Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0068 FLINT ROCK ROAD - Health
,68flint Rock !Road 'Barnstable' p ; ,. 2 .. A = 316 080004 u e i T COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTETLO , RECEIVED APR 0 8 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A Q CE/RTIFICATION MAP 3 < <o Property Address: O /�►��/OC h� /Q� - PARCH • O$O 00 aj- � /Saz t - Owner's Name: 'c 'z LOT 4 Owners Address: ,,,, !oc Date of Inspection: lot p Name of Inspector: (please print) Company Name. Mailing Address: O 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: 4/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments **** This port 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 n conditions of use. Page 2 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: J-�� Owner: Date of Inspection: / Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Systtee Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: " s One or more system components as described in the"Conditional Pass"section need to be replaced or repaired pair,The system,upon completion of the replacement or re a as approved by, 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 exdiiltration 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: x 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a vear 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: r v Page 3ofll OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY AS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � c h// �� / Owner: Date of Inspection: /.7L C. /Further Evaluation is Required by.the Board of Health: ' ZFu 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: _ 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. 4 — 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 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: _ it r Pagc 4 of l l _. OFFICIAL INSPECTION FORK[—NOT FOR VOLUNTARY ASSESSNIE NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION (continued) Property Address: rh Owner: Date of Inspection: 4� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/- zAackup 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 ccesspool tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _Aiquid depth in cesspool is less than 6"below invert or available volume is less than%day of times pumped flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ,Any portion of the SAS,cesspool or privy is below high ground water elevation. -0[�y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water pply. portion of a cesspool or privy is within a Zone 1 of a public well. y 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.] y v (Yes/No)The system fails.I have determined that one or more of the above failure crit eria 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) yes no the system is within 400 feet of a'surface drinking water supply the system is within 2.00_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 CNM 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ° PART B CHECKLIST Property Address: r�, Owner. Date of Inspection: Check if the following have been done.You must indicate"ves"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,.or Board of Health ere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period Z1HHave 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) r/ Was the facility or dwelling inspected for signs of sewage back up 1.� Was the site inspected for signs of break out M 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 �flh�ees 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- Ye no Existing information.For example,a plan at the Board of Health_r Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of t t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: O Owner: r/' Date of Inspection: D !J FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):'7— Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �v Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no),./ [if yes separate inspection required] no): Laundry system inspected(yam Seasonal use: (yes or no): !/ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): 14�0 Last date of occupancy: COMMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and 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): Pumping Records GENERAL INF RMATION Source of information: ��'"�. ,i- Was system pumped as part of the inspection(yes or no): ;F710 If yes,volume pumped:_pllons—How was quantity pumped determined? ' Reason for pumping: 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/Altemative 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 _Other(describe): w. Approximate age of all components,date installed(if known)and source of informatio 01 Were sewage odors detected when en arrivingat the site es or n � o 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: SC kor b�?o Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: " Materials of cons tcuctio _cast iron _-40 PVC_other(explain)`. Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ._(locate on site plan) ' Depth below grade: t� Material of construction: A_l concrete_metal_fiberglass_polyethylene _other(esplain) , If tank is metal list age:_ Is age confirmed by a Certificate of Compliance )es or no : attach a co certificate) p �' ( py..of Dimensions: Sludge depth: Distance from top of s130ge to bottom of outlet tee or baffle;Scum thickness: v�L___ / r LL Distance from top of scum to top of outlet tee or baffle:_ �, Distance from bottom of scum to bottom�nutlet tee 99§g baffie: How were dimensions determined: / o% f<a� ���� Comments(on pumping recommendations,inlet and ou et tee or baffle condition, structural integrity, liquid levels as rebated to outlet invert, deuce of 1jakag ,etc.): / 01,1 J GREASE TRAP:Z/-(locate on site plan) 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.): ' - ry v Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � rdl�/Fi1C�i , j Owner- Date of Inspection: rokG TIGHT or HOLDING TANK. (tank must be pumped at time of inspection)(locate on siteplan) Depth below grade: Material of construction: concrete—met al fiberglass_polyethylene other(e�cplain): Dimensions: Capacity: eaLtons Design Flow: ea'Ions/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 of solids carryover,any evidence of leakage' o or o t of bpx,etc.): PUMP CHAMBER:ld—/(Iocate on site plan) Pumps in working order(yes or no) Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): - s k Page 9of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: F�iV1 �/4r�✓ n� n C9 Owner. �� �L�I✓r' Date of Inspection• SOU.ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)' If SAS not located explain why: --------------------------------------------------------------- Type leaching pits,number:_ u leaching chambers,number: �46Ching galleries,number: i leaching trenches,number,length: ' 44 D x leaching fields,number,dimensions: overflow cesspool, number: innovativetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): T�Pht he CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan] Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: , Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY✓" (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition.of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM'—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: G "4ror c Rj Owner: �3 ,0, Date of Inspe r 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. �fe 'l_ z T a, 3_ 3�_, d- 3 5 ' 3� u Page 1 L of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY`ASSES SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) Property Address: CJ r•��/p� Owner. G1C Date of Inspection: SITE EXAM Slope Surface water Check cellar «' Shallow wells + Estimated depth to ground water 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 rved site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: r"7��5 .+ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: des w you establish the high ground water elevation: // NC � �'d ' JP<oA,- gust - / � �S / raj h n i.✓a-7�� - i -__ . ./So p✓h p f'` f/-e na (o 0 r � TOWN OF BARNSTABLE `e^ 14CATIOiJ In F/sni?/t' Rc� SEWAGE # VT`.LAGS L3aP 4 b/, ASSESSOR'S MAP&LOT �T INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY y:EACHING FACILITY: ( pe) (size) D _ 140.OF BEDROOMS -'—BUILDER OR OWNER PERMITDATE: 422 COMPLIANCE DATE: 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 �l s � w, p 3 w� A � _ � A No. s �i 3 • T Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for �Digooal *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(�)Abandon( ) ❑Complete System ❑Individual Components r Location Address or Lot No. Owner's Name,Ad ss and Tel.No. Assessor's Map/Parcel b �c� y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i S lS 01-� S �_ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �j�C7 gallons per day. Calculated daily flow � �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ¢ ti, Type of S.A.S. t &iL`l ycv Description of Soil 1 CabE�c&e SAA p� 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 place the system in operation until a Certifi- cate of Compliance has M-TROalth. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 24-al— 7,3 Date Issued Q No. 2 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pphratton for Mtopoal *pl' em Con.5tructton Permit Application for a Pertrlit'to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Loot No. U "`r� Owner's Name,AN-1ss and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AA,0-cA(eSr- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures d Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank )!5-`7 a �!-l 0m.) Cja Type of S.A.S. Description of Soil �0. , `t Nature pf 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 En ' on mental Code and not to place the system in operation until a Certifi- cate of Compliance has be l�ued�'y' o ealth. ' Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. � Z 3 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS s Certificate of Compliance THIS IS TO CERTIU, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by pV 0"CA� �. at (0-b tom_ "rl �a has en construct d in-accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z 3 dated i�' " Installer } ! Designer ,- r ,. n The issuance of this per lhai�lnotbe construed as a guarantee that the s s 4vill fun t�ion as designed. Lji Date 1 1 �/ Inspector V r UT No. 'z3�---------'-�----------------Fee �t_�,.�- s THE COMMONWEALTH OF MASSACHUSETTS 3 16 -°(P rcOYPUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ltgpoeal 600tem Construction Permit Permission is hereby granted to Construct )Rep r( )Up ade( )Abandon( ) System located at Y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 a4the following local provisions or special conditions. ' Provided:Construction must be completed within three years of the date of this p rmit. ;,.. Date: �-� - � Approved by �• � �` i /.) 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated '_4q`OD , concerning the property located at 6D Fla meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. (O • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system here is no increase in flow and/or change in use proposed ',ZT'here are no variances requested or needed. A/The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: pr7 " A) Top of Ground Surface Elevation(using GIS information) ! J �VJ B) G.W.Elevation a +the MAX.High G.W.Adjustment SO DIFFERENCE BETWEEN A and B • �� SIGNED : DATE: [Please Sketch propo d plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert ,> . . ��l�V-- ^ � v a ��c "� i -�.: f ,_ _I 'g TOWN OF BARNSTABLE I LOCATION Rd SEWAGE # VILLAGE le ASSESSOR'S MAP & LOT•�E1"W INSTALLER'S NAME&PHONE NO. S'r c SEPTIC TANK CAPACITY %e o c LEACHING FACILITY: ( pe) �R�.�� (size). NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: lad- 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 l within 300 feet of leaching facility) Feet Furnished by I �L17 � d �Jr old 1 L E Craig Mudie 68 Flintrock Road _. ii ]6 Mass . j 02630 1=1000,;gallon septic tank. 1-Distribution box . 1-1000 gallon precast leaching pit . t. c f r 1/8/00 D AT E:-- ---------- PROPERTY ADDRESS:6--Flin-t34.9,k_24a51_____— 02630----------------- On the above date, I Inspected the septic ,system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank. 2. 1-Distribution box . 3 . 1-1000 gallon septic tank. Based on my Inspection, I certify the.following conditions: 4. This is a title five septic system. ( 78 Code ) 5. The septic system is in hydraulic failure:' A New Leaching area needs to .be installed . The present 'leaching pit is in hydraulic failure . 6. Pumped the septic system at time of inspection. Waste Y P water was over all of the invert pipes . Tank, Box & pit . SIGNATURE:,f ._ 1o& - Company: J eeh_P. Macomber & Son, Inc . Address:_ Box_66_------------ Centerville L M$__02632-0066 Phone:_ 508 775_3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY �� JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Q Pumped & installed Town Sewer Connections P.O. box 66 Centerville, MA 02632-0066 AN 2 5 2000 775.333a 775.6412 ,am �pJ • 9 �U j 1 v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-6600 TRUDY C Secr ARGEO PAUL CELLUCCI DAVID B. STR Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM-WSPECT)ON FORM Cottttttus. PART A CERTIRCATION Property Address: 68 F l i n t r o c k Road Narrsa of Owner Craig M u d i e Barnstable ,Mass . 02630 Address of Owner: Date of Inspection: 1/8�/nQ n� Name of Inspector:(Plait:.lPrU Joseph P.Macomber J r . 1 am a DEP owed system 4upectw to Section 16.340 of Title 5(310,CMR 16.000) cormpeny Narr». J.T.Macomber. & Son Inc . btaa Address: Box 66 Centerville .Mass . 02632' Telephone Nam: 5n8-7 7 5-3 3.38 CERTIRCATION 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 inspection. The Inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes .�= eeds'Further Evaluation By the Local Approving Authority ails Inspectors Signature: a Date: The System Inspect shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wttNn thirty(30)days completing this Inspection. It the system Is a shared system or has a design flow of 10,000 gpd or greater,the Irtspettor and the system owi shall submit the report to the appropriate regional office of the Department otr£nvironmenul Protection. The original should'be sent to-" system owner.and copies sent to the buyer,If applicable,and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page Iof11 �,Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Pf.piartyAdd ; 68 Flintrock Road Barnstable ,Mass . Owner: Craig Mudie Date of Inspection:1/8/0 0 INSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: I have not found any Information which indicates that any of the failure conditions described In 310 CMR 1S.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: k0 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. Indicate yes, no,or not determined(Y,N, or ND). Describe basis of determination In all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial Infiltration or exfiltration, or tank failure is Imminent. The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 40 Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box Is levelled or replaced - The system fequired pumphiginore than-fourtlmes v yeardus to broken or obstructed pipe(s). The system wHtVvvs-- Inspection if(with approval of the Board of Health): - - -- broken pipe(s)are replaced obstruction is removed revised 9/2/98 page 2or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contirxred) Property Address: 68 Flintrock Road earn stable ,Mass . Owner: Craig Mudie Date of Inspection: 1/8/O O C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: p ,q� Riv Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WI LPRQTECT THE PUBLIC HEALTH.AHD SAFETY AND.THE ENVIRONMENT Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: i/!fZ 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 soil absorption.system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pros rice of-ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid).- 3) OTHER N revised 9/2/98 Page 3of11 It v % SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Flintrock Road Barnstable ,Mass . Owner. Craig Mudie Dace of Inspection: 1/8/0 0 D. SYSTEM FAILS: You must Indicate either"Yes"or"No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yeses, No Backup of•eswage intofecili"-eYatemcompo_nent•dnstto an overloaded orcbgagedSA"rceaspool. 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 a distrUtion box above outlet invert due to an overloaded or clogged SAS or cesspool. lc X1Vf h7-__ _ Liquid depth in;caaspoeHs less than 6"below Invert or available volume is less than 1l2 day flow. Required pumping more thT4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or.privy is below the high groundwater elevation. x/ Any portion of a 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 I of a public well. Any portion of a cesspool or privy Is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for P q tY Y -coliform bacteria,volatile organic.compounds, ammonia nitrogen•and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply j1 the system•is-within 200 teetota•tributaWAoasurisoa.drirAW@.watw.-oupply• rim Well head Protection Area=IWPA)or a mapped Zone II of s public the system is located in a nitrogen sensitive area(Into PP water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforlr►ation. revised 9/2/98 Page 4orii j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddress:68 Flintrock Road Barnstable ,Mass . Owfw: Craig Mudie Data of Inspection: 1/8/0 0 Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes Now Z/ Pumping information was provided by the owner,occupant,or Board of Health. -None of the system-conwowants.hausAm n pawiped4owatJeast two.,4voW a and4he-vystem hssbaeoaoco(awge==W"flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. . . _ All system components-efrcluding the Soil Absorption System,have been located on the site. _ The septic tank manholes wereuncovered,opened,and the Interior of the septic tank was Inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on-the site has been determined based on: Existing information. For example, Plan at B.O.H.. _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance Is unacceptable) — (15.302(3)(b)] The facility owner.(and.o ,n.-ts,1f difleraut troo�.o�ner),aces.prayided wlth Informatioacn �� rhn ggnpag mskla:aaaar ..f SubSurface Disposal Systems. i i 1 i revised 9/2/98 Page sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Flintrock Road Barnstable Mass . Owmar: Craig Mudie Date of k-P-6—: 1/8/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: 1/D g.p.d./bedro Number of bedrooms esi Number of bedrooms(actual):1 Total DESIGN flow_ ; Number of current residents: Garbage grinder(yes or no): �I Laundry(separate system) ( es or19:_;: If yes,separate impaction.required _ Laundry system Inspected es or no) Seasonal use(yes or no): Water meter nadlng s,It evsileble(last two year's usage(gpd): Sump Pump(yes or no) Last date of occupancy: COMMERCIALMIDUSTRIAL• Type of establishment: Design flow: d (Based on 16.203) Basis of design flow . Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)—&/j Non-sanitary waste discharged to the Title 5 system:(yes or noW-01 Water meter readings,If available: wit - Last date of occupancy: AJ4 OTHER:(Describe) Last date of occupancy: f' GENERAL INFORMATION PUMPING RE RD n,Ohource of Infor o : 1- -�d System pumped as part of ins ection:(yes or no) If yes,volume pumped: 6 gallons Reason for pumping: /. /1 liUJ1s' Wj1f jam/. y TYPE 0,F 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) VA Technology etc Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other 440 APPROXIMATE AGE of all components,date installed{if known)-and source of,information: Sewage odors detected when arriving at the site:(yes or no)4�0 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddiess: 68 Flintrock Roack Road Barnstable Mass.. owner: Craig Mudie Date of Inspection: 1/8/0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:(/cast iron/0 PVC.4•other(explain) Alh Distance from �ivate water supply well or suction line/ Diameter Comments:(condition of Joints,venting,evidence of iaakage,-etc.) Joints appear tight No PvidPnrP of 1Pakngp 4Wetam is —u tad SEPTIC TAN K 019 (locate on site plan) Depth below grader Material of construction: concrete✓O metal&FlberglassAkPolyethylenaA/460ther(explainI If tank Is Instal,list age—Ao'ly Js.age•confirmed by Certificate of Compliance (Yes/No) Dimensions: r d ��e 6`71- Sludge depth: Distance from top of sludge to bottom of outlet tee orbafflr. "-' Scum thickness: (� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottormof outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumpin ,condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structural4ntegrity, evidence of leakage,etc.) FUMP tank every 2-3 years once the leaching area ; G ' upgraded Inlet & outlet tPPR arP in =lsrP Tha tank is etriirtiirn11W -� n ii n d and chowP, nn virj dQ p6e 9 28�E8$-e r GREASE TRAP: e (locate on site plan) Depth below grade:-d Material of constructionyIconcretwAmetal FiberglasW&Polyethylenq4�eother(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:_/ Distance from bottom of scym to bottom of outlet tee or baffle:IVO Date of last pumping: 112 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Grease trap is not present N revised 9/ /2 9 8 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) prop"Addre". 68 Flintrock Road Barnstable ,Mass . Owner: Craig Mudie Dam of kowwtion: 1/8/0 0 TIGHT OR HOLDING TANK:/& (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: A+ Material of construction- concrete./(RmetalAlAFiberglasasU olyethylenel other(explain) Dimensions: AM Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm iq working order:Ye"O N44-Q Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) iQ t or holding tanks are not present . DISTRIBUTION BOX:- (locate on site plan) Depth of liquid level above outlet invert: °tr� Comments: (note-if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box, etc.) — -Distribution box has one lateral , There is evirienca of gnl ; ric carry ovar - Na esidence of leakage late el^ eat- e€ the box . 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 chamber,condition of pumps and appurtenances,etc.) Pump chamber is not nragPnt _ revised 9/2/98 page sorii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Flintrock Road Barnstable ,Mass . Owner: Craig Mudie Date of Inspection: 1/8/0 0 SOIL ABSORPTION SYSTEM(SAS)2 (locate on site plan,if possible;excavation not required,location may be approximated by non-Intrusive methods) If not located,explain: Type: • leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dim nsions: overflow cesspool,numb r: Alternative system: A4_ Name of Technology: /I TiIL- 4Wt Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) Loamy sand to rl ny to QaFse 8eftd . T,Pnrhjng stni t i a in hydX:QjQ j a CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: 4119 Depth of solids layer: _ IVIF Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) eSSDOOls are not prpspnr _ Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of.vegetatlon, etc.) Cesspools are not nrPsPnt _ PRIVY:dld4/t0, ' (locate on site plan) Materials of construcl!on: /1/!9 Dimensions: Depth of solids-A_ Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation;etc.) Privy is not prPGPnt _ revised 9/2/98 PaQe9orn I �l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Flintrock Road Barnstable Mass . Ownw: Craig Mudie Date of Inspect'o': 1/8/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) Z4 / revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P,.op.nyAd&"$: 68 Flintrock Road Barnstable ,Mass . Owner: Craig Mudie Date of Inspection: 1/8/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells 1 Estimated Depth to Groundwater' Feet Please Indicate all the methods used to determine High Groundwater Elevation: 1/ Obtained from Design Plans on record Observed.Site(Abutting propert bservation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _zchecked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 /I s revised 9/2/98 Page 11of11 r wnRr�T-nIT�•TT•' Tnralr•n..wrrtrn nndnfnT++wnr/�*wwT nRS1Y 1�'�IUrt. *'RT7-�.�Tn.*�'..t..r TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �•TP1 R•'. ::1�T.11R�.rTTV.1 n111'n.�IT+IRJR'1/n".T.:T-l'I T"NTR�lI�1-Tw���.�.twRt I�n1 1TrT•Tr�r -. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 68 Flintrock Road Barnstable ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Craig Mudie PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & S-A' Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or city state LIP COMPANY TELEPHONE ( 50.8 ! 775 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ®rlecommendations his address and that the information reported is true , accurate, and omplete as of the time of.-inspection . The inspection was performed and any regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check, one: .'t Systeui 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 ted has found that the system fails to Protect the jiublic 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 , 4)7 Inspector Signature Date A-ne copy of this c rtifieation must be provided to the OWNER, the BUYER ( where applicable) and the DOARD OF HEALTH. * If the inspection FAILED, the owner or•Ihoperator shall upgrade ' the system within o'ne year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 , 306 . partd .doc ti _ I v { y: ' 7':.2 ` � M ��O a si` - - ( �✓A T 17 zoom A D G?1. r Fc�rMr- J�vcI< r� < #aA?-.-'`4� l't�dJ L'_ ��-. • "� -.. n At r } , s .:::.. 4.' ,� ' }. % tip• [ {" "- �5.-t' I r�~F' PY "'+ / `` - ,tY-`v_G.�. K., , pY ,: S , Ax t► t� aTPi tui gQ F +'J.1 I ©tZEc ol�c wA i.s ` � {,a �.,: t. �' ., ,��'- i 1..1F.- - LL �. 71� •N. ,[ -<., ,�: '; Tb E3L)V� - C4, �_NL�7.c� .. .4.�vS' � F'prl1..�L1 .(J.l�..s`r'Yl :.. .s�r . i 1 4 G yf a _ E �f4y n '- k Yk ,"v• - ?ti . 14 e ��- ^.I, 'n p. ' :_+'. .a i. .3 t -,�� pi .�.:. •k .! "fa'µ .ice - _-- .kk" ,� .a ,• ,� ,.• k� �,-� m� J � I S T^-> � 75'� .�T1•�,;-lGt.} ' 'Z/2�Sg 7'©P PC—AT-- % w ff - Al n a L �... t• r ..� x o ,e e s w' x. - / T s. 5 ' S a �' - %Z-�./-t-(.3t/—. � •' . x :.-. , � ...- •.: :....� � .I. .li yr '.x' +Y r' , 1rIGN- r .. CA n F ' F 4(j e i a --ioC, S T-iz 4 t�14- f . D 1 } "lam. o;t s7-v A �D • f p — _ - 7TZA�F._17vG� _Lz c�uV S _ WA, g rw�SU/.iRy l'�o Q4 IS r I rA — �Xi S !'YI�V� Cyr(Grl�l- Si,�6� {Gi-r�o1Z r' 6 r ^ F�MA R -Aiaj; �. f � L, 0 C A T 10N Qft A G E' PE RMIT NO. I N S T A LLER'S NAME 6 ADDRESS D U I L D E R 'OR OWN ER DATE PERMIT ISSUED F DAT E COMPLIANCE ISSUED � � r 1: 23 3� P- h o T Al =�-noaa T arc Eb od► -�- pgt� �:; No....... .. Fx ... �"— THE COMMONWEALTH OF MASSACHUSETTS OAR F HEALTH ` ....... OF...... ::. ..... ...._----•------•---------------- Appliration for Dhipv.5 al Workii Tomitrurtion ramit Application is hereby made for a Permit to Construct �) or Repair ( ) an Individual Sewage Disposal System at: ......-- - ` Location-A r s o, or Lot No. ....elf._.._.. f/.. ...... ......... ............................................................. a1_l C .-r__•^�,�_• //-• -•-•------`� �F Address Insta pp Type of Building Size Lot_ ._A3.._Sq. feet U Dwelling—No. of Bedrooms._.___ __ _ _ ___________________Expansion Attic ( ) Garb4ge Grinder ( ) 44'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria a Other fixtures ....................................... d __......_..._..---------------------------------------•-• ---•••. W Design Flow............................................gallons per person -------------rson per day. Total daily flow..._._______. 0..............gallons. WSeptic Tank—Liquid capacity/kIV.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 ( ) -------------P"__-�---_��-P._&��----•-. Date.----•-•----� ✓�+" Percolation Test Results Performed by.____..._ Test Pit No. 1 ,t7���Minutes per inch Depth of Test Pit.................... Depth to ground water_____.__._.__________._. (s, Test Pit No. 2 ...... per inch Depth of Test Pit____________________ Depth to ground water........................ a' ----------- Description of Soil - -------------�-_.---- j ------------------------------------------•------------------------._...----------------------------------1----•--•-•....•-•-----•-•---•-----•-•-------•------=•=---•---•----•-.••----•--•---•---=-•- x -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------•---- UNature 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 TIH.;.:. 5 of the State Sanitary Code— The undersi In :er agrees not to place the system in operation until a Certificat of Compliance 1ias been issue by the` oard of healt igned.-•----•--•••-- - _.. __ R............... -• -•-------- .......... I?ate Application.Approved By.......... ........ . �� Dat Application Disapproved for t e following reasons:................................................................................................................ -----------------------------------••--------•--••••-----•-•......:j. y, Date PermitNo.................. ........... Issued........................................................ Date • �..�J 1 - • t . No.----•-•................. Fmis.............................. THE COMMONWEALTH OF MASSACHUSETTS --~-BOARD--OF HEALTH Appliration for Uh4posal Work.5 Toutitrnriion lirrmit Application is hereby made for a Permit to Construct ,O or Repair ( ) an Individual Sewage Disposal System at: � , � M .... - ............-- .'_ ................ ...--.... - -- Lotin-Address _.... --••• --- or Lot-No. .............................................. Owner Address •- W '= - ........�" - �`' %` ........ ,d.srt ..................................r '/ I.......---•---- Installer d Address U, Type of Building Size Lot ____./ ' ...Sq. feet Dwelling—No. of Bedrooms___S,,S..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............... No. of persons-__-___-____.._-____-______- Showers — Cafeteria Pa Other fixtures ---------------------------••••• - W Design Flow............................................gallons per person per day. Total daily flow............ -62•___-•-_-••__-_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 b ._ ........ .... Date..... Test Pit No. 1, _minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2-�;A_+�.-- -._minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil +�` //�/'/' .... /V_25---------•-- f �``� f i.- -- U --•----------------•-----------------------•-----------•---. . .----- -------------------... W .•--••••--•-------------•-•---•-••----••---•••-••-••--••-----••-••......••••---••••-•----••----••••----•------••----•---------------•-••-•---••----•------------••••---•--•--•-••-•----•------------•-- UNature 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 TITHE 5 of the State Sanitary Code— The unde�rsigr��er agrees not to place the system in operation until a Certificat of Compliance has been issued by the; ob and of health. igned :" �����.n�/G�(.•'�"' _ ...-•---- -• - -•-L--}-- ......-ate- --- Application Approved BY----------......... . -------- --•-----• ----- . --- --- ------------1 � Dat Application Disapproved for the f oll i�ng reasons----------------------------------------------------------------------------------------------------------------- .--•------------------------------------------------- ................--------------------------•--- .... Date F PermitNo......................................................... Issued:....................................................... .Date THE COMMONWEALTH OF MASSACHUSETTS or. BOARD OF HEALTH ............... .........................OF......... ..!1!'........................... Trr$ifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ') or Repaired ( ) 'C:f _ C! R at................. ................................................ Instoller,............................................................. has been installed in accordance with the provisions of TITLE �5 of The State Sanitary Cade s��cribed in the application for Disposal Works Construction Permit No-------....CP_'.z` ___-_-_-. da.ted........... ...__` __._.._....._..__._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A CU RANTEE THAT THE SYSTEM T L FUNCTION SATISFACTORY. DATE. 2 G' Inspector... . •---------- THE COMMONWEALTH OF MASSACHUSETTS ,� . • BOARD OF HEALTH No.! 2..5 FEE......................... Biopnsal Vorkii �nna�#rnnrUan [rrnti�-�f` Permission is hereby granted............... _1_�)1../� ....... ....................d�-�� ---- -.b .......... to Construct ) or pair: ) an Individual Sewage Dis osal Ifin at No. ....._.:.. '... �t_I F ..+ ........................ Street as shown on the application for Disposal Works Construction Permit No.@"a15:. Dated.__._4 :.Q 01 a ...................................................-- a-- -- •-- ' •----• Boar H t DATE....... ••. ••--• t - u&_•--•------ FORM 125 B S & WARREN. INC.. PUBLISHERS - 20 FT. M/N. /VOTE'.: /P E/TN�K 7 t/� SEP7 G Z-A,y k OR - ARE .. eQRB.:_T.�'�►_<7/V_ /o ter. M/N. •5RAOE,vr4 24'O/AME'7'ER' CONCRE?'E COYER S�AL'L 'eF BA?0&6, IT: 'TO G/tAvE.!AN EXTR/4 y q'oVC P/Pc CONCRCTE MIN. P/TCN !`1EAYy CAST IRON Co{/e�'I� s//.�4 L L Q� USEO L 83.`� COVERS ► . /F//V DR/VEWA.Y rA - / pR,4oE EUY`ER CLEAN .SAND (. A D/A. 2NLAYER j SCHEOOLS40 � • I 'b M/N.P/TCN I U O G/1L. • 1 • • . • • • .`,< n WASHED S727NE D/ST. 4 V4 PE/t n SEPTIC TANK • J • •i • • • . e � •• .•• �:..: BOX v • 1 � � • • • • • ► c� pa✓j,ar ,/JK,�r �D• 1 1 •EFFECT/VC ► •a .314 � /3 EwJ•.�. • • ►"I ' D�PTN • 1 1"-► � e - W/1�XEO STOI!/E i. Z2lo K.2o � �SZ• LgV��Z `� 1 1 • • • • • J.� O o PRECAS T SE $t/lo 6rA L la`1 y ►" . ► . J • • • • ► ► e o P/T OR EQ 6 /NlV�rt'T ELtc'c/A�IONS P/T CifP/1 C/T y • a EL ?..�' '7 Z• 6 /NYE,RT AT 0011-0/N6 ��-O FT. /NL ET SEPTIC• T.4N/l 9 a FT /L F. "14 M. i C C•S--C TA8 JON� t i aarLET SEPTIC rAt4J --7fT t{ ` 79.3 GROUND W,47,6fT TABLE /N,GET®ISrRi�uTiN COX . FT 00rLETD/sTR/9l/T/0/1F_BOX ./ FT. //VL6T LEACH/N* —/r 78'8 Fr. SEN/AGE O/Sf'4S'R rL.SYST�/�f 7A•ff4,*4A7l0H L Ei4 CH/N!s /M/T 3 SCALE �4 . DE316AI CRITERIA D/�►tc-ws�an/ NUMQER OF BEOROO/�'. 3 Dwzw /V G GAR.8.4GE DISPOSAL UNIT No�E SOIL BOG TOTAL E.ST/MATED FLOJn/ 33 GA[./DAY DSO/L TEST AE/ $OIL TEST#2 SOIL TE .7� ,VUM8ER OF 4e4CNfNG P/YS _- / f^.�'LC'Y. 82;8 E��rY. ,DATE OF SO/�. TEST Fl o��',~ S/OE L eAC Hd�VG DER P/T 22L ,SQ, PP. V - • RESULTS *VdT/V&.VS 'D BY PSI .COAO'"Al 60 TTOM 4,cgCH//VG Pe R PIT SQ. PT. OL A•T/O,-.,v A'ATe.c A6 M/NlI NCI•! .TOTAL I -ACHI&Cr �4REr4 �_SQ. fT. Sv�3 So �L A�JrCOLAT/0 R.AT `e� RESER✓E LEACN/NG ARrEA—S4. FT Z Q r JR�41..�4 Yrv1._15! 7 ' RAC. a 3 y.�'.J/ FLGcRt\`�' _y meSTA, L- ' : ;�y.o.�i G EL.ORED4GE G/N.E R//VG:CCt,JNG_ W Z "MA sAt a fIYA V AI V `M.4 �G Grp ter; `C'a i.t. ' ` •: 4Ll.EN7r S, D:IT6, / Z.►'`,�{ :./O G/q .tIND:.yN.!i.T_�R-..�N.COUi1[TEleEP _ :e NI GKuLA; �iiROU 40,'W-477ZriQ J 4 IK 40 v 1\ if 0 Art ILK 4� V96• SSv oc��-,e�ozv?-AG-' � 5;v-r9-t c rc r } \ , Ware : Assvn/C---D LO-r pR vTC-G71V i✓ Pee- Aga T.27J, 5ccT,i7l G.E. Towv )edAtA4' LEGEND ' :EXISTING SPOT ELEVATION Ox0 ��='=;� CERTIFIED PLOT PLAN ';EXISTING CONTOUR --- 0 - - - ��,v- .tis',.,:� ll �tll.r 7Zv��� ;FINISHED SPOT LE1�ATIOON Q[ iJ �o ;:r,Y -,,;E g,4 RN5—r,*6`or 'FINISHED CONTOUR ., APPROVED BOARD OF HEALTH \3 rti IN cDA E AGENT SCALES I =40 DATE� J�Z/i�� ` LOREDGE ENGINEERING CO. IN N�CKVL/I5 CLIENT I CERTIFY THAT THE PROPOSED LEGTERE REGISTERED JOB NO. 13sv9 BUILDING SHOWN ON PHIS PLAN VIL LAND CONFORMS TO THE ZONING LAWS EER ,SURVEYOR DR.BY' A -A OF BARNSTABLE � MArSS. 712 M Ai N STREET CH. BY / 7 is MASS, Z � a HYA N N I S� DATE REG. LAND SURVEYOR ,,,;.; ET-1— OF