---------------------------*---------------------------------------*------------- - ------------------------------------------ --------7-------------*---------........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.... A--------1,0 1M. ..- �..
........... ...............................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITAM 5 of the State Sanitary Code z-- The undersigned further agrees not to place the system in
operation until a Certificate of Compliauccla&.1rw issued b eiTlj�Ith.. ...... .
--------- .... ... ..............Signed.-- ........ ......
........... .. ................
Date
Application Approved By..................C�-?- Z_,t. ..
'Date
Application Disapproved for the following reasons:................................................................................................:........._7
.......................................................................................................................................................................................................
Date
PermitNo............ .................. Issued........................................................
Date
No._ Ll 79 � �. -, FE$...� _�...�...._
' a 1 '7 CS � � '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........oF.. -1�,.. ?. r�5� ca .
Appliration for Disposal 18orks Tonstrurtion Permit
Application is hereby made for a Permit to Construct (' ) or Repair ( I-)=an-Individual Sewage Disposal
System at:
....... l._�..___•G V9:1(T .;tVt1112.1/)-��'�• (ZIS� Ci. ,h - .......:.....
.... ..
Location-Address r or Lot No.
Owner Address
- -- , -- -•-•--------= -------•------------__ ______-
Installer Address
Type of Building Size Lot.................... .....Sq. feet
U Dwelling—No. of Bedrooms.•_. .. :�.. ....5......................Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—Type of Building No. of persons.................•...._..__. Showers
YP g -------------•-----•-------- P ( ) — Cafeteria ( )
dOther fixtu es ..---•--_._. --•..................•-•-.•------__.._.._.......-•-•-••--•--••_.._...........-•---...---•--•........_•---....__••--_.....
W Design Flow._._...__.<._1....................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity A SM.gallons Length..-_Z....... Width_.... (....... Diameter................ Depth................ .
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.....J............. Diameter.....1_a...... Depth below inlet....... Total leaching area..................sq. ft.
z Other-Distribution box ( Q Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
�
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to.ground water....................,...
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
19 ...........
---------------------------------------------
___--------------
_..........
••••-•----•----------------------------
--•-----••-• ---------
0 Description of Soil........................................................................................................................................................................
W
V .......................
•----------------------------
---••----------
--•----------------------------------------------
•--------------------------
•-----------------------
•-•---••-----•------•----•-
W
UNature of Repairs or Alterations—Answer when applicable....
......0._- Ox--........`^�-xtc• opx- , ill �--3�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system-inf
operation until a Certificate of Compliance has been issued by the-boa-rd-of health. '
PP PP Y S ne d. ,�` - Date
..
A
g
Application Approved B *-------------- .......
L7 Pate^
Application Disapproved for the following reasons.....................................--•••-•--•------•--•-•--•-•---•-----•-•-.._...-•••-•-----••....._----•----
. .................•-••-•-•-•--...---------•------•--•---•---•-•-•-----------------•----------------------•._:.. .....•......••-•----••••••..._.....--------------•-----••--•-••--------•........._._....
Date!
Permit No.............. ��.= ... g....... ........ Issued ............
Date
————————— __..—_ —————— ----_� —r— ——————------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
®wY.`.-.'..........oF.��w�T�6�-e .....................................
Trrtif iratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bY....................... ---•---•----------._....._................----.........--------..............._....--•--•------....--
Installer
at........................... 1......C.'sp:%7••--•Ah.O•9-_c)..k. , ---••--- --------------------
has been installed in accordance with the provisions of TITL 5 of The State Sanitary Code as described in--the
application for Disposal Works Construction Permit No......F_6.-__1.78.......... 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
__ � !. ..........o F. •V���G=•lip.�' ................................... r--_
No.._ ....!7 sl. FEE.... )-.......
Disposal Works Tonstrnrti t, rrmit
Permission is hereby granted..............O)R-e...l.• 1 wl/1 - ' --•-•-•-•- .....................................................
to Construct ( ) or Repair (cyan Individual Sewage Disposal System
at No...............0.... ras-- Jln. , V)l r !tt=o 1
I Y YStreet
as shown on the application for Disposal Works Construction Permit No..g$:-7�.=Dated.._..•....................................
. In
................................... -...... _•........ .............................................
Board of Health
DATE.._.. �W Cl a ----------------- /
Commonwealth of Massachusetts 5/ 7-®3 D
Y Title 5 Official Inspection Form pr45s,6d
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rvt,G rt-
11 Captain Murphy's Way JJ
Property Address
Kari Anne Hart
Owner Owner's Name
information is
required for every Barnstable j/ Ma. 02630 June 25 2015
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
, filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Thomas Roux
use the return Name of Inspector __
key. 3,��,f i1.46aa�d Fja7_e��ii,
"ICI Company Name j
89 Mayflower Lane
Company Address
Ion East Wareham Ma 02538
Cityrrown State Zip Code
774-678-9066 S14531
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. 1 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 Evaluation by the Local Approving Authority
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630 June 25, 2015
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by ,
the Board of Health,will pass.
s .
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):
M -
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is required for every Barnstable Ma. 02630 June 25 2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cost.):
❑ Observation of sewage backup or break out or high static water.level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ 'ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ 'Y ❑ N ❑ ND (Explain below):.
,
C) Further Evaluation is Required by the Board of Health:
'❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a,bordering vegetated wetland or a salt marsh
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form' 1
Subsurface Sewage Disposal.System.Form -Not for Voluntary Assessments
M s 11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is required for every Barnstable Ma. 02630 June 25, 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 tas 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.F Other:
D) System,Failure Criteria Applicable,to All Systems: . Y
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less '
than Y2 day flow
t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System--Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630 June 25 2015
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within,a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No _ 4
❑ . ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 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
11 Captain Murphy's Way
Property Address
Kad Anne Hart
Owner Owner's Name
information is Barnstable _Ma. 02630 June 25 2015
required for every +
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).
0 ❑ 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(design): 3 Number of bedrooms(actual): 3 .
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): +330 gpd
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
11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630 June 25 2015
required for every Barnstable
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents` + 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No .
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: March 2015
Date i
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? e, ❑ Yes ❑ No
Water meter readings, if available:
t5ins-_3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 11 Captain Murphy's Way
Property Address
Kad Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630
required for every June 25, 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: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool r
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is required for every Barnstable Ma. 02630 June 25, 2015
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
28 years. The installers as-built is dated 8/7/87.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
"Distance from private water supply well or suction line: +30'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: .5,feet
Material of constructiow ,
® concrete, ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal; list age:- years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8'L x 5.5'W x 5.25'H
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Captain Murphy s Way
Property Address
P Y
Kari Anne Hart
Owner Owner's Name
information is required for every Barnstable Ma. 02630 June 25 2015
page. Cityfrown 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
23"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle 24'
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The septic tank does not ned to be pumped out at this time.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 11 Captain Murphy's Way
Property Address
Kad Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630 June 25 2015
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Captain Murphy's Way
Property Address
Kari Anne Hart '
Owner Owner's Name '
information is Barnstable ' . Ma. 02630 June 25, 2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
oil
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 distribution box was severely corroded and breaking apart..It was replaced on 6/24/15.
Pump Chamber(locate on site plan):
Pumps in working order: m ❑ 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:
The pit structure was dug up and inspected.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System rage 12 bf 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner - Owner's Name
information is required for every Barnstable Ma. 02630 June 25, 2015
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/aftemative 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 structure was dug up and inspected. There was 2' of standing water in the pit,which leaves 4'
of void space remaining. The inside walls of the pit structure were clean. The pit could be pumped out
whenever the septic tank is pumped out to remove some of the solids in the pit.
i
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3M3 Title 5 Official Inspection Form:Subsurface S%vage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630 June 25 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is Barnstable Ma. 02630 June 25 2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of SewageDisposal System: Provide a view of the sewage disposal system,including ties to
at least two permalnent 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
\/ IA �S t
dew 92c
to 0t)f
.to
t5ins•3113. Title 5 Official Inspectim Forth:Suhsudace Sewage DiaPoselSystem-Page 15 of 17.
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11 Captain Murphy's Way
Property Address
Kari Anne Hart
Owner Owner's Name
information is required for every Barnstable Ma. 02630 June 25 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
t.
Estimated depth to high ground water: 20' +/
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:
From the website of Digital Models of groundwater flow on.Cape Cod.
You must describe how you established the high ground water elevation:
From the website listed above.
Before filing this Inspection Report, please see Report Completeness Checklist on next'page.
t5ins-3/13 Title 5 Official Inspection Force: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
11 Captain Murphy's Way j
Property Address
Kari Anne Hart
Owner Owner's Name
information is required for every Barnstable Ma. 02630 June 25 2015
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
s
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information-Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
r
r -
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
III
III�L-.,►
d
.` V
BORTOI-.OT TI CONS'1'';: ', .-'TION, INC.
45 INDUSTRY ROAD, MAILS 1:'00 `► MILLS, MA 02648'
508-771-9399 508-428-8926 FAX: 508-428-9399 �"'�%• � ��
V 4�
SUBSURFACE SEWACF, DISPOSAL, SYSTEM INSPECTION FORM
PART A
CIAR'I'I FLCATION
Property Address: . M� ��,"1
Date Of Inspection d U Ins +ec -_Name:
w ier's Name and Addres _*
CERTIFICATION STATEMV'M' .
Certify that I have personally Inspected I lie Sewage Disposal System at this address and that the inlorma
lion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform-
ed based on my Training and Experience in the,Proper Funclion and Maintenance of On-Site Sewage Dis-
posal Systems.Tlpe system
Passes
Conditiouall ses
Needs Fu ie �,valu, 0: 1 y the Local Approving Authoi ity
Failur /7
VJ
Inspector's Signature Date:
The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with'Thirty
(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 Omier shall submit the Report to the appropriate Regional Office of
the Department of Environmental Proteclion. The Original should be sent to the System Owner and copies
sent to the Buyer,if applicable and the Approving Authority.
INSPECTION SUMMARY:
A) SYSTEIyfPASSES:
i V I have not found any Information which indicates that the System violates any of the fail-
ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi-
cated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more System Components need to be.i::eplaced or Repaired. The System,upon
completion of the Replacement or Repair, 3 (!,ses Inspection.
Indicate yes,nor,or not determined(Y,.N,OR ND). Descril: aces of determination in all instances. if"not
: determined",explain why not.
The Septic Tank is Metal,'Cr.cked,Structurally U��sound,shows Substantial Infiltration of exfil-
tration,or Tank Failure is imminent. '.The System will Pass Inspection if Existing Septic Tank
is Replaced with a conformiog Septh-Tank as Approved by the Board Of Health.
Sewage Backup or Breakout or High Static Water Level observed in the.Distribution Box is due to
broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System
will pass Inspection if(With Approval of the Board Of lliealth) ,
- I
A
SUBSURFACE ,SEWAGE,,D.ISPOSAL SYSTEM, INSPECTION FORM
PART A
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is leveled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The System will pass inspection if(with approval of The Board Of Health):
Broken pipe(s) are replaced
Obstruction,is removed.' ° -
C)FURTHER EVALUATION IS REQUIRED BY'THE,BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board Of Health in order to determine it'
the System is failing to protect the Public Health,Safety and the Environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC,HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or Privy is within 50 Feet,of a Surface Water
Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM-IS FUNCTION-
ING IN A MANNER THAT PROTECTS.THE'PUBLIC'HEALTH AND SAFETY AND THE
'ENVIRONMENT:'!= ,•. `.• . ' " �,.
Tliesystem'has a Septic=Tank and Soil Absorption.System and is within 100 Feet to a Surface
Water Supply or Tributary to a Surface Water Supply. > 'r
The System has a Septic Tank and Soil Absorption System and is with a Zone 1.of a Public
Water Supply Well.
The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private
Water Supply Well.
The System has a Septic'Tank and Soil Absorption System and is less than 100 Feet but 50
Feet or more from a Private Water Supply Well, unless a Well Water Analysis for coliform
bacteria and volatile organic compounds indicates that the Well is from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm:`
D)SYSTEM FAILS:
I have determined that the System violates one or more of the following Failure Criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overload or clogged SAS
or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to all
overloaded or clogged SAS or cesspool:
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
X_i ged SAS or cesspool:
in'cesspool`is less tliai�G"'Below'invert or available volume is'less than 1/2
day flow:
Required pumping more tlian 4Ltimes in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
2 _
1.--- x - r
S1113SURFACE S'EWAG1 UISI'OSAI; SYST11,M I'NSPE1 TIONp'VORA'.
PART A .
(;FlITIFICATION('continued)
Any portion of the Soil Absorption_System,cesspool or privy is below the high groundwater
elekation.,, � ,
Any portion of a cesspool or privy is within .f00 Feet.of a surface water su Jply or tributaryy to
a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a Public'Well
Any portion of.a,cesspool or privy,is;within,50 Feet of a.private water supply.well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
-j' compounds,ammonia nitrogen and nitrate nitrogen.
E) LARGE-SYSTEM FAILS:
w, The following criteria apply to a large system in addition to the criteria above: ,
The design flow of a system is 10,000 ggd or greater(Large System)and the system is a significant
'threat to public health and safety And the environment because one or more of the following
coiiditions exist. ?r_
'The s "stem is'withiii 400 Feet of-a surface'deinking-water supply i": > P °re;
Y
The system is within 200 Feet of a tributary to a surface drinking,water supply
r-'syste' is located in a nitrogen sensitive area:Interim Wellhead Protection Area
(IWPA)or a mapped Zone ll of-a public water supply well. t;
The owner or operator'of any such system shall'bring the system and facility into full.compliance with the
groundwater treatment program 'requirements of 315 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL` SYSTEM INSPECTION FORM'
PART B
CHECKLIST
J Check if the following have been done: E
Iumping information was requested of the owner,occupant,and Board of Health.
one of the system components have been pumped for atleast 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.
s-built plans have been obtained and examined. Note if they are not available with N/A.
he facility or dwelling was inspected for signs of sewage back-up.
'lie system does not receive non-sanitary or industrial waste flow,., f'
The site was inspected for signs of breakout.",,J.•; . , , ,
All system components,excluding the Soil Absorption System,have been located oil site.
Theseptic.tank•manholes were uncovered,,opened,and'the interior of.the septic tank was in- ..
spected for,condition of baffles or tees,material of construction,dimension's,depth of liquid,
q depth`of sludge;depth:of scmn.
, :t..• �. ' '.
X'' The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
_ _ 3 _.
i
S'
i`_SUBSURFACE'SEWAGE DISPOSAL SYSTEM. INSPECTION FORM
PART B
/ CHECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of.Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL: "
Design Flow: 33gallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder:f�_ Laundry Connected To System: (.&a Seasonal Use:
01
Water Meter Readings,if available:
Last Date of Occupancy:
COMMERCIAL1INDUS1RIAL•/)
' TYpwolf Establishment:
Design Flow: --gallons/day 'Grease`Trap Present:' &s`or no)''Y
Industrial Waste Holding-Tank Present:
Non-Sanitary Waste Discharged To The Title V System: -
Water Meter Readings;If Available: Last Date of Occupancy:
OTHER: (Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS any source of information:
System Pumped as part of inspection_ I yes,vo me pum d.V gallons
Reason for Pumping:
TYPE F SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any) -
Other(explain):
ROXIMATE-AGE of-all components,date,ins ailed(if known) and souree�of inf6rniati6h:';
Sew ge odors detected when arriving at the site:�/yJ�'
-4- n
SCbBSURFACE`SEWAGE'`DISPOSAL f SYS'l'FM' NSPECTION FORM
PART C
GENERAL` INFOINATION (continued)
SEPTIC TANK: Ft
Depth below grade:_ Material of Construction: concrete metal FRP Other
(explain)
Dimensions: Sludge Depth: (a i I Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,conditioin of inlet and outlet tees or baffles,depth of liquid level
in relation too tie invert,structural integrity,ev'dence of leakage etc.
i
GREASE-TRAP,! IA '
Depth Below,Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:_
Comments: (recommendation for pumping,condition of inlet and outlet tees4r baffles,d W.617hq'uid level
in relation to outlet invert,structural uitegrity;evideuce of feakage,..etc)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.).
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: e
Comments: (not . level anal distribution is a ual,evid ce'of solids carryov r,evidedce of leakage into or
out of box,etc.
�:.. ..
Puilip is m'worku g"order
Ccaiinents: (note condition of pump cltanmbei,condition of jwmps n appurtenances,etc.)c ,..v;
t
- 5 -
"SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive
methods) if not determined to be present,explain:
Type:
Leaching pits,number: _ Leaching.chambers,.number: Leaching galleries,number:
Leacahing trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
C nnnents: (note conidtion of soil,si s of hydrau'c failure level of pon ing,condition of vegetation,etc.)_
.CESSPOOLS:
Number and nfiguration: 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(cesspool must be pumped as part of inspection) `
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments:(note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation,
etc.)
- i.�• \ .. - t. , t i R.. y '.. � tif'1,4w1 1. -
_ G -
BSURFACE;,SEWAGE "DISPOSAL;.SYSTEM"1NSI'EC'1'ION!,FOIZM
VART G
SYSTEM INFORMATIOM(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benclunarks.
Locate all wells within 100 Feet.
1
-3 7,
DEPTH TO GROUNDWATER:
Depth to.groundwater: � Feet
Method of Determination or,Approxi� atio»:
D�' 6 is se r�' d J, to
WI? fC/1 �'IOD Soor
7 _ i
.. •,t x�� n'* �s^.. •r1*i,tJw�S�y � `,4 s?ro+�.t �. -_. ' ,
41 TOWN OF BARNSTABLE
LOCATION�rllp
VILLAGE 6( 2 tM 46 U"f) __ , ASSESSOR'S MAP & LOT'---t-V'7L4m
INSTALLER'S NAME & PHONE NO. C
SEPTIC TANK CAPACITY l 6�c� C, t� t�-eUA 2
LEACHING FACILITY:(type) CS'�' T' (size) lit.
NO. OF BEDROOMS PRIVATE WELL O UBLIC WATER
BUILDER OR OWNER Yv 0,u\d S
DATE PERMIT ISSUED: d 7
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
13` 21PkT
1 Oao GtYZ C1� o .
P1e�,-cam -
W'2� .S��CIc� T+Pwk
No.-9-•7_--318 Fas....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
............. ...ty..............OF...... 14(RL\1 l.! ..............................................
\� Appliratiun for Disposal Works Tonstrurtiun rrrmit
\5 S Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage. Disposal
(� y
.... ---C. .P.: : W_! cuvnvn� � �e►y u --.-..........-
Location•A dress or Lot No
...-----••---. .1 ........ s✓... .e;j..•..................•............ .... ..P�.......b0.6..---.....�. C.. .S . \k_..........
Own��er�� Address
Installer Address
Type of Building Size Lot............................Sq. feet
'U Dwelling—No. of Bedrooms....:1...................................Expansion Attic .( ) Garbage Grinder ( )
Other—T e of Building ......... No. of persons--- ...... Showers — Cafeteria
Other fixtures ................----------------................
WW Design Flow.......1�. ..........................gallons per person per day. Total daily flow...., ......................................gallons.
WSeptic Tank—Liquid*capacityl4.00-.gallons Length.--�...._. Width... ...... Diameter................ Depth_._y
x Disposal Trench-No..................::. Width....=.............Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No._....l............ Diameter..... Depth below inlet.... ............ Total leaching areal' -.:..sq. ft.
z' Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
,1.4j Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----•---•------------------- ... ---•-••---• .........................................................
O Description of Soil................. :�� 13
. 1.Q..QO.... �' �- �k!!`� .......C.sQ...f.....o�'.....................
V ..----•------------------------•-•--•--------.-a_0. 2-: — A '�2.�Gc
W ----•--•------•-•...........................•-•-•-•-----•...........--.........------•-•--.......---•---•-•----•--•-------•-•--...--------.............••-••-......-----
U Nature of Repairs or Alterations-Answer when applicable......-cOn!13.5� .. ................................
-------------------•--•-•------•-----••--..�_� �'f�f '
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i1TL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has lien issued b the
Signed.. Z�A.... ......... ... ........... .....�.......... _....
Date
Application Approved By.......... .�0 ---•-•••-•-•--•--------------•-----•--------( V ....................Date ...
Application Disapproved for the following reasons:...........................................................................................................
...............•-------------........----.......-----.......--•---...........-•----•--....----------......--•---------...:-..----•--------••-:•-•-••-•-----------•-•-----------.............••........._ .
Date
Permit No.•.i... ^....-3... ...........-. Issued.......................
��..•�-�..r._^...-� w ^-,..��.-'�:;...r.... .. . .f.:. . •_ _-.....�.ts...:s�—:.. :aLi� `s.'d.'r..�.•.^•k,�'e•.✓'�-r���v-r...i✓s'..._: Ya k..�,_....'-,�..r .:'y.--..� ._ ..
•/ ,
k
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t3 'Y..!Y..............OF....... ,-Ih� 1 ` 7 ........._........._......._....:....
Applutttion for Disposal. Works Tonstrurtion 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (t-•" aan Individual Sewage Disposal
J System at•� _
,_= »»» »!»�?_1- (1 U�Z 7�ate••--. ........ .....G U A M', i U:.0.r
✓ Location Address _7_ _ or Lot No
- ----.»..» 1 ,-+ < - -'-_�- - •.................................. ..........:Z ki I�
^� 6 Own Address
W �� �� d k� c' r ,4 1�it1lA^t
- - ................. .�_.... ------------••--•••-•••--- ---••---------....--•-........`!.. •- ..........................................»....-....
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.__........................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Buildin No. of persons............................ Showers — Cafeteria
04 Other fixtures -----•------------------•-------------------•----•--...._........_.:--••---•--•----------••--•-•----•-•-•----._....-•-------•--•------•---•----••-----
d -
WW Design Flow........ .........................gallons per person per day. Total daily flow..- .3d.......................... gallons.
WSeptic Tank—Liquid capacity'?Dn.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_611.sq. ft.
Z Other Distribution box ( ) Dosing tank
''" Percolation Test Results Performed by......................................................................... Date........................................
0.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ------------
----•-•-•-•...... .........................:......•-----..............._-••,...........................................................
D Description of Soil..................... A�.S`7 A (� 1 Q 0 o `"'P�`t C--r A'Jr.- Li\s 1 �a?,-
----...--•....................................... ........•----•-•-----•--------•-•-•-•-------•••........._.......... --_----- •••...
U ..........................s n�?:r?....4�. ..� .- ;�-` f `',� '��r�_ 2... -.a.q...�e- �,c _C P S S�'c
�.....
W ------------------------•-••-----•-------------•----------------------- --------•- ---------------------
---------------------•--- -------------------------------------
••-•-•••-•.... ..
UNature of Repairs or Alterations-Answer when applicable_._.__ <� �?5 '_.._1`�t. .__._S "` .............................•..
C. ,l\ -e S'• /'/,/ itil
•.........................................................................o_........r --•-----•---........---•-------------•------•--.......•-----.......... -•-•---•-•--..._..----------•---•
Agreement:
The undersigned agrees ,to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi 51,of the State Sanitary Code—The undersigned further agrees not to place the system m
1 operation until a Certificate'of Compliance has.been issued by,the board`of-health -
k�
Signed. - ) � ..
' ... �.....••. -••=_. -
Date---•�--•-
Application Approved By.......... --------------------•---_--•-
r �• Date
Application Disapproved for the following reasons:-•-•...........:...•-----•---•-...........-••----•-----•-4-•---•••---•.._..._•-------..._•--•-• »»»
.....--••-•---•--•--•---.....-•-----------------------------------•-----------•--•----......-•-•----...».........._..-------,------------•............................................................
Pem d-
ut No.--•-� ? =----- ,�... - ..».». Issue ........................................»D�.---»
---------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t ................... &-�\l ..........OF..^....6 XZVU� 1,•�1(?��...................................
tfirate of Touts haurr
THIS IS,TO-CERTIFY, the Individual,Sewage Disposal Slstem constructed ( ) or Repaired
by..........:_•------_.....1,1 _:_ _ K»� 1�aac
-
at...........................•-- 1 -- C 'A lri !` �_?.Y _Q ............................1 Ib �/ o�i�'..b � -•--•-------- ...............
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----6.2•r__._:_!)1R........ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. e
DATE .................................. Inspector. -: - ............................................................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i °...............................
No...
No.:,g FEE.....2.�, »
Disposal Works Tonotrurtion rrrmit
Permission is hereby granted...... .. ..� r �- o� �''� ».... a
... . .. :.__...__ .. ------ .
to Construct ( ) or Repair (L-)-an-Individual Sewage Disposal System 69'
................ --
Street
as shown on the application for Disposal Works Construction Permit Dated--------------•-:---_-----.............._.
2....C,w.....
O Board of Health
DATE.............L5..... -