HomeMy WebLinkAbout0008 GRANITE LANE - Health 8 GRANITE LN. ,BARNSTABLE
" A = 316071
TOWN OF BARNSTABLE {�t 611pe,
LOCATION &1 6 .4 k // L. A 6 SEWAGE # b O S -
VILLAGE ASSESSOR'S MAP & LOT /I
INSTALLER'S NAME&PHONE NO.;IC , i.,-s a �- '7 7.�g 7 7
SEPTIC jTANK CAPACITY
LEACHING FACILITY: (type);�/,��--o �?' L f. (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE:_& 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 _
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No.�20:fo..r`ICJ/ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for 33tgw5ar *p94ent Conotructfon 3permtt
Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
cation Address or Lot No. Owner's Name,Address and Tel.No.
Granite Lane , Barnstable Dan Callahan
Assessor's Map/Parcel
lmuellei's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
E. - Robinson SEptic Service
fox .1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting
of an H 20 P—hnx and 3 H 20 leach. Chambers with stezQe all
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 been issued by thisBogxd of Health. /
Signed AuI Date J ✓�/`��`�
Application Approved by _ Date�� ?�Ov
Application Disapproved for the following reasons
Permit No. Date Issued
----- ---__—.�_ -- -- —
TOWN OF BARNSTABLE
LOCATION t M A d SEWAGE # Q O 27
JJ ,
j VILLAGE S-44 S A b f t ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. �s a 7 �S 7 1
�. SEPTIC TANK CAPACITY
LEACHING FACILITY: (type),� O -r?' L- (. (size)
NO.OF BEDROOMS_ _,,//.
BUILDER OR OWNER Ce1 /Y4 y"
PERMITDATE:_`: (s—ti 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
f
Furnished by
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No. __" I Fee�✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rppiication for Migooar *potent Construction Permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) El Complete System L1 Individual Components
cation Addrgss or Lot No. Owner's Name,Address and Tel.No.
Granite Lane, Barnstable Dan Callahan
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
_Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting -w --
of an H 20 D-box and 3 H 20 leach nhamherc teti t)i st®ng 211 prol.1nd
Date_la
�sJnspected:
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 been issued by this_Bo of Health. /
Signed I Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
Callahan BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( )
Aba o d s
b Wm. t. Robinson Septic Service
at r�n�t Dane, arras a e has been construcied in accordanc_j�l,�
with the provisions of Title 5 and the for Disposal System Construction Permit No. MCV' dated
InstallerWm. E. Robinson Sr. Designer / q
The issuancSpV this pe •t shall not be construed as a guarantee that the sy ern ill function as des
Date OnL51 nen Inspector
----tt —
No. =V— _,�!s Fee $50
THE COMMONWEALTH OF MASSACHUSETTS
Callahan PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migw6al *p5tem Construction Permit
Permission is hereby grRtedtroaCto"s ectL'aA ,p tSi�Y`TIft���2 )Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by,(:: '�"
116/99
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)
I, William E. R ob ins on,S1 eby certify that the application for disposal works
construction permit signed by me dated Jr'r� �" , concerning the
property located at 8 Granite Lane , Barnstable meets all of the
following criteria:
• The failed system is connected to a residen 1 dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS 1 and a percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 f t of the proposed septic system -'
There are no private wells wi ' 150 feet of the proposed septic system
There is no increase in flow dlor change in use proposed
• There are no variances nested or heeded.
• The bottom of the p posed leaching facility will na be located less than five feet above the
mwdmum adjust groundwater table elevation:JAdjust the groundwater table using the Frimptor
method when a livable]
• if the S.. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will Wtt be located less than fourteen 114)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using G1S information)
H) G.W.Elevation +the MAX High G.W. Adjustment. --�_ -z 6 ,
DIFFERENCE BETWEEN A and B i
SIGNED DATE:
[Sketch proposed plan of system on back],
y:health folder:cen
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CO3.%I,.%10.N-X"EAi;TH OF MASSACHL;SETTS-
'' _ E�iECI;TIVE OFFICE OF E:�'VIRO\ME\TAI. AFF_AIP.�
F DEPARTMENT OF ENVIRONMENTAL PROTECTION
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ONE WINTER STREE . BOSTON NIA 0210� i61"j 292-550k,
TRH DY COVE
Secretaz-v
�31E0 PALLLLCCI r• DAVID B STP. '?:S
Governor �" Comzniss:one-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
>;r PART A r
CERTIFICATION
Property Address: 8 Granite Lane Name of Owner Dan Callahan
Barnstable Address of Owner:
Date of Inspection: Js
Name of Inspector:(Please Print)Wm. E. Robinson Sr.
1 am a DEP approved systerr2 inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinson Septic Service
Mailing Address: PO Box 1069, Centerville,_MA
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 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
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: I Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to Ore
system owner and copies sent to the buyer, if applicable, and the approving authority. '
NOTES AND COMMENTS
'a
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revised Page Iof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
'roperty Address:8 Granite Lane , Barnstable
Jwner: Dan Callahan
Date of Inspection: g—��)
INSPECTION SUMMARY: Check/ ,/B, C, or D:
A. SYSTEM PASSES: l/
v 1 have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure'
criteria not evaluated are indicated below.
COMMENTS:
B. YSTEM CONDITIONALLY PASSES:
One'or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
ompletion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate y , 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.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
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 required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revise 9/2/98 Page 2of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(cwrtinued)
Property Address: 8 Granite Lane , Barnstable
Owner: Dan Callahan
Date of Inspection: S'-• S—o-u
y
C. FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
C ditions exist which require further evaluation by.the Board of Health in order to determine if the system is failing to protect the
pu lic health, safety and the environment.
I SY TF1M WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS T FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 fAND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:+
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less'
than 5 ppm. Method used to determine distance . (approximation not valid).
3) OTHER
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revised 5/2/5b 1`2Qc3of11 r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 8 Granite Lane , Barnstable
Owner: Dan Callahan
Date of Inspection:
D. SY M FAILS:
You must ndicate either "Yes" or "No" to each of the following:
I ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility-or system component due to an overloaded orclogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
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
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE YSTEM FAILS:
You must ind cate 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
hea th and safety and the environment because one or more of the following conditions exist:
Yes N
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well)
The owner r operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of th Department for further information.
revised 9/2/96 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM.
PART B
- 'CHECKLIST
F'roperty Address: 8 Granite Lane ,, Barnstable
Owner: Dan Callahan
Date of Inspection:
Check if the following have been done: You must indicate either "Yes",or "No" as to each of the following`
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ 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. i
_ The system does not receive non-sanitary or industrial'waste flow. ~
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
✓ _ The septic tank manholes were uncovered,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. '• J''
Determined in the field (if any of the failure criteria related to'Part C is at issue, approximation of distance is unacceptable)
11.5.302(3)(b)1
_ The facility owner (and occupants,if differeru from owner) were provided with information on n
the proper
SubSurface Disposal Systems. T
ret sea °/2/98
Page 5 or I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: 8 Granite Lane , Barnstable
0'" ": Dan Callahan ,
Date of Inspection: S-o2f�y v
FLOW CONDITIONS
RESIDENTIAL:
Design flow: si 5 g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms (actual):
Total DESIGN flow�j
Number of current residents:
Garbage grinder(yes or no): /L 6
Laundry(separate system) (yes or no)4 0: If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):_A� 0
Water meter readings,if available (last two year's usage(gpd): 1999 56, 000 gal.
Sump Pump(yes or no):,olf-"0 1998 55, 000 gal.
Last date of occupancy: s-�-0—v
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Design flow: gpd ( Based on 15.203)
Basis /design flow
Greas trap present: (yes or no)_
Industr al Waste Holding Tank present: (yes or no)_
Non-s nitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last ate of occupancy:
OTHE : (Describe)
Last ate of occupancy:
GENERAL INFORMATION
PUMPING RECO/RRSS anosource of information:
System pumped as part of inspection: (yes or no)A Q
If yes, volume pumped: gallons
Reason for pumping:
TYPE,OF,SYSTEM
Septic tank distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records:if any)
1/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)_A� G
I
revised 9/2/9. Page 6(if 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropeny Address: 8 Granite Lane , ,-Barnstable w
owner: Dan Callahan `
Date of Inspection:
BUIL G SEWER:
(Locate n site plan)
Depth b low grade:_
Materia of construction: cast iron 40 PVC other(explain)
Distan a from private water supply well or suction line
Diam ter e w
Corn ents: (condition of joints, venting, evidence of leakage,-etc.)
- I
SEPTIC TANK:_ F
(locate on site plan)
Depth below grader N
Material of construction: ✓concrete_metal Fiberglass •_Polyethylene_otherlexplainl
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance (Yes/No).,
i o
Dimensions: !r OG ZS
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:/
Scumthickness: (S—!
Distance from top of scum to top of outlet tee or baffle: "
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: O
'omments: .,
(recommendation for pumping, condition of inlet and outlet tees or baffles, de th of h id level i relation to outlet invert, 5tru turel integrity,
evidence of leakage, etc.) 6 T9-.0 ;
GREASE T P•
(locate on s to plan)
Depth belo grade:_
Material of nstruction:_concrete' metal_Fiberglass _Polyethylene_otherlexplainl
Dimensions a
Scum thick ess: "
Distance f om top of scum to top of outlet tee'or baffle: c�
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of I st pumping: "
Comm s:
(recom ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evident of leakage,etc.)
revised Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
+roperty Address: 8 Granite Lane , Barnstable
Owner: Dan Callahan
Date of Inspection:
TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
llocat on site plan)
Depth elow grade:
Materia of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dimens ns:
Capacit gallons
Design ow: gallons/day
Alarm resent
Alarm level: Alarm in working order:Yes_ No_
Date f previous pumping:
Co ments:
(c dition of inlet tee, condition of alarm and float switches, etc.)
t
DISTRIBUTION BOX:v
(locate on site plan)
Depth of liquid level above outlet invert: y
Comments:
(note if level and distribution is equal, ey'id� of solids carryover, evidence of leakage into or out of box, etc.) -
PUMP CH MBER:_
(locate on site plan)
Pumps i working order: (Yes or No)
Alarms n working order(Yes or No)
Com nts:
(note co dition of pump chamber, condition of pumps and appurtenances,etc.)
revise% 9/2/98 Page 8ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"AddressB Granite Lane, Barnstable '
Owner: Dan/Callahan
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): r
(locate on site plan, if possible;excavation not required,location may be approximated by.non-intrusive methods)
If not located, explain: j
Type:
leaching pits; number._
leaching chambers,number:3
leaching galleries, number._
leaching trenches, number, length:
leaching fields, number, dimensions: -
overflow cesspool, number:_ „
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure;le el of ponding,damp soil, conditi n of ve etation, etc.)
{ a-.en i L ll hr i .b G
r
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: A9L.1
)epth of scum layer:
Dimensions of cesspool:
Materials of construction: :
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condit on of soil, signs of hydraulic failure. level of ponding, condition of vegetation, etc.)
PRIVY
flocate on si plant
Materials o construction: Dimensions: `
Depth of olids:
Comments.
(note conditi n of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PrR c 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Nop"Address: 8 Granite Lane , Barnstable
1Wner: Dan Callahan
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
a
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revised 5/2/9R Page 10of11
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
rop"Address: 8 Granite Lane , Barnstable
owner: Dan Callahan
Date of Inspection: S'��S o--L)
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
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole.basement sump etc.)
Determined from local conditions
v/Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators._installers
Used USGS Data
Describe how you establi hed the High Groundwater Elevation. (Must be completed)
'S l,% v A,T a' / -a
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revised 9/2/95 Page 11 oft►
No..-.a.. ... Fmic 2.::�..........
THE COMMONWEALTH OF MASSACHUSETTS
BOmum ARD F HEA,:.LTH
F .
..................OF......&
-- ----------------- ........
Appliration for Bifipasat 19orko Tomitrurtion rumit
Application is hereby made for a Permit to Construct or lypair ( ) an Individual Sewage Disposal
SYS�m Pr
. .......... ... .................... ........
-a n-Add Lo N
...... .......... .. ...................
. . ........................ WL, 1 No.
... .... ..... .....owner es
... ... . ........ ..................................... ....................... ...7
......................................................
Installer Address
Type of B Size Lot..2-k..5z_ Sq. feet
U Building
of 8 ------------------
Dwelling edrooms------------- .......................Expansion Attic Garbage Grinder
P4 Other—Type of Building ------------------------_- No. of persons._____.............__._____. Showers Cafeteria
Other fixtures .
----- -::::_-.__9.L i i on"s...per r---p_,e_,r's',o'n....per-day.y.......Total...---....daily 1'y'---fl---o-w---------------0-----------------------------------------------
Design Flow..........................._._..gallons 4177_117_77 _.gallons.
1:4 Septic Tank-�Liquid capacity//.W. -g-allons Length................ Width- Diameter---__._.____.... Depth-_.-____----___.
x Disposal Trench—No NV*d I ta engt .................. Total leaching area--------------------sq. f t.
-0 Width___
------- ---�c
� engt ------------------
Diam flow
Seepage Pit ept low inle ................._ of leach' g area...._______..._... ft..
Other Distribution box Dosing tank ( )
1-4 1117- - 161
Percolation Test Results Performed by-----------------------------........................
... .........../Date..................................
Test Pit No. 1--------_------minutes per inch Depth of Test Pit.................... Depth to ground water..--____________.._--._.
(� Test Pit No. 2................minutes per inch Depth of Test Pit.___..........____.. Depth to ground water-______---_.-_._____---.
............ ......... ..... ---Description of Soil ------------------------------------------------------
...........C.Md.. —Z-- ---------------71----------------------------------------------------
0 -------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------
----------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----_---------------------
U Nature of Repairs or. Alterations—Answer when applicable-------------------------------------------------------------------- ------_-----------------
........................................................................................................................................................................................... -----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed--
. .... .......
Date
Application Approved By----
44. . .
-- ------------*----------------------------------------------------- ------------71-- _;-------------
Date
Application Disapproved for the following reasons:..................................Z............... -------------------------------------
...... ........... ... .. .. ..
........................................................................................................................... ----------------------------------------------
Date
Permit No.................................................... Issued.....
-------------
J
a
---------- ---- --------------------
1
...........,..........
THE COMMONWEALTH OF MASSACHUSETTS ,
F
BOA FaDr F HE•A , TH
t.k ... ..--.....OF..... 1 ?' �
------
Application is hereby made for a Permit toConstruct ( ) or Repair ( ) an Individual Sewage Disposal
Sys=em t
.,.._ ------ --- --------
$ l oc n-Ad ! or Lo/No.
�` Owner g ddress .
'Installer Address
d Type of Bulld Size Lot a*-i - Sq feet
Dwelling No. of Bedrooms._.. .._.... ____________________:_._Expansion Attic ( ) Garbage Grinder ( )
aOther--Type of Building ___________________ No. of persons._______,___________________ Showers ( ) Cafeteria :( )
d Other fixtures -
Design Flow________________ ______ gallons per person per day. Total daily flow_____ _�. _................gallons.
W �.
WSeptic Tank k Liquid capacit �e gallons Length................ Width.............._. Diameter_-_-_ : Depth__._____.___. .
x Disposal Trench No_ __________ _______ Width__ Aft
:Total eeng. .__ ............ Total leaching area......................sq. ft.'
1• 3 Seepage Pit No ___ -_____ Diameter , :_:_ elow inle ::__. _._.___. Total leaching area_. s j ft.
Other Distribution box ( ) Dosing.tank
a Percolation Test.Results' Performed by :..................................................................... Date..................................
Test Pit No. 1................minutes per inch Depth of Test Pit _____._....... Depth to ground water--------
................ .
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---- - --- ---- -------------------------------------------O Description of Soil .................-------------------- ------- --
x r
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed....................
r �,}}6/_7 Date_`
Application Approved By---
Application Disapproved for the following reasons__________________________________
-------------•---------------._.-------------------------------------------------•------------•-•-•----------------------------------- ------------- ---------------
Date
PermitNo......................................................... Issued.__E- ... ...........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ............:OF......... w � ..........
rdiftratr 'fdoutphattrie '
THIS IS TO CERTIFY That the Individual Sewa e Disposal System constructed ( /rRepaited ( )
by (" '. L -
,( fd..........
a t r
at
1 a co>r cbi' i t?1e�3�ov ]on o Article, XI of The State Sanitary Code as described in.the
application for Disposal wooriks Construction Permit No.............. __ dated____.__.a
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GU NT iETHAT THE
SYSTEM WILL FUfiCTION SATISFACTORY.
DATE `� .:;:... Inspector ------•--••P
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH -
. A. 9 e ...OF.... ..... �sus .:� ......... ;'°
FEE__ r
X
4
Permission is, hereby granted -'.' E ,
to Constr 'tA
Repair ( ) an Individ Sewage Dispo a] ysten)
at N
Street
as shown on the application for Disposal Works Construction Per7)nit No __� Dated___°
..............................
Board of Health
DATE -- -- --
-
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ..