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Home My WebLink About0037 DORCAS DRIVE - Health 37 DorOs Drive Barnstable ...P A = 277 016 n COMMONWEALTH OF IVIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTALTROTECTION • �. r JUN 2 3 2003 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. - SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: `Owner's Name: - 2� MAR ,.,.,® � .�.,...�,� 7- Owner's Address: 30 PARCEL , bolt Date of Inspection: LOT' 1 Name of Inspecto plea ye p int er Company Name . Mailing Address: e �a� i/�i Telephone Number: CERTIFICATION STATEMENT I certify that I have personally,inspected the sewage disposal system at,this address and that the information reported' below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the'proper function and maintenance of on Site sewage disposal systems. I,am a DEP, approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:` IPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: \1 — Date: The system inspector shalljsubniit a copy of this inspection report to the Approving_Authority(Board.of Health or DEP)within 30 days of conP leting this inspection:If the system is a shared system or has a design flow of 10,000 '. gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office-of the DEP..The original should.be sent to the system owner and copies sent.to the buyer, if applicable,and the approving authority. Notes and:Comments. �� 1.... .. r ........: � r.. . ww ... - ...__.»„ „ .-,.....u.. •ter v..•.... ,....-. ,., .-.«... .... .. • ****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 6/1.5/2000 page 1 "Page 2 of l l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) . Property Address: , Owner: Date of hnspection: 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 ofth.e,failure criteria described..in 310.CMR 153M or in 310 CMR l53b4 exist.Any failure criteria not evaluated are indicated below. Comments:- B. System Conditionally Passes: One or.more system components as described in,the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved-by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the ... for the following statements. If"not determined"please. explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not),is structurally unsound, exhibits substantial infiltration or exfiltration ortan.k 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: ,.. ,. ;.,_r. ,:, .> s•F:-, r ..:; 7 .,_:, .c :;... :;:. care, .:: z.;, e. � .t Observation of sewage backup or breakout or high static water level in the distribution boxAue'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: 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,pf Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -.NOT FOR_VOLUNTARY;ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' CERTIFICATION(continued) Property Address: Owner: Date of Inspection: / 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 wit#pail unless Blba' d of Health'deter;„fines in`-accordan.e.w.th:310 CMR 1.5.303(1)(b) thkat'the- system is not functioning in a manner which will'protect public health,safety and the environment: Cesspo.ol'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.environmen.t: The s stem.has a septic tank and soil abso tion.s stem(SAS).and the-SAS is within 100 feet of Y P rP Y surface water sti P1 o rYr tributa to'a surface water suPP1 Y _ The system,has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and.SAS and the SAS is within 50 feet of a private.water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet.but 50 feet or more from a, private water supply well*.*.Method used to determine distance **This system passes if the well water analysis;performed at'a DEP certified.laboratory, for.coliform bacteria and volat le o.rgI4mc compounds indicates that.he ::e!!is free from pollution from thatfacilityand 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: . t • a 3 .• r :,y, FS Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSP:ECTIONTORM PART A CERTIFICATION(continued) Property Address: A. 1� Owner: Date of Inspection: 0 D. System Failure Criteria applicable to all systems: "Yes" 'u ». - You must indicate yes or no to each of the followinga for all inspections: Yes- N q1 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 1/ 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!/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ . Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. ortion of a ool or is within a Zone I-of ic well: _ V Any portion of a cesspool or privy is within 50 feet of a.arpvatle water supply well. YP P privy P PPY 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 eoliform 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 most be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above fail Y ure 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 correctthe 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) 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 questibn 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 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 37 Owner: _ Date of Inspection: Check if the following have been done. You must indicate"yes or"no"as-to-each of the following: Yes No _6_ Pumping.information.was.provided by.the owner, occupant,or Board of Health r • t/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? _V 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? — P 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.? V Was.the facility owner,(and occupants,if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes. no. __L/_ Existing information. For example,a plan.at the,'Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is.unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C. SYSTEM INFORMATION Property Address: Owner: A Y2244b6S Date of Inspection: FLOW CONDITIONS RESIDENTIAL • Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C l R 15.203 (for example: 110 gpd x#of bedrooms): D Number of current residents: Does residence have a garbage grinder(yes.or no). A(T• ,L Is laundryon a separate sewage system es.orho i `p g y (y �,�p-[ f yes separate mspechon required] Laundry system inspected(yes or no / ✓�— ®®� Seasonal use: (yes or no) Water meter readings, 1 available(last 2 years usage(gpd)): Sump pump(yes or no) Last date ofoccupan COMMERCIAL/INDUSTRIAVX& Type of establishment: Design flow(based on 310 CMR.15.203): gpd 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: �ZQ/Yl Was system pumped as part of the nspect' (yes or no): If yes, volume pumped: gallons„--How was quantity pumped determined? Reason for pumping: TY"F.SYSTEIVI _V Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _:Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) . Tight tank _Attach'a copy of the DEP. approval L Other(describe): pro imate age ofAll components,date in.Called(if know and source of information: V. 9� Were sewage odors detected when arriving at the site(yes or no)/ 6 P Page 7 of 11 OFFICIAL INSPECTION. FORM—NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan)//)6 Depth.below grade: . Materials of construction: cash iron _40 PVC_other(explain): Distance from private water.supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): r SEPTIC TANK: V locate on site plan) Depth below grade: �G�,� Material of construction: concrete_metal fiberglass __polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate)' Dimensions: ' Sludge depth: o/ Distance from top of sludge to bottom of outlet tee.or baffle: Scum thickness: , /i Distance from top of scum to,top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffl : ,r�U�® How were dimensions determined 0,�� I-�'J� Comments(on pumping recommen ati let and outlet tee or baffle condition,structural integrity, liquid levels rebated to outlet invert,e " ence of leakage etc. Pt ): �O GREASE TRAP- locate otl site plan), �y Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum.thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owne Date of Inspection: T1GHT or HOLDING TANK• (tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal__fiberglass_polyethylene other(explain): Dimensions.` Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes'or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: if present must be opened)(locate on site'plan) Depth of liquid level above outlet invert: Comments(note if box is Level and distribution to outlets equal,any evidence ofsolids carryover; any evidence of leakage into or out of box,etc.): PUMP CHAMBER locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): . Comments(note condition of pump cWamber, condition of pumps and appurtenances,etc.): 8 Page 9.of 11 OFFICIAL INSPECTIONYORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: l SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not.located explain why: Ty pe leaching pits,number: leaching chambers,number: leaching galleries, number: leaching trenches,.number, length: leaching fields;number, dimensions: overflow cesspool',number: .inn Item system Type/name of teclmolo"y. Comments(note condition of soil,signs of hydraulic failure, level of ondinQ dam soil condition of vegetation, P �, P g s et (� <r 000 P .cMCI IV 07' ��` 3.a CESSPOOLSY(, (Cesspool must be pumped as part of inspection)(locate on site plan) �J . Number and configuration: `. Depth'—top of liquid to inlet invert: Depth of solids layer Depth of scum layer: Dimensions of cesspool:. Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding condition'of vegetatton;etc.) PRIVY:ZAL�--(locate on site plan) Materials of construction Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �� Owner. Date of Ins Inspection: d P � O 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. ��i�2 a✓ C�1J� s19 0 . 10 Page I 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART'C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection. I SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water ZZ feet Please indicate(check),all methods used to determine the high ground water elevation: Obtained from system design plans on record 1 If checked,-date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) - Checked with.local Board of Health-explain: Checked with.focal excavators,installers-(attach documentation) _Accessed USGS database-explain: You must describe how you established the high ground water elevation: ' 1auww levp 11 Permit Number: Date: Completed by: XC> HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 3.7lJl✓n5l!� � Lot No. Owner: Q' .. - Address: Cpntractor: -Address: Notes:.. STEP 1 Measure depth to water fable to nearest 1/10 ft. ............ ............................. ......:....Date J 3. rnonth� i STEP 2 Using Water-Level Range Zone and-Index Well'Maplocate site and determiner O Appropriate index well.. /.✓"!.�!o..... l.Y/ • I OWater-level range zone .............. STEP 3 Using monthly report."Current Water Resources Conditions" determine current depth to 'water level for index well ... ..... �• ��/ � I month/year i STEEP' 4 Using Table of Water level Adjustments for index well(STEP 2A), current depth to water level for index.well(STEP 3)., and water-level:,zone (STEP 28) determine water-level adjustment-.: 7 STEP 5,. Estimate depth to hi.gh water by subtracting the water level adjustment (STEP 4) i from measured depth to water level at site (STEP 1) .................................. ...... Figure 13.--Reproducible.cornputai10n TOM 415 11j i ' i TOWN OF BARNSTABLE LOt'ATION SEWAGE # 5�` VILLAGE �'S� ASSESSOR'S MAP & LOT ,.p277- 0/4 'NSTALLER'S NAME & PHONE NO. ;SEPTIC TANK CAPACITY A�d � LEACHING FACILITY:(type) R/T (size) 6;klO NO. OF BEDROOMS PRIVATE WELL OR BLIC W TA E 1 BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes Novi '�_ 36 ��. t� ` '�--� 1�.�+ l� `) 17. - �� 7"'r - - oC&.TION ' , _ SEWD,C;E PERMIT QO. 0 17 .- VILLAGE • -. - _ _ IWSTQLLER 5 U&ME ADDRESS - L1 O- LA O LAW � - - BUILDERS Q &MF- �. ADDRESS fF DD,,TE PERW-T ISSUED DATE COMPLI bJ-4CE ISSUED : — — — �,: ��'�� as No.. - a i -- .... Fss............................. r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �. TOWN OF BARNSTABLE AVVIIraa#ion for Uwpaii al Works Tonotrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair 0< an Individual Sewage Disposal System at: 4..... .....:.._................... -- ---------........--•-••--.....--- .,rs. ��----•-....,Z �......... f� Locatif d espy- �j �j ^ per.. TNJ Z. ..........:. 1.__... iF...............Yn r Lot Nolc ` �/ ., -....... Ow. �. •• J / '.5 GIJ�O�-�-JS y Addres�A Installer 0. ......... ........................ Address d Type of Building Size Lot..........:.................Sq. feet U Dwelling No. of Bedrooms................. .....Ex Expansion Attic� g— ---------------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------------------------------------- W Design Flow................5.:�._...................gallons per person per day. Total daily flow-------- ..................................gallons. 1:4W 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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a -----------------------------------------•------•-----------.....-•----•-------------••••---•---•-_........ O Description of Soil---------------- s- � ! sf�,r (//� •. ---- -�?........._-��.d----•----- -----------------------------•----------•------------------------------......---•-----•-------------- W U Nature of Repairs or Alterations—Answer when applicable_____.! /�-.-------- 1�- --- .f >. 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 Complianc as een iss ed the board of health. Signed ...... ------- -----..... -- ---............... -------- ----- ':............... Application Approved B PP PP Y ..... ... �7` i -------------- - -- - Dare Application Disapproved for the following reasons: ........................................... ...: ............ ------------...-- ---...---...........---------------...--------------- P � Permit No. ?��..._`------ - - Issued to -- . ..... ate ii N � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t lj� TOWN OF BARNSTABLE' ' Appliratilan for Biipo,iai Workii Tomitrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair (!� an Individual Sewage Disposal System at: 11 .. > Locatio - d ess�- � !......... s7 .. ..----�---Y--�-.u/�or Lot •N•-o•.-�--�----�---� ....... Owner sT . . Addr's�---- ---------------- Installer Adres 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 ( ) dOther fixtures ................=..................................................................................................................................... W Design Flow.............: J`5 ................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. I................minutes per inch Depth of Test Pit.................... Depth to ground water...__-_-_____-__-----__. 0 Test Pit No. 2................minutes per inch I Depth of Test Pit.................... Depth to ground water........................ O Description of Soil - ..1_ 2. h -SO�_�: •�1.._-_✓��4c�•.SD_......_.. v .-------------`=-......'=1-..------•--`-....`��,J- r2_s-----•---------------....---------•--------. W - --------- ----- U Nature of Repairs or Alterations—Answer when applicable....___OM........ ........ G 1. ----------------------------------- 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-,'..as,been iss board of health. / �- �ed.4b.Vthe ¢ : Signed : . - f.. ............. ��/ ".. --- Dare Application Approved BY P �✓ J. ..------.. %..�'.. /0�C� �; /� Application Disapproved for the following reasons: 1......................................... ---------- ----------------------------`----....... -------------. ----- ...... ....... ... .. .:.......... -� �D Permit No. ... Issued . + are THE COMMONWEALTH OF MASSACHUSETTS BOARD OF;HEALTH TOWN OF BARNSTABLE (IlextifiratP of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( k ) b ------- - :...... ' /' c-)TI7... - 'd%'`is 7 -✓<j_/ d�J Y ---------------- -- ---------------------- ------ Installer ,/ at .................. 5, 7. 1�Q► s ......... / U............--- ........------- has been installed in accordance with the provisions of TITLE of The St vironmental Code as described in the application for Disposal Works Construction Permit No. .....'�....... :� F .-.. dated -----------------------------.--------_-..----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE --- ........ ......�----------I--. ----------------- Inspector - - ,} THE COMMONWEALTH OF MASSACHUSETTS ='L'7 2 — Gib BOARD OF HEALTH TOWN OF BARNSTABLE 5 No.._..r_.�...� FEE...`.-5-<<............. �i��a��1 �r�� nn�trnrtuan rrntit ��i`at o�i Permission is hereby granted ----------------••----_... ..._.....---------•• :_-------------•-------.......---..........---....... to Construct ( ) or Repair '(----')r-an Individual Sewage Disposal System at No.......................... vG�C �'-4, �� (1 .. 1............. Street as shown on th/plication for Disposal Works Construction Permit No.. .._ �ated: /� I I iBo�rd ofIealth�,- FORM 3850E HOBBS 6 WARREN,INC.,PUBLISHERS _ � i�~ ��- ' , N - . ��-��-___ THE COMMONWEALTH OF mAssAo*uSsrrS ��K~��& �� ^^" ~�� « --� �-~�r°-----'cxF--.�9=� -',--------- ��~° ��~ �K �� 8�� K�� umil Application is 6oceby`ouuIe for u Permit to Construct ( } or Repair ( ) an Individual 5cvvugc Disposal System~' ' � � V �� ^m xw-~~�� -__----------'_'---'-_-------------'_----'----'--' --_--.=.-^----~-.--~'°-~.'-.-'___-'-_-------'----- � ��"�° or Lot m^ �� r�� -'---'--'-----------�~_'---_'-~~-'-----^--------'----' ----.--._--'~°'^'°'^-~........................................................ Address Installer _'`--_-_---___'- Address '' "';�? Buildi Dwellinof �� feet c6 8�6,00ms----��=�--_-_--��uo u�u` Garbage Grinder Other--Iyp� �� Bu�d�o� -----.---.- 1�o� o6 p�rsma---�t---.-- Showers Cafeteria � Other c 6 � ^� ^` --------'------'-- ------' r��'-------------- Design ��......................g�oosper y�suu day. Total . .................gallons. Srp6cT:n�oZZ�oi6 i��] �ns Length-'C^__- \�ibh--��-_ D�m��r-----' Dqxl��----' Disposal Trench--No. .---.-_-' Width-------------------- Total Length.................. Total area--'-----sg. h. Total Seepage Pit No-----.- .................... Depth �uciugurra----'_sq. ft. �� Other D�t�6u6oubox ( ) Dosing tank / ) �� ~ �^~��w� -- .I ` 2�A/- ~~ Percolation Test Results Performed by----------�-----.-----------. Du1c'.------------' Ies Pit No. L'..----mlnutcsp�rinch Depth of Test Pit.................... Depth to ground water-------- �4 Test Pb No 2----------------minutes per inch ',Depth of Test Pit-------------------- D�nt6to �rouod water------------------------ � O � --'"--- - | � �n ! � ---------------------- '''��—'-_'-----_' � ___' ^ `- --'' --'-'---'-- ----'---'--'---- ''-'------' �� Nature of Repairs or Alterations—Answer when uon�xb�-----------------------r---------' --''-''-----''_--'-- ------------------------------------------------------------------------------------------------------------------------------------- Agreement: . The undersigned agrees to install the uforcdcacribed Individual Sewage Disposal System in accordance with � the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to y6cc the system in operation until a Certificate of Compliance has been issued by th board of6eal °=~~-~~ - Date Application Approved Dr-.. - -'----'- '��'^�� u7 ~^~ Application Disapproved for the following reasons:................................................................................................................ .......................................................................................--'-------__-------.---''_--------------._---_--- � Dat" � PermitNo.................................. Issued........................................................ Date � '~~^--'^~--'--'-''----'-'''--'-----''`''-- No......................... --� 'Fug ... ...� THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH / L✓Yt _..._... OF....... .. ....�� .....:--------------------------- Appliratinn -fur Riipoiitt1 Vorkg C owitrurti n Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----.� ..._...'�...........�o-t,c_✓�------.............................r ' ----------- j✓ Q --Q..--------------------.---.------------ Location-Address or Lot No. .............................. ....................... q f -----------•-••--------------------..--..-•--••-•------ �� n r Address Installer Address QType of Buildin Size Lot.. .._ G_C S. feet DwellinNo. of Bedrooms.................... n At tic 00) Garbage Grinder (� p, Other—Type of Building ---------------------------- No. of persons..........f---------------- Showers Cafeteria ( ) P4 Other fixtures ------------•-•--------------- W Desi n Flow........... f ...- Mons per person er day. Total dail flow........�.----.. Mons. WSeptic Tanl�Liquid capacity-!.gallons Length___.-__-_---- Widt...... .. Diameter................ Depth.--._-_-_--- x Disposal Trench—No..................... Width------------------_ Total Length.................... Total leaching area-.-----_-_.-.-----sq. ft. Seepage Pit No--------_---------- Diameter--..._--_______---_- Depth be w inlet____._____ ______. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) ` �� _ - °/— 74 . Percolation Test Results Performed bY........................................................................... Date........... -------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit............_....... Depth to ground water------------------------ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit..--_____.---_____-_ Depth to ground water-------..---.--.-------. a ----------------' ........ =� Description of Soil- },� - LlJ,rN - ---`';�•`----------- G --- . -- ••--•--- -------------- c., VW -----------------------------Y..........------------------------------------------------------------------------------------------------------...................................................... 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 healtl . �4 Sign -------------------------------- Date Application Approved By-------- ------ ...- ----�-------------------- ��r D te /� �C Application Disapproved for the following reasons:-----•---------•--------------------••-•---•---•--------•-----...................-•-•-----.....-----•-----_----- ••-------------------•------.....--•--------------------------•--•-------•------•-••-----...----------•••.................... -------------------------------------------------------------------------- Date PermitNo......................................................... Issued----------------------........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH;' �1 �...1, .........OF.............�.,e�. !1"::• �.. ........... Trrtif iratr of 'OhImphaurr THIS IS TO CER" IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired In ( ) byEd I . r "I 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--_�,C. tAj...43 f.___I__�1.74 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIIyON SATISFACTORY. DATE------ ...... {---------->- -------.---. Inspectoro....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH` ' ......I.........OF..........h..a-,-W.— ........................... � *� No......................... FEE----/ ............ Permission is hereby granted..... .. .....................................................................•-----------•- to Constr t //,) or Re 'r ( ) an Indivi u 1 Sewage Dis al Syst at No. Street as shown on the application for Disposal Works Constructioncmit Dated,___ 11�J:_j _�1.� . U� j. Board of Health DATE...L3-------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • LOT 515 O, t • S/L L fLE.✓.. FF�T A80 t/E YDAD PL O 7 " PL A /`/ SCALE , iF_ v—DAT& — — PLAN /2EGE,i2ENCE : �?;�GIr'w/c .! �x I NEX2E8Y CEPrIFYTNAT 7AiJ6 6XIS7-- m /NG C-OUVDA T/ON LOCATION /55 COZZE .45 6'410WN AND_ t? _CONFOk'M i'Y/TN .4,�, L F. a; Tfl�' BUILDING 3ETf3,�JC'�PEQCU�L�EM /T OF.T TObt/n/ OF 4Jv t/E YOB' ?G • Cad w�� '� T�Yco� Co.�'