HomeMy WebLinkAbout0241 CARRIAGE LANE - Health 241 Carriage Lane
Barnstable P
A = 297 033
{
TOWN OF BARNSTABLE
LOCATION j SEWAGE #
VILLAGE ASSESSOR'S MAP & LOTo1g7 ' U 33
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)A / P� (size)
NO. OF BEDROOMS I
BUILDER OR OWNER sl�lA
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leagung Facility (If any wetlands exist
within 300 fe f lu 'lity) Feet .
Furnished y c
. ._ �InrkTFrz l i►�E � .
a
Me j
. . A t 33
2
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of d
DATE: 2/7/02
PROPERTY ADDRESS:?41 _Carriage Lane
MV
o ;
'Barnstable Pimm .
Mass.---------------- LOT S5
..
------------------------
On the above date, I Inspected the septic system at the abV. &Xd�gbff
This system consists of the .following:
1 . 1 -1 000 gallon septic . tank. MAR 0 7 2002
2-2-1000 gallon precast leaching pits. 6 'X9 '
TOWN OF BARNSTABLE
HEALTH DEPT.
Based on my inspection, I certify the following conditions: ;
3 . This is a title five septic system. ( 78 Code
4 . The septic system is in proper working order
at the present time.
5 . Repaired line leaving the septic tank to the
second leaching pit. Lite Sch. 30 pipe taken out Sch. 40
4" PVC pipe put in its. place.Old pipe was crimp d.
SIGNATURE:f
Name:_J_p _ Macomber Jr�_____
Company: Josei)h_P_ Macomber_& Son , In'c .
Address: Box 66
_-Centerville , _Ma_-02632-0066
Phone: 508_775_3338 ,
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC. .
• Tan ks-Cesspools-Leachflelds "
Pumped & Installed
Town Sewer Connections ..
P.O. Box 66 Centerville,.MA 02632-0066
775-3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 241 Carriage Lane
Barnsta le,Masss
Owner's Name:Robert Simmons
Owner's Address: 2/7102
Date of Inspection: 2/7/02
Name of Inspector: (please print)Joseph 'P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66
Qagg 02632
Telephone Number: 508-775-3 38
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuan
t to Section 1.5.340 of Title 5(310 CMR 15,000). The system:
.
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
F ils
Inspector's Signature: Date: a?� dal
The system inspector shall Umit a copy of this"inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. 1f 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
authoriry.
Notes and Comments 4
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different.,`
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 241 Carriage Lane
Barnstabie,Mass.
Owner:Robert Simmons
Date of Inspection: 2/7/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys�Passes-
I ha�10
ound an �.ny
hich indicates that any of the failure criteria described in 310 CMR
15.303 or tMR 15.304 exisailure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
Present time.
B. System Conditionally Passes:
dZ 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.
.per The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the .
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
P Observation of sewage backup or break out or high static water level in the istribution box ue to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
44 The system required 'pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 241 Carriage Lane
Barnstable,Mass.
Owuer:Robert Simmons
Date of Inspection: 2/7/02
C. Further Evaluation is Required by the Board of Health:
Wg� Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or,privy is within 50 feet of a surface water -
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the,
system is functioning in a manner that protects the public health,safety and environment:
�(L 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.
tlt) The system has a septic tank and SAS and the SAS,is within a Zone 1 of a public water supply.
Uhl 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 0 feet or more from a ,
private water supple well". Method used to.determine distance� f
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and
• the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure.criteria are triggered. A copy of the analysis must be attached to this form.
3. Other: ,
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
-
Property Address: 241 Carriage Lane
Barnstable_,Mas.C;_
Owner:Robert Simmons
Date of Inspection 2/7.n? _
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge 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 Mbution bo bove outlet invert due to an overloaded or clogged-SAS or
cesspool 0&mz� 7,, S7—T 7
_ Liquid depth in4acsp@4is less than 6"below invert or available-volume is less than IX,day flow
Required pumping more an 4 t_tmgs in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped!,Ii ,W�•'
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the.well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(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:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
4
yes no J
_ _y 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(I.nterim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"tto any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
i
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 241 Carriage Lane
Barnstable,Mass.
Owner:Robert Simmons
Date of Inspection: 2/7/0 2
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 wccluding 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
lion of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
r
- 1 ,
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'PART C
SYSTEM INFORMATION
Property Address: 241 Carriage Lane
Earnstab e,Mass. ,
Owner: Robert Simmons.
Date of Inspection:2 7 02
FLOW CONDITIONS '
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):�
DESIGN flow based on 310 C 15.203 (for example: 110 gpd x# of bedrooms): 'Voel-"O ,
Number of current residents:
Does residence have a garbage grinder(yes or no):•XP�t
Is laundry on a separate sewage system es or no): 410[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): A b
Water meter readings, if available(last 2 years usage(gpd)): 2000-1 35, 000 gal lons= `r°., GPD .
Sump pump(yes or no): 2001 -1 33, 000 gallons=364 . 39 GPD
Last date of occupancy;, '
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): A),4 gpd
Basis of design flow(seats/persons/sgft,etc.): �Ur9
Grease trap present(yes or no):11L4
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: i1J/9
Last date of occupancy/use: _
D '
OTHER(describe):
GENERAL INFORMATION 4
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):.�r
If yes, volume pumped: 0 gallons-- How was quantity pumped determined? 4,� _
Reason for pumping:
TYPE OF SYSTEM
{/Septic tank, soil absorption system
y�Single cesspool ,
Overflow cesspool
UPrivy
)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) `
-4d Tight tank .4_Attach a copy of the DEP approval
4 Other(describe):
Aplpjoximatq age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 I
OFFICIAI. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 241 Carriage Lane
Barnstable,Mass;
Owner: Robert Simmons
Date of Inspection: 2/7/02
BUILDING SEWER (locate on site plan),
Depth below grade:
Materials of consrruction: cast iron -P—/40 PVC •%other(explain): AllJ
Distance from private water supply well or suction line: IV"�
Comments (on condition ofjoi_nts, venting, evidence of leakage, etc.):
Joints appear tight-No Pyidenep of 1eakage_ThP sys{-Pm
is vented through the house vent. L
SEPTIC TANK: locate on site plan) /OGD���(l�rvy
Depth below grade: �
Material of construction: yec.�crete�,y metal,&fiberglass.UOPolyethylene
/JLlvther(explain) eR _
If tank is metal list age:.�4V Is age confirmed by a Certificate of Compliance (yes or no): attach a copy of
ceniftcate) e/
.,�� >
Dimensions-
Sludge ��'�f
depth:
Distance from to2_oLsluege to bottom of outlet tee or baffle:
Scum thickness:%ie�
Distance tom top of scum to top of outlet tee or baffle:/mot %
Distance tom bonom of sbaffle-t'm to bonom of outlet tee or baffle-
How were dimensions determined: At
Commcn(s (on pumping reco:mendations, inlet and outlet tee or affle condition, structural integrity, liquid levels_
as related to outlet inven, evidence of leakage, etc.):
Pump the septic tank every 2-3 years.'Inlet & outlet tees
are in place.The tank is structurally sound and shows
no evidence of leakage.Liquid level 'at the outlet invert is
fifty one inches.
GREA E TRAP local; en Site p!an)
Depth below grade:Ahf
Material of cons truction:,&9concreteAZ!ZmetaI�jfiberglass4apoIyethylene4f Locher
(explain):
Dimensions:
Scrim thickness: �y
Distance from top of stun:to top of outlet tee or baffle:
Distance tom bonom of scum to Lonom of outlet:tee or baffle:,_�/�
Date of last pumping:
Comments (on pumping recon:me:.dations, inlet and outlet tee or baffle condition; structural intepiry, liquid levels "
as related to outlet inven, evidence of leakage,etc.):
Grease trap is not present.
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:241 Carriage Lane
Sarno ah1 _,14as„
Owner: Rnht-rt Ri mmnnc
Date of Inspection: 2/7.1(12
TIGHT or HOLDING TAN K(tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade:
Material of construction: 2aconcrete,l�metale,�f_fiberglass�olyethylene 449 other(explain):
Dimensions: d1i8
Capacity: rQ gallons
Design Floe: AIR gallons/day
Alarm present(yes or no):
Alarm level: 4M Alarm in working order(yes or no).-,&24.
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOxttt'c� °•(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _ W
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box is not present
PUMP CHAMBER�6�(locate on site plan)
Pumps in working order(yes or no): 414
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Piim= rhamhar i s not praceat
8
r
Page 9 of 1 1 '
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:241 Carriage Lane.
Barnstable,Mass.
Owner: Robert Simmons
Date of Inspection: 217/0 2
SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not
2-1000 gallon precast leaching pits. ( 6 ' X38 ' I
If SAS not located explain why:
Located; See page 10
leaching pits,number.,
_&h leaching chambers,number: D
A)6_leaching galleries,number.
4,0 leaching trenches,number, length:
tV leaching fields,number,dime sions: jf
overflow cesspool,number: �-�
innovative/alternative system Type/name of technology:; rye ;e, �
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to medium sand No signs of hydra»lid failure
or ponding-Soil s are d y_Veg - a i r)n . i G ncirma 1 _Pi t to 1 of t ooerat-i ng
pit to right was not. Leveled line leaving tangy. Both pits are
now operat}}' ng properly.
CESSPOOLSRb�(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: A)iQ
Depth of solids layer: ,VA
Depth of scum laver: Al/A _
Dimensions of cesspool: NA
Materials of construction: /IAA
Indication of groundwater inflow(yes or no): /L✓fI
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present.
PRIVY/ / (locate on site plan)
Materials of construction: 1V/4
Dimensions:
Depth of solids: iL
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy is not present::
6
9
Page 10 of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) '
Property Address; 241 Carriage Lane
Barnstab e,Mass
OwOerc Robert Simmons
Date or lnspeetioo;2/7/02
SKETCH OF SEWACE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanenrreference landmarks'or
benchma-rks. Locate all wells within.100 feet. Locate where public water supply enters the building.
2� 1 �arrai�c L,n ,
0
nt,j
33' 2 r
3 1 �
eld -
10
Pege 1 I of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 241 Carriage Lane
arns a e, as,s.
Owner: Robert immoms -
Date of Inspection: 2 7 U-2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water Ilef feet
Please indicate (check)all methods used to determine the high ground water elevation:
NpObtained from system design plans on record - If checked, date of design plan reviewed:
rv -siz5butting RM bservation hole within 150 feet of SAS).
_ Checked with local Board of Health-explain:
YES Checked with local excavators, installers-(attach documentation)
Yes Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used; Gahrety & Miller Model 12/16/94 Ground water elevatic)ns
ahnvp gpa l eup..1
rued; USGS Clbservatic)n well da-ta June 1992
Used; USGS Annual ranges of ground water levels. January 1992 '
ivy ul r un-92-000-1 Plate #2
Leaching
Pit y :eet
Groundwater: Feet Below Bottom,of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is ;v
feet.
11
`+•n'nr+�n•r7*�•n- Tf..-mr•nrPrnrlre++lrrrn�r•.•fe+t+TrlTr�*t'nm trTrw�rTAlllenlRl Tn•'T•T-7•ntr--.-t-..-..,1
1 TOWN OF Barnstable WARD OF 11EALTII .
SUDSUR FACE.3EHACF DISPOSAL ,SYSTEM INSPECTION FORM - PART D CERTIFICATION
«•T•1«�••.••.• -T.tlt��1TI tT T.T11'R.'11r1 T1R1R911A1¢T1'r•t-•1VTR't illaf-'n1R�Ar/T-RI�RTIR� + I.Tn ..�r•T'r•1. -. J
.-TYPO OR PRINT CI,EARL1•-
PI?OPERTY INSPCCTED
0
STREET ADDRESS 241 Carriage Lane Barnstable,Mass. '
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Robert Simmons
PART U - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber Jr.
COMPANY NAME - Joseph P. Macomber & Swn Inc
COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 .
Street Tovn or City State LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX (508 790 _1578
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage disposal system nt
this address and that the information reported is true , accurate , and -
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and, maintenance of on-
site sewage disposal systems ,
Chec}y one :
✓//System PASSED
The inspection 'which •I have conducted has not found any information
which indicates that, the system fails to adequately protect public°
health or the environment as defined in 310 CMR .15 . 303 , Any failure "
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have con acted -has found - that' the system fails to
Protect the public health and the environment in accordance with Title `
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE.
CRITERIA of this inspection form . -
Inspector Signature
Date
ti
ne copy -of this rtification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALT'Ji,
* If the inspection FAILED, the owner or•"Moperator shall u pgrade ' the system
within one year • of• the date of "the inspection , unless allowed or required
otherwise as provided in 3.10 CMR 16 , 305 .
partd .doc
23t"ATI0N SEWAGE PERMIT NO.
241 Ut 1"Agoz S5--(D-7'1
VtLL.AG E
INS,TA LLER S NAME A D D R E S
S UILDE R OR OWNER
61 �'lFuCyYV 5
DATE PERMIT ISSUED -� PS
DATE COMPLIANCE ISSUED [3
�;
' ,,
� �
� �� � �/
,i ��,�
� �� ��
� � � , � � ��
� /` \ Ji� l
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No.: ..� � 7 F>$... d
THE COMMONWEALTH OP MASSACHUSETTS
BOARD 9F HEALTH
........... .........OF........ /'�! is/�/r' C%....... ..............
Appliration for Dispas al Works Tonstrnrtion JIrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (/-r an Individual Sewage Disposal
System at
.... r__G� . . -, �,� ..... ... .................
oca on-Address or Lot No...... '! t� ' . ---------- • ..... ----------- ------ .........-
wner, l�"� Address
Installer Address
Type of BuildingSize Lot............................Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
� Other fixtures ....:.................................................................................................................................................
W Design Flow................:...........................gallons per person per day. Total daily flow............................................gal
Ions.
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
� Pe colation 1Test Re ults ) Performed by.ng tank(-----)..........................•----•-•----------•...... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(To Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+
® Description of Soil------..S9 - - - - -- - - --
x
UW ---•---•--------------•---------------------------------------------------------••-----------•-•-•------•---•-- . ---- -•- ----- -------
Nature of Repairs or Alterations—Answer when applicable._.... _-----------------�� ._.". t� .........
-----------------------------------------------------------------------------•---------•-----......----•---------------------------------------------------------------------------------------•---•---
Agreement: "
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of THTL B 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by thedloard health
Signed �Z% "
I Date
Application Approved By---•--• -L`-......... •-----.._
Date
Application Disapproved for the following reasons-------------•--------------------------...-------------------•-------------------------------------•-•---------
----------------------------•-.......----._.......--------------•------------........------•-•------•--------------------------.-----------------------------------------------------------------•.....
Date
Permit N ... .... Issue
-- ........ ...............................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I m A- 'L�
DATA
No.��..°� ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ..:.....!'...!dl-..-----.....O F....... .... v....•.j = =••:�'..............................
Appliration for Dispuiittl Worku Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (i ) an Individual Sewage Disposal
System at
. If
..- ....__� - •-- ............................... ---••••-•--•-•---•-••-•.................... ......----•-•-•--•......-----......_---•-•
Location.Address or Lot No.
:..._.__:... = .......................................................•. ---------
.--------------------------------•------------------------------•-..--------------------
i
Owner Address
a ✓. s ♦ --•-••....................................... ....................................••---•-••••-•-
M Installer Address
UType of Building; Size Lot............................Sq. feet
Dwelling—'"No. of Bedrooms..............................,-------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther 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 ( )
a Percolation Test Results Performed by •--•---------------•---------------=...
Date
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_----_________•----._-
f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
M •---•---------------------------
•-----------
-..............
•----------------------
-....
.........
....
•---------
•...
•---------
•---------
-•........
•............
O Description of Soil---------------- y ----------•-----...........-•-----•--••---••-----•-----•--••----••---•------------•-----------••-••-•--••-----•-•------••-----------••-
x
w
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------...........---
U Nature of Repairs or Alterations—Answer when applicable..................... '. ' '�'J i'� ' • '/
. •-------------•-----•••••••-•-----•----------------•••--:......•-------
---.........................-••-----•-------•-•...--•--•-•-......--------•----•--••--.._..........•-•-•--•----=••-•---•••-•-----•-----•-•----•--------•------...•-•-•--------•-•-•----_._.._..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed........ ........... ....�---•-•=-•U--`' : - 1~!!/ f µ _.
- - ... `
/,I Date
Application Approved By............. ............................................... r
a;
a Date
Application Disapproved for the following reasons-------------------------------------------------------•-----------------------------------------------•--.....--
-------------------------------•-•-•-----..........--------....---------------•-------..---•-----•------- ....--•---------------------------------------------•---------------------------•--------•---
- Date
Permit No............
--------------••. Issued.......................................................
k.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l ......:'......... OF.... ffj`
r.
mun ifiratr of f�nntplianrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by......................................................................................................................................................................................................
.............. ••.•. ........----............--- :� �......----.....--•---..... ---•--•-•.......---•-------•--•-•-......----••-•--
alle
J / .,Installer 1 r '—
at.........................................I / ~J !� l` ,/• i^ t '�._ / I:. "I'll p*��r I� � ✓: .r 'r��.,*if
J /`e I ��
• r
' .`...................-----...............-.....----......._,..................................__.........................................................
has been installed in accordance with/the provisions of TIT 5Fo �eState SanitaryAas desc i d in the
application for Disposal Works Construction Permit No ------------------- dated..- _J$ h1"
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIOJ SATISFACTORY.
DATE......... .f.....1 ----•....--••---•--•----•- Inspector........ .
-_--------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F• HEALTH
No -�.. ram._. FEE. .....................
in nr inn n I t#
Permissionis hereby granted_.... --_.... ...•--•- ---••.... ...........RE............................................................. ..................................................................
Construct ) or R ai v ual S `Tage Di oral Sy
at No.. 4./.
Street
as shown on the application for Disposal Works Construction PeEguit No� .. __ Dated.......... .. ��"...................
• 9
F i //}} t� i, Board of Health
DA ----------:5....;
ff Jf
`j. FORM 1255 A. M. SULKIN, INC.,IBOSTON
.LbtA"i10N �`�� , SEWAGE P RMIT NO.
VILLAGE t
INSTALLER'S NAME V ADDRESS
BUILDER OR OMi�NEIt
e
DATE PERMIT ISSUED - -�5�
DATE COMPLIANCE ISSUED `�
,+ .;..�
q _ �l
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No.--••8--�� :C G Fps S-.00............
THE COMMONWEALTH-OF MASSACHUSETTS "
BOAR® OF HEALTH
--------------------T.own_........OF....Barnatable-----------------------------------------------------
Appliration for Eligpniial Works (filimtratrtion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
Carriage Ln. , Barnstable
................_...---••---............-•--------------•-•-----------------------------------... ------•---------•---•---•-----------•------......._...........•--.._...........--..........-----•.
Location-Address or Lot No.
Robert Simmons Carriage Ln a__,_:Barns table
-.....------- : ..... ........•--•------------------------------ -------- .......... ---------
Owneri Address
a A & B Cesspool Servce 128 3ishops Terrace, Hyannis
Installer Address
Type of Building Size Lot..... ......... .........Sq. feet
Dwelling—No. of Bedrooms.....................4.....................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building .........................•.. No. of persons---------4................ Showers ( ) — Cafeteria ( )
a' 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
------------------------------------------------------------ ------------------ -------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Testa Pit-------------------- Depth to ground water........................
....--•------------------------------------•- --: .,_.--------------------------------.---------------------------------------------------------
O y
Description of Soil-•------------------�r3Vel---------•------......_._....-----------•-=------------------------------------•--------------••--------...--------......----•-----
W ---- --------------------------------------------------------------------------------------••----• -:-------------------------------•----------------------------.------...---------------•---.....--
x
V Nature of Repairs or Alterations—Answer when applicable--------Insta.11.at- 4n...af---c-1.,000-----------•--------
(one...thnuaand.)...gallan---atane..:.packed.-.laac-h---p-it------------ -- ----- -- -=- -------------------------------
Agreement:
The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b e b r f health:
Signed
1012178.
Date
ApplicationApproved By.................................................................................................. -•----_--1-0,21.78---------
D ate
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•-•--
----------
---------------------------
.-------
-•-----------
------------
--------
.-..................--.................................................................
Date
Permit No......................................................... Issued.................10/2/ 8.
Date
jnt1i
No,� .... Fps 5...Q.Q..........
,. .. n
THE COMMONWEALTH OF MASSACHUSETTS
BOARS OF HEALTH
............_...Tmt'1..........OF...Darnstable-• --------------------------------------------•------
, ppliration for Disposal ]Burks Ton,strurtinn rrmit
Application is hereby made for a Permit.to Construct '( ) or Repair (X ) an Individual Sewage Disposal
System at:
...................••--•. •----••-----------------•--------------- ---- --•--•----------------------------.--••------
Location.Address a or Lot No.
->tahe_rt Slmans- ---------- .:: Qrr3.a��.. ..,... r �tab�,�... -• -- ...
Owner Address
a A... ---R..0.e89Pgal--.TeX-ring---------------------•------------- 128---BishoLpa..Ta.rvace r.,.-Hy-annis-•---•----------...
Installer Address
� Type of Building Size Lot............................S q. feet
�., Dwelling—No. of Bedrooms--:.................A --------------Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building 1
a —Type g ____________________________ No.. of persons.______..�.___________.___.-Showers ( ) — Cafeteria ( ) -
dOther 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...........*-V....sq. ft.
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........................
Test Pit No. 2..........:.....minutes per inch Depth of Test Pit.................... Depth to ground water........................
L�
O Description of Soil ......Grarerl
W airs or '----•--------------------------------------•-----------------------------------------------------------------------------------------------------....--••--
UNature of Repairs Alterations—Answer when applicable-------lne tallati an----&f----a--1:-;00G....................
Cfine---thousand-- -- a�;lon---atorne---- e-ked---leae-h- it-.-------------•--- -------------•--•-
Agreement: � P� --g-- ---
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI`L i.;.,. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued.
.4y,,ftebpar f health.
f
c
` ............................... E}� 1� --------
ate
Application Approved B ••••••••-•••••....---•••••--••-••• ...............................
ate
Application Disapproved for the following reasons:-----••---------------••------------•---....-------------------------------------..............................
---------------------------------•-••-------•-----••---•----•----------•----..........._.....----------•---•--•.•••---•••-•••------------------------------------- --- ------------
-
"' Date
a .
--•-•-.... 3... Issued_----...---•---• ........
Date
No------------------------•---------------------- �r y0��:,c� ...-------=-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
2
................Town.............OF.........................Bern$table......................
..... �=
�rrt�f tr�a�r oaf f�,a�n�li�anre -�
THIS IS TO CERTIFY, That the Individual';Sewage Disposal System constructed ( ) or 6epaired ( x)
by A...8c---B--£eaopaal...Se-0 ....BiUh,fps••• errace.,...H3r-a nis.,•..Ma .-.026.0-1--------
Anstaller
at_Raber-t---Simmons......--Gar_r-i.age----Ln.,"� mat.aW 94 Ma-•----------------------------------------------------------
has been installed in accordance with the provisions of ZWE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------.7 ----------------------- dated- 1.0/2/78____-_--__---_--••-•-
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED.AS A OARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............10/.Z/7.8-.............................................. Inspector.......................................................................................
ter......-a•...+.w. -.__.war..>.`.+r'1...,.h���...W:.�.:.�-.... ...:...........+-..,:.i.�3. .min;+ S.a.+ _. .ti:+c .e� i a. y, ��:.L.v�. ._ _n �...... ...-._.+w-.......-.. ....x...�._+.�.�.a.a-*M..-....I.......... �.-.��....w+.a.a........_.•._.....�._..�..� ....�.
TWE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
78 OF.... 1
fj1 ...... .... i�1� r��i}:CC3........................................... FEE.... �IIL .....
} Disposal Works Tonstrnrtion rrmit/'
Permission is hereby granted_•A_-g�-- --(i98f� 10.UZ B' G@ ----1-28---Biehops--- -••Hyannis
to Construct ( } -or Repair ( an Individual Sewage Disposal System
at No.__G4rr':1age---Ln ,---Barnatable,----_-...,, -----Robert--S mone----------------------------------••-----------------__
Street
as shown on the application for Disposal Works Construction Per No _____ _______ __ ated.,__�-4/2�78........_........
••..... ....... . •... ......... ---- -- - --------•--
Bo d o Heaith
DATE..•....10/2 78......-••-••......•-••••--•- .......•....----------- f
"-1%.'FORM,';,'1.25,5,,�HOBBS &.WARREN, INC., PUBLISHERS - -