HomeMy WebLinkAbout0019 CARRIAGE LANE - Health 19 Carriage Lane, Barnstable
A= 298-048
E
TOWN OF BARNSTABLE
LOCATION I c2 GZ //0JoE LA ,V< SEWAGE#2=0/,2-— D F
VILLAGE 3.4 n/srd s If ASSESSOR'S MAP&PARCEL,2`�,F_
INSTALLER'S NAME&PHONE NO.AQ cN (e NST S G f- 7 7>, i 36 2
SEPTIC TANK CAPACITY E X t s T /o o D
LEACHING FACILITY. (type)(%b)f/l�� 1,✓ 2�rodL(size)3)(
NO.OF BEDROOMS
OWNER (!/o v,,
PERMIT DATE:V1311,2 COMPLIANCE DATE: �—
Separation Distance etween the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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No. Fee f�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppliLatlon for MispoBal *pstrm ConstCUttlon 3pPrmit
Application for a Permit to Construct( ) Repair(411'u'pgrade( ) Abandon( ) [:]Complete System, dividual Components
Location Address or Lot No. /3A 2 V S 7,0 S 1� Owner's Name,Address,and Tel.No.
/Ay CA 41t 1 .s c Z- 401 S F Jo v Ir-t 2
Xssdssor's Map/Parcel X V7, tf f� S,p 4%
Installer's Name,Address,and Tel.No. Designer's Name,Addre s,and Tel.No.
�2-e/+ evw f-s Ram r�aP. Y7i4e-
5`0 8 7 7> 1 3 6.) S O r 7 -P 5- 0
Type of Building:
Dwelling No.of Bedrooms -3 Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 0 gpd Design flow provided 3 6 gpd
Plan Date �� �z Number of sheets Revision Date
Title
Size of Septic Tank F_ x S 7' b e d Type of S.A.S. /D /7-2 p 7 o A J-
Description of Soil
n
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to lace the system in operation until a Certificate of
Compliance has been issued by this Board of H alth. -
Signed A Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 1 a --0 Date Issued 1 2—
n i �
No. AF Fee h{Y
THE COMMONWEALTF OF`IVIASSACHUSETTS Entered in computei:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
es
01pplitation for NspoBal *pstrm Construction 3permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System U drf ividual Components
Location Address or Lot No. Owner's Name Address and Tel.No.
l3sa R �✓s T oa � �� ,
1 CMp air ar,�cel 5, .✓ Govi s i3. t rz
Ass sor s a �
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
/-9 2 eis �'v s�-- /?G (�rQ. Y/,, --
S`o P '7� � S`. 7 7a. 77 00
Type of Building: ,
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(4/
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33 O gpd Design flow provided e!' 4 gpd
Plan Date // A-Z Number of sheets Revision Date
r Title
Size of Septic Tank F x , s T /G o d Type of S.A.S. LP �/,In G' fi, 4 A > n 'a r
Description of Soil
1
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: r.-
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. -
Signed G `, Date Z /2
Application Approved by ` � i . , Date -,G/
I
Application Disapproved by Date
for the following reasons
Permit No. o A Q Date Issued 7/
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
eertifitatr of Compliantr
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ,)' Upgraded( )
Abandoned( )by 10, y
at 1�y has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 _ dated j
Installer /.')of i-f Designer /f �„� �, ✓,n
#bedrooms- 3 Approved design flow gpd
The issuance of this permit shall not be const%rued as a guarantee that the system wilh fu~ricti on as designed.
Date t & �� ' Inspecto,
i L --� -
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS
Bisposal �&pstrtn Construction i3Prmit
Permission is hereby granted to Construct( ) Repair(�/ Upgrade( ) Abandon( )
System located at— /-- -9 12,r2
-3A /� a
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date (� f / Approved by I
a`
Town of Barnstable
4� cl Department of Regulatory Services > I J
"•A.�.. - Public Health Division Date •/ ( ! J
n�� 200 Main Street,Hyannis MA 02601
Fo
Date Scheduled / ! / / Time Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By: �.
LOCATION.&GENERAL INFORMATIO
Location Address .�,� ��J _ _^ J_ Owner's Name
�! ltr n LLiFf7.lti Address 'CJ q����r»'1 }e
Assessor's MaplParcel: P I '_ o ll& Engineers Name C 1 A VC
NEW CONSTRUCTION REPAIR je!" Telleephone#�7CJ�� 77-5^ o® f
Land Uge I(� Slopes(%) ZtJ� , Surface Stones .�� /2� a'✓r"
Distances from: Open Water Bodyj fl Possible Wet Area I/l 1 i'F ft Drinking Water Well tl f!i fl
Drainage Way R Property Line _(5Lfft Other r 1 1IT�_—ft
N � SKETCH:(Street name,dimensions 01710t,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
3 00
To z I
de Its
3 Parent material(geologic) +�. A Depth to Bedrock_ h
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE . Eni
Method Used: 5ce j�2 4E. �Depth Observed standing in obs.hole: in. D th t6 s���Depth to weeping from side ofobs.hole: in. Groundwater Adjustment fLIndexWell# ReadingDate: Index Well level Jul-VAdj.factor Adj.Groundwater Level
v - PERCOLATION TEST Date Time
C\^ Observation / . 7
v \^ Hole# Time at 9"
�• Depth ofPerc �C
Time at 6"
�3 Start Pre-soak Time 8
�V End Pre-soak //,'/ Y2
Site Suitability Assessment: Site Passed Site Failed Additional Testing Needed(Y"
Original: Public Health Division Observation Hole Data To Be Completed on Back---
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
r
Q:ISEPTICV'ERCFORM.DOC
i
DEEP OBSERVATION HOLE LOG Hole# ,
Depth from Soil Horizon Soil Texture Soil Color Soil Oi1(er
Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones.Boulders.
Consistency%Gravel)
ve
DEEP OBSERVATION.HOLE LOG
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
FConsistency%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency% vel)
DEEP OBSERVATION HOLE LOG Hole.#.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
-- - Consistency-%Gravel)
Flood Insurance Rate May: /
Above 500year flood boundary No_ Yes V
Within 500 year boundary No— Yes
Within 100 year flood boundary No_ Yes_
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? �
If not,what is the depth of naturally occurring pervious material?
Certification
r I certify that on Clate)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required pertisA an xp rie e d c be 10 CMR 15.017.
Signature Date
Q:1SEPnC1PERCFORM.DOC
°FTHE T Town of Barnstable
Regulatory Services
BARNSTABLE,
9 Mass. Thomas F. Geiler,Director
�A s639• ♦0
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Designer Certification Form
Date:
Designer:
g ROO kid i 04-P'
l C,L 4e--,
Address:
VV
® b7 .
On 1 was issued a permit to,install a
4dale) (installer)
septic system at L AY�t, based on a design I drew,
(address) ;
dated 2 -Z, ,
V I certify that the septic system`referenced above was installed ,substantially
according to the design.
I certify that the septic system referenced above was installed with changes but in
accordance with State & Local Regulations., Revision or certified as-built by
designer to follow.
P�-��k oF,t9
ROi+lALD o� ?,
DAMES `
CA ILLAC �
0 #106 a
(Designer's ti nature) (AffixsSt"ainp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.
CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS
FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE
PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form
RONALD I CADILLAC, PLS, RS, P.C.
Professional Land Surveyor&Registered Sanitarian
P.O. Box 258, West Yarmouth, MA 02673
(508) 775-9700 (800) 520-5591
TRANSMITTAL FORM
To: Y Job No.
op
Re:
Date: Certified : ❑ No.
Fax ❑
Enclosed:
c
Message:
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Commonwealth of Massachusetts
TitleOfficial Inspection Form - Y
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L _ � 7
19 Carriage Lane, Barnstable
Property Address — ---�- ------_----- ---- -------- -
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 _September 10, 2010
required for every ------------------------ - -- — - --p----=-- ----
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form Insteectiorp farms may not be altered in any
way. Please see completeness checklist at the end q�tFle form.
Important,When .� General Information — --- -- — — -
filling out Forms '
on the computer, , COPY
use only the tab 1. Inspector:
key to move your
cursor-do not move
/y Williams
use the return key. Name of Inspector -- -- -------- ------ — ----------�—
Troy Williams Septic Inspections _
Company Name
19 Hummel Drive
-- Company Address
raw„ South Dennis MA_ 02660 _
i Cityrrown State ---- --— ..- Zip Code -------
508 385-1300
S 1682
Telephone Number -----___---------=------._--__--------------------
p License Number
0. 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
-- kle i1tD CR 15.000). The system:
U Passes qii Conditionally Passes Fails
SEPAQs rdi-ther Evaluation by the Local Approving Authority
BY
Se !ember 10 2010 _
Inspector's Signature Date
The system inspector shall submit a copy of this inspection repoft to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the sys system is a shared system or
has a design flow of)0,000 gpd or greater, the inspector and the tem 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.
--------------
° "*Thus 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.
V
t5iiis 09108 Title 5 Official Inspection Form:Subsurface Sewage Dis o I System•Page 1 rf 17
s
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010
required for every. p
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
N/A
t5ins•09/08 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
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is P
required for every Barnstable MA 02630 September 10, 2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ `N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y . ❑ N ❑ ND (Explain below):
N/A
❑ 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):
N/A
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is p required for every Barnstable MA 02630 September 10, 2010
page. Cityrrown 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 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:
N/A
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'/a day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owners Name -
information is P required for every Barnstable MA 02630 September 10, 2010
page. CityTown State Zip Code Date of Inspection
B. Certification (cont.)
k .
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: N/A.'
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool,or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a.cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following,.in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is-considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is P
required for every Barnstable MA 02630 September 10 2010
page. Cityrrown 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.
® Ei 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010 .required for every p
page. City/Town 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?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑, Yes ® No
Water meter readings, if available last 2 years usage(9pd))' 09=39,000 gals.
08=34,000 gals.
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203)' NIA
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspect'Inspect'on Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 19 Carriage Lane, Barnstable_
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010 _
required for every p _
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
General Information
Pumping Records:
Source of information: No_ urn incg_info available. —_
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: NIA
gallons I
How was quantity pumped determined? N�'�--------- — —
Reason for pumping: N/A_
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
t
a .
C ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°u 19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010
required for every p
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank&pit#2 are original to home. D-box& leach pit#1 were installed on 3/20/97 per compliance
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
Building Sewer(locate on site plan):
Depth below grade: 18"+
feet.
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line- N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Flushed lines and found clear at the time of inspection.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5'X 9'X 6' 1000 gallon
Sludge depth:
4"
t5ins•09108 Title 5 Official Ins
pection 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
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010
required for every P
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
21811
Scum thickness Thin layer
•Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Probe/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.):
Inlet and outlet tees were present. No evidence of leakage or damage was found at the time of
inspection. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins-09/08 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
.�" 19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA _ 02630 September 10 2010
required for every P
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions:
Capacity: N/A
gallons
Design Flow: N/Agallons per day
Alarm present: ❑ Yes ❑ No
Alarm level:. N/A - Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.): .
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
E
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
19 Carriage Lane, Barnstable -
Property Address
Louise Baker `
Owner Owner's Name
information is Barnstable MA 02630 September 10 2010
required for every P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cone.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert level with
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.):
D-box was found level and in working order.
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.):
N/A
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not•located, explain why:
N/A
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
*s
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner owner's Name
information is required for every Barnstable MA 02630 September 10, 2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
Type:
® leaching pits number: 2 -6'X6'with 2' of
stone
❑ 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.):
Soil was sandy. Newer leach pit was found full and in hydraulic failure at the time of inspection.
Original leach pit was found stained above inlet line from hydraulic failure of pit in the past.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer NIA s
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
f
c Commonwealth of Massachusetts
W Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010
required for every _---__---_ — _ .• �
page. Cityfrown State Zip Code Date of Inspection
D. System Information (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of Qonding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A ---------- -------— ----
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition•of vegetation,
etc.):
N/A
.. 'Vt
W F
4 it
a #
t5ins•09/08 Title 5 Official Inspection Form subsurface Sewag�Dts sel Systerq r QagQ�4 ��7 �'��
L ; 4' 3„v'�7 ,c�..f'ir� ..x,�k.i A..7'e Y,Ewt .,..Uzi• i
i .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 19 Carriage Lane, Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010
required for every _
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cant.)
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 poxes below:
® hand-sketch in the area below
❑ drawing attached separately
p' r
l5imi•09/08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System;.Page 15 of 17
I
Commonwealth of Massachusetts
Y 'Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Carriage Lane, Barnstable _
Property Address
Louise Baker_
Owner Owner's Name
information is Barnstable MA 02630 Se tember 10, 2010
required for every _ __ — _— _—�
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cons.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15 + —
. 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:
AIW 247 Zone C 22.6' 2.5' adjustment_ _
You must describe how you established the high ground water elevation:
Hand augered 3' below bottom of leaching with no water found at 13.0'. Groundwater adjustment was
2.5'at the time of inspection. Bottom of leaching at 10.0'was found not to be located in the high
groundwater level at the time of.inspection. USGS groundwater maps showed groundwater to be
a� ox. 32.3'. -- — -- - — ----
Before filing this Inspection Report;please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System!,Page 10 of 17
f
t .
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
N 19 Carriage Lane Barnstable
Property Address
Louise Baker
Owner Owner's Name
information is Barnstable MA 02630 September 10, 2010
required for every _ p
page. Cityrrown State Zip Code . Date of Inspection
E. Repo�t �®mpleteness Checklist
® Inspection Summary: A, B,.C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
Tills A5t5ins 09I08 x t :r1�s it R'ubsy act Se 1g4 pi to{a t 'X 0 7QTgpl Inspedio Form S
taaDaat 7 i4� t1 'Y� it kr"St Ix
_ TOWN OF BARNSTABLE
'LC ,ATION ►Aae I-Awt- SEWAGE #
-VILLAGE 3Anj44�t ASSESSOR'S MAP & LOT 119
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) L•1� (size) \aO ('PA.
NO.OF BEDROOMS
BUILDER OR OWNER N''C7C`r
PERMITDATE: .3 9\5—COMPLIANCE DATE: 3'Zy-�1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet.
Furnished by
53� DeeK Zu
a
Zr
F ,
k
No. ..... F>�s.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
. ppfiration for Di ipwml Work.. Towitrurtion Prrmit
Application is hereby made for a Permit to Co► sti'uct ( ) or Repair ( an Individual Sewage Disposal
System at:
Location 2thiress or Lot No.
hex �` r ....1 ---- �-__-- . ... - .....
Owner Address
.............
------- ............................................... -----••-------------------•---•--.......... --•---------••-•--••-••---------------__-•.
Installer Address
dType of Building Size Lot............................Sq. feet
V Dwelling Ito. of Bedrooms........�13 --Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons.--------.----------------.- Showers ( ) — Cafeteria ( )
0.t 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.
Seepage Pit No--------------------- Diameter.-.--.---- --------- Depth below inlet---................. Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by-------- -------------------•--••---•••-------•--------•-•---------------- Date......................................
,..� Test Pit No. I................minutes per inch Depth of Test Pit...--...........--.. Depth to ground water...---.......
G% Test Pit No. 2................minutes per inch Depth of Test Pit...---......----.... Depth to ground water........................
------------------------------- ---•----..------------------------...---•-----•-•--------------••--.................-----••-------•-••.....------------_.....
0 Description of Soil.........................................................-............................-----------------....----------...-------------------------------••••------------
x
V
W
UNatu e of Repai or Alterations Answer when ap licable.-.-. --nS44.1-(.-. -1._'..... .. ........� ?_._.. /..I:) i
t �.._Le.-....., ------------------------------------------------------
V)LP 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 Compliance ha b is ued the board of health.
igned .... ....... ...................... - ..` ":.
Dace
ApplicationApproved By ...�.... .. . ... ......... ....................... ........................................
Dare
Application Disapproved for the following ream ....................................................
.............."..............................._ ................ ............. ..... ...- -...............
��
Permit No. .......... ....:... ...................... Issued --- -....... .. . ...��.. � .... :... .............
re
_ ... C/
���.0✓//)L/
0"
_ THE COMMONWEALTH OF MASSACHUSETTS FEB
BOARD OF HEALTH
TOWN OF BARNSTABLE,' ,
Aplifirati>att for Diripmi it Works (Int0trnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
System at:
................. o cation-T
L ----•-• -----------Lo ddress or Lot No.
O,ner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling— No. of Bedrooms........... --•.-. -..._.---------..---Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
} Other fixtures ----------------------•----------------........--------------------------•--•-----•----........---...---------------•-•------•-•--•----••--•-•--•-•--
WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons.
9. Septic Tank—Liquid capacity............gallons - Length................ Width---------------- Diameter...-----_--.-- Depth................
x - Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No............._------ Diameter---------------..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
i,. Test Pit No. 1....:...........minutes per inch Depth of Test Pit.................... Depth to ground water........................
(X4 Test Pit No. 2................minutes per inch Depth of Test Pit.....--............. Depth to ground water........................
W •--•-••••-•-------------------------------------•------------------•-----------..........._......•........-----......................................--•-••.
0 Description of Soil........................................................................................................................................................................
x
W
x ---•-•----------------------------------••-••-•••-----•--•--.•.....-------------•--...••--•-----••------••••--TT------------------------...............................................................
U Nature of Repairs or Alterations Answer when applicable.-..._,S_.n:,T. A.. .. ........ .'.....! ..1�......�OD _____l, _I c�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has b^en is ued b the board of health. /
�. .. ..:.. - :.. .-. ..y-. .,5
1 Igned - �'y9�i..................................(_ Dace
Application Approved By ... .........vim'... ........ ... ✓.... ..................................... ................---_--------------
// Dace
Application Disapproved for the following reason . .......................�............................................................
................................................�.. f-....................... ..... ......)................4.......................................c...� f........
------.
' Dare
Permit No. � ) ..
•._ ......... t. Issued .......... . .........
i' gym.__... --------- --...- —.....--:..... ——————————— . —®o®®—m®sue--------._. ————————
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ter#ifirate of Tompliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ..............................................cq.. e- c.v-----------------._................. .. .. .............................. . ................../........._..............:......
at -----------/......................... / �.. ..........._. h� - ..............._... �� .3. i4. ..�-��---------------------------------
has been installed in accordance with the provisions of TITLE 5 -f The Stat Environmental Code as described in
the application for Disposal Works Construction Permit No. ".._.._._........_._..............._ dated ...__........ ..__.......
the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C�O�NSTRUEA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. .._.............._.._.... ......-.�`.�...../�........... _...... Inspector -..".' .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.. .�_...........W FEE.--..2 ..........
�i��n��tf nrk� �nn�tr�tirrn �prntit
Permission is hereby granted..... ... i 7 ------ --------------------- ------•-- .........
to Construct ( ) or epair ( i) an Individual Sewage Disposal System
at No......../-5--•--•----:.=!f -- �•-----r'�s ....-•---------.------..StI ��'t-------------------�- . --
_ ��........
as shown on the application for Disposal Works Construction Pe m t1No` �./ .......... ....�X�...:......
Dr�aRed.
.......... � ---./r�/ :1✓� � = •f 7 1_if,f�-/`r,-n'S. - .
v Board of HGaltdi �~
-•-
DATE............. ✓//
FORM 36508 HOBBS 8 WARREN•INC.,PUBLISHERS a ,F/
y COMMONWEALTH OF MASSACHUSETTS f
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT,.OF ENVIRONMENTAL PROTECTION
—� - 350 MAIN STREET
%Ca WEST YARMOUTH,MA'
508-775-2800
TITLE 5 "
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 19 CARRIAGE LANE RECEIVED
BARNSTABLE,MA 02630
Owner's Name: BURGER,REX 1
Owner's Address: 19 CARRIAGE LANE 2 9 2 Q
BARNSTABLE,MA 02630 TOWN
Date of Inspection AUGUST 6,2001 HEAL BARNSTABLE
H DEPT.
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street "
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper f inction`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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Si'nature: ; Date: G
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 Y
appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot
he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at '
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
_ 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: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to bicken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
C. Further Evaluation is Required by the Board of Health: N/A
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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility _
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Tide 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in pits is less than 6"below invert or available volume is less than%day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
Check if the following have been done. You must indicate"yes" or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X 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)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CUR 15.302(3Xb)]
Title 5 Inspection Form 6/15/2000 S
Page 6 of 11
OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): . 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330---)
Number of current residents: 4 Does residence residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 58,000/2000 59.000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN.NEW DISTRIBUTION BOX AND PIT 1995 PERMIT#95-892
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain),
Distance from private water supply well or suction line:
Continents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 14"
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: F,
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 20"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL. OUTLET TEE,TANK AND COVERS 14"BELOW GRADE. NO SIGN OF
OVERLOADING SEEN IN TANK.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: _ concrete metal _ fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Conmtents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene 'other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no) '
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Continents(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 16"X16",ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND SOLID.BOX IS 22"
BELOW GRADE.NO OVERLOADING SEEN IN BOX.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no): -
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 2
leaching.chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Commments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS TWO 1,000 GALLON PRE CAST PITS. PIT(1)OLD PIT 27 BELOW GRADE,COVER AT
11 V.PIT DRY.PIT(2)NEWER PIT 42"BELOW GRADE.COVER AT 1 S",30"WATER.NO HIGH STAIN LINE.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
S'3 ao
91
O
O
o q�
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 CARRIAGE LANE
BARNSTABLE,MA 02630
Owner: BURGER,REX
Date of Inspection: AUGUST 6,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 25.2 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA
WELL AIW 247 25.2'
ZONE C 6'
ADJUSTED 18.8'
Title 5 Inspection Form 6/15/2000 11
i
TOWN OF BARNST ABLE
LOCATION i g Cr,fr%A QP L.wue, SEWAGE #
VILLAGE AY-13 AA6e- ASSESSOR'S MAP & LOT k1 -
INSTALLER'S NAME&PHONE NO. A? 8 CAN
do
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) \Ora CPA.
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: _ � — / 'COMPLIANCE DATE: 3-Zy �1
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
.Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
F3.�ck a.0 Ll��t
53 L�ccK Zo
ZL
�z' o
zti'
7-3 Z3 --—
-LOCATIONr:*6l 5EW&C4E PERMIT UO.
VILLAGE
a - AS S MAP
� 0: �C
iWS-TQLLER5 UWE � `ADDR09
BUILDER 'S Q &"F- ADDRE 55
DCsTE PERMIT ISSUED
DATE COMPLI &MICE ISSUED : — — —
J
r
V �
No. 7 3 ,
...............3....... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /C :J,�?F HE H
OF......./0.. °-.......................
Apphration -for Uhipmal Works Tomitrurtion Vantit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Aol.....................................37............C-ta,11.0
--------------------------------------
L Addre - or Lot No.
OC"'"Z�2AQ 311,
.............. e..F_i.. 40 ------------ --------------------------------------.........*------------- --------------------.......
Owner oe.. ......... ..........
................. .......................... Address.......................................................
Installer Address
U Type of Building Size Lot.... �jaa�tsq. feet
Dwelling-/-No. of Bedrooms.,--'3....................................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.
r4 Septic Tank—Liquid capacity------------gallons Length________________ Width...._.._....._.- Diameter_____.....-_____ Depth_.-.__.-_-..__.
Disposal Trench—No. .................... Width-___-__--.-________- Total Length__________-____--__ Total leaching area--------------------sq. f t.
Seepage Pit No_____________________ Diameter-------------------- Depth below inlet .... Total leaching area------- ----------sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by------------------------------- ........................................... Date........................................
Test Pit No. I...............minutes per inch Depth of Test Pit.....__..._..___._.. Depth to ground water------------------------
rXq Test Pit No. 2----------------minutes per inch Depth of Test Pit._______.._......._. Depth to ground water------------------------
................................. --- -- - - ---- - --------/
-----------?,-- , - -
0 Description of Soil.------------k_:7:75�----- ......S........./ -------4____W-----
U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------- .....................................................
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------- -------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the�ooisions of Article XI of the State Sanitary Code Th nd i ned further agrees not to place the system in
operation until a Certificate of Compliance has be i ued b rd of h It
�igne ----- -- - ------- ---- -------- ------- ---- -----
Da
........
Application Approved By------ ..... . ...... ... .. 1-4zle/------------------- ---0------
C71- Date
Application Disapproved for the following reasons:--_-------------------- ...................................................................................
.........................................................................................................................................................................................................
Date
PermitNo.--...................................................... Issued...................... .................................
Date
----------------------- -------------------- ---------------------
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
Im A� ,
DATA
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_ --....OF........!{ . l(.} L-f
......................... .
Appliratiun -fur Uiopuoal 10orkii Tonotrurtiun Prrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ,
Aa7 ? inn
-------------------------------------------------------------------------------------------------- --------------------------------•---------------------------------------------------------------.
Location-Address, +.(/ or Lot No.
PA � , ( 'A^(.. �,H p n Y A,
------------------------------ ........................................... - -------------•-----•--------------------------------------•--------------------------•-------•----
W I- p caner Address
...-------••-•-•---•--• - ._...
Installer Address —d-
Q Type of Building Size Lot... .-J..l'!4..d....Sq. feet
Dwelling No. of Bedrooms-_._3....................................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P4 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..................... Diameter.................... Depth below inlet.................... Total leaching area__.__-.______--__sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) �/ J- /fC �`�— t. "C
Percolation Test Results Performed by........................................................... ___ Date----.--------------------_--.-..-.------
Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---.__-.__._-.__._-.-.
f4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__.-__-___-_.__._.--.
W ------------••---•---- -----'-.................................. --•--------------•---•----•-•--..... -........'................ -------------------
0 Description of Soil-------------!�,----? ....... ............ --i-----=�'Z------- rC'�t���..0 �,;.. � `e. -
U --•........................••-•-----------•------..._....._..-•--••--•-•----------•-------•--•-------•-••----•-------•--•-•-------•-••-•--•-••--•-•----------------......-----------•---
W
------------------- --------------------•--•-- ----------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-..............................................................................................
--------------------------------------------- ....... -------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been Issud
he board of health<....... -------- Y--.....__... '^� �l_ .......
Dane
Application Approved BY `' ..... . ......--
Date
Application Disapproved for the following reasons:.................................................. .............................................................
....................................................•---------•-•--..---------------•--•----------••-----..
------------•-•-•-
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
T BOARD OF HEALTH
................0F.... .-7 626 .t .� i
Qlrrtifiratr of f JIMIt aurr
THE S TOICERTIFY, That,the Individual Sewage Disposal System constructed ( �)or Repaired ( )
by --------="'----=------ ---- = d ----- ,. jl....... ...............................................................•---.............
7 Installer
at...............,--i_ .. .
has been installed in accordance with the provisions of Article'XI of The State Sanitary Code as described in the
(7 y 7 _? —
application for Disposal Works Construction Permit No__ _ _______________-_______-_______ dated...._..:___'_- _.7 4..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE . Inspector--------..........• ------ •-- --- ----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFj HEALTH
3 ...........:�.:-�!I...............of......`k':.:�..r ?. .-�------......�-----------.......... ��
j
No.----------............. FEE- -.............
Dirivoiittl orkw0lan,itrurtion rrrmit
to Construct ( ), or Repair/( �) an Individual Sewage.Disposal System/ `
Permission is ranted___ _____ ________�. -__-__ .............................................................
at No.(f/ -r i ==' /_...........................•t—t 1 c./ d ---------
.--•- ----- -----=t- -
Street
as shown on the application for Disposal Works Construction Permit�No..._.f...._ ...�. _____ Dated....:..-/7'._7`'............
! ( �
Board of Health i
DATE.................-------------------------------------------------------------•
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No......................... FIn$............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ......................O F.........................................................................................
Appliratinn -fur 43i"vital Works Cnnnutrnrtinn Prrntit
Application is.hereby made for a Permit to Construct (- ) or Repair. ( ) an Individual Sewage Disposal
System at:
--------•-••-----------------------•----•----......••-••----------•--..............----•----...-•- ••-------•--••••-•--•-•-------••-••-'••-•••-•--•-•-•••-----•••••••-••---------------...--•.••....
Location-Address or Lot No.
..---------•--.......-------•--•-----.....-•...............••------•••-'--..........---•---------- -•-•--'-•--------•'--'----•---...-•----------••---'........•---.......---•---•--•---•---••'•-----
Owner Address
W
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
A, Other—Type of Building ............................ No. of persons---------..---------.---.-.- Showers ( ) — Cafeteria ( )
P4Other 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..................... Diameter.....--............. Depth below inlet--.-------_-_--.-. Total leaching area........----------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------- ----------------------•--------------------------•-----•--•-••-... Date-------------------------- -------------
a Test Pit No. I................minutes per inch Depth of "Pest Pit-..-.--..---..------ Depth to ground water....------.-------.-----
�14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-------..--..---------..
Ix .-----------•-------------------------------------------••...--------------•---......••-------''----......................................................
0 Description of Soil------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------
x
U ------------------------------------................................................................................................................................................................
W
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------- ------ -------------.
------------------------------------------------ ----------------------------------------------------------------------------------------------.......-------------------------------------------..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
ApplicationApproved By----------------------------------------------- -------------------------------------------------- -•-•-........---------- . --------------
Date
Application Disapproved for the following reasons:........................................................................................... ....................
-•-•--•-------•-------.••••-------•----------------••-•'--------••••.•--•--••--•.••.•
Date
PermitNo........................................................ Issued........................................................
Date
..........................-..............,.r.......s..............-..........................e.......................i.�.....•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF....................................................................................
Qrrtifiratr of f1.1kontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
at
has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated-----
.-.-............-----.--..-----------------
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
..........................................OF..................--•--.....--------------........................---------.........
No.......................... FEE........................
Di-sVoml Norkii ClInntitrurtinn Vrrmit
Permissionis hereby granted--------------------------------------------------------••••-------•---•••------••--...--------...•-'--------•••---.................•..-'---
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No.
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated....-......-----.--.---------------..-----
••-•-•--••••--•-••--•-----•...--------•-----...........................................................
-
Board of Health
DATE.....................................................------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No......................... Flms............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... ..._.............OF............................................_...............---....................-----
Appliratiun -fur 43i.apu al Works Tonotrurtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•.......---•----------------••--•..........------------....••-•------------------------........••. .............................................................:..............................
Location.Address or Lot No.
•--••-----•-------•-•-------•-........-••-------•-------••...-----•••---•-••••--•-•............... ..••-•-•-----••-•••-••••••----•---•-•...............-•--•---•---•-•---..........--.............---
Owner Address
W
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons..--.........--............. Showers ( ) — Cafeteria ( )
Q' 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--------------------- Diameter.................--. Depth below inlet----.------.---.-.-. Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date------...---------........ .............
a Test Pit No. 1----------------minutes per inch Depth of Test Pit....----.---........ Depth to ground water....--...-----..........
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.....---............ Depth to ground water-..--.-..-..--.----..__-
�+ ------------------------------------------•-•-----•--••-•---•-•--•----•---------•-----•---....-----•••-•••------•-•--•-•••-•---- ............................
ODescription of Soil-------------------------------------------------------•-----------•------------------------..._..----------------------------------------------------------------------
x
w
--------- ------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable:-------------------------------------------------------------------------- ....................
-----------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
ApplicationApproved By-------------------...........••---.....--•--------------------------------------------•---------- ----------------------------------------
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
•••••-•••••--•---•-----•--•-•---•---•------------------------•• ....................................................... --•--•---•••--•--••------••--------------._._...-••-••......---------....-•--•••.
Date
PermitNo......................................................... Issued........................................................
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
�rrtifiratr of "9 m�liatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by................•---••--••--•-----•------------.....•-•-••••••------••......•--••------------- . --••----------•----•-••-----•-•---•---•....•--••-•-•-••......-•-•-------•----•-••••• ..............
Installer
at....................................................................................................................................................................................................
has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described in the
application for Disposal Works Cotist'uction Permit No----------------------------------------- dated._.-------------.---------.-..-----------------.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................................I......OF_...... . ..........................---...............................................
No......................... FEE........................
Bi-spotittl 39orko Tonitrnrtion Prrmit
Permissionis hereby granted---------------------------------------------------------------------------------------------------------------------------------------------
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No--------------------- Dated..........................................
------•-••••••-•••-••-••--•--••-----------------------•- ..............................................
Board of Health
DATE. —-----•--•-•-----•--------•---•-------------------------•---- ...............
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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