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TITLE-
OE CD. WSPKTI FORM—NOT FOWVOLUNTAWYASSESSMENTS .
SIB ACE SEWAGE WSPOSALSYSTEM POD
---,CERTIFICATION
Property-Address �1<P/d���9.v %�I ,4 i
OWner's Nwne: �T� J_ 'y
Owaees`Address:_
Name—of g€tspectot:(please-paint) Ay�r �tZ ci�:9�r
__Compauy*aute:.,. A/2 e W
Mailing-Address:_" �'Q L3 o X 9 / yr
_'elepltoue-Nvmber:- 157.o g 7-!;-/..3 6.2
_ _CE -'1FF1 -0N-STAB - - J
--I-Eerrif3+that I-have personally inspected-the sewage disposal system-at this address"and-that�e,information reported
-beIGw is-true;ace-unite-ante.-asiofzthe time_of the-inspection_-The_inspection-vas performed based on my
_ gaining and zxperiegmin. - ion-aad-maintenanee-bf on=Site- dl systems.t am a DEP
- _approved-syetean ine—rem"AmnuawAaSection .3,40 itte-5{-WC_t57 ihe��tem�
!/Passes :
Conditionally Passes_-
_ — Needs-FiniherExaaluatifm bv-the-Leal Approvipg Authority }
hnspect®r's SYgnaturea St 3
The-system inspector.shall_-submit a_cogy_sfthis_inspectzon report to_the.Approving_Authwity(Board of Health or
I2EP_)-within-30.days of-com*ting this-inspection.ifs system is-a_sharedsystemn or.has a design,l ow of 10,000
_gpd or_9eater Ae.inspectQr and the,systean ownershallsubmkAhe_report-tc�Akeappropriatepgionai ofrice of the .
DEF The ongamal should-be_sent-to the_system_ownerand conigs sent-to the_buyer,ifappliole,and the approving
autilority. ,
Notes and Comments
`tom*This-report only describes-conditions-at the time-of inspection and trader the condtions of use at that
time.-'Iris-iasgectiQia_does_aot-addr-ess-haw_thesystem-will perform-in the future-fa der the same or different—conditions of use.
I W 2_of I I
W DACE SE DISPOS : ` _PiSP
FORM,
_CERTIFICATION_(continued)
- -PropertyAdd
Qwner: /-7 S ti
�Date_of-I<nspection: 5 i o
Inspection Sumer ye`Cheek-AJBgC,6-or E4 AL AY&co aplete-tM of- €n-D:
-.A.__Syste )Passes:- ,
l h7ve not found.a�n'information whit 'nil; at -c that an"fthe failure criteria-desekibed in 310 CMR
__.�5-303 or in'3I'6 CMR 15:304 exist-Any failure cm-eria-not evaluated-are indicated below.
Caminents:
._ System Conditionally Passes:
One or more syst m components as 4escr ed in.thh "Conti tional Pass"section needxo be replaced or
repaired.The system,upon completion oft a repla ement or r�air;as approved by the-Board of Health,will Bass.
-Answer yes,-no or-not determined-( AND)Lin the €or<the-€allowing.statements.If"not determined"please
-explain.
The septic tank is-metal and-ovver20,rears.old¢.or-the_sT&tank=( ether metal-:er not)-is,structurally
Awsoundrexhibit substaptial-infiltration or_exfiltratioa_or-Aan-tip=abrimincaL system wiii pass.inspection Mhe
existing.tank,is.replaced va -a-complying aeptic_tat}k_a:�__aM;)wd_l y__the Bwd Health..
*A.metaiseptic-tank.acidpass_inspectionif_ii_is_snucturally-sQtu4,..not_leaking-and-if a Certificate-ofCompliance
_indicating-that.the tank Jess_than_2Qyears_Qld is-availalte. _. ..
ND-explain
Observation_of sewage baekug-or bra o � - tic woter_levd ink rti l ;on box due;to broken or`
obstructed pipe(s)orAue to a broken,settled-or.unevm distribution,box-System will_pass.,inspection-if(viith
approvkl.of Boatd_of Healthy-"_
broken-pips .replaced
. @bstreetio��t.is_r+e�xe�,
distribution_boxiS_ `orr
-NIA-explain_ ,
The system required)pumping more-than 4 times a year-due to-broken_orabstructedpipe(s).The system will
pass.inspection_if(with appko_va1-ef the Board of Health):
broken pipe(s)are replaced
- - --dbstruction is removed
r S \
NB explain:' J
•
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: k� Al
Date of Inspection: S"
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, saf//ety�or the environment.
1. System will pass un1 s Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioni in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is wi in 50 feet of a surface water
Cesspool or.prvy.is withi�.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 a public health,safety and environment:
_ The system has a se tank and soil/absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tribu to a sur&ce water supply.
The system has a septic and/SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank a SAS and the SAS'is'within 50 feet of a private water supply well.
_ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more froni a
1
private water supply well**./Method use o determine distance
**This system passes if.th�ewell 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-pprn,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM39SPECT1ON FORM
PART A
CERTIFICATION(continued)
Property Address: ,9 4 l
Owner: Art
Date of Inspection: 5 ,-!?/ o/.
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to.an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ 11`1 squid 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
yvater supply.
y�ny portion of a cesspool or privy is within a Zone 1 of public well.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
y 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,forcoNform 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.hessthim.:5 pipm,provultil that no other hHure criteria
are triggered.A copy of.the analysis must be attached to this form.] _"•"
(Yes/No)The system fails.I have determinedahat.one or more of the above-failure criteria.exist as
described in 310 CMR 15.303,therefore the systesafails.The-system owner should co=ct the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the systemanttst°suv.t:a.facgity�Wt&:a design-tlow of.10,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of die-following:
(The following criteria apply to large systems.in addition to the criteria:above)
yes no
_ the system is within 400 feet of a surface.drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system 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
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: L Xr �✓ �/L A
Cwr+ �i Ate, v �
Owner: /7-2 si
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes ��mping
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?
Have large volumes of water been introduced to the system recently or as part of this inspection?
/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_Z_ Was the facility or dwelling inspected for signs of sewage back up?
L — Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depthW 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:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
.Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEMINSPEM- ON FORM
PART C
SYSTEM INFORMATION
Property Address: 4,1 9,✓ A/�
"
Owner: / i✓
Date of Inspection: X o
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Z14 Number of bedrooms(actual)`
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#-of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): /V
Is laundry on a separate sewage system(yes or no):Al [if yes separate inspection required]
Laundry system inspected(yes or no): 5�
Seasonal use: (yes or no): IV
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): IV "
Last date of occupancy: o cc
COMMERCIAL/INDUSTRIAL
Type of establishment: ,
Design flow(based on"0 C 15.20 d
Basis of design flow(seats/perso /s ,etc.
Grease trap present(yes or no):
Industrial waste holding tank se es or no):
Non-sanitary waste discharged to tle 5 system(yes or no):
Water meter readings,if avai le:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): —At
If yes,volume pumped:_gallons--How wasquantity,,pumped_determined?
Reason for pumping:
TYPE OF SYSTEM o
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
Other(describe):
Approximate age of all compo ents,date installed(if known)and source of information:
iA, s i.s�/Pc S'r P7 /5 !�3
Were sewage odors detected when arriving at the site(yes or no): 141
6
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: z sa
Owner: Ati A✓
Date of Inspection: S 3
BUILDING SEWER(locate on site plan)
Depth below grade: 2 _
Materials of construction:_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:ZI (locate on site plan)
Depth below grade:
Material of construction:_concrete metal fiberglass_polyethylene
_other(explain) //,�Z y cv i T Li A U G,2,,9 C .
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: /D ; )e S, S x . s
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 4:!�
Distance from bottom of scum to bottom of outlet tee'or baffle:
How were dimensions determined: /L t"cP')
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlei invert,evidence of leakage,etc.): I 1 ,
h�ao �.n h 7 o r R ,9KA t /�2opEQ /�1Ai ,,7' ✓-
O<L Sys7E M y'l��� t yzAV 'T�Q l fF `A2S
GREASE TRAP: (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.):
7 r
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,#ontinued)
Property Address: n/�iq�✓ /2 9
Owner: �rF�
Date of Inspection: S 3 / v /
TIGHT or HOLDING TANK: /`/ (tank must be pumped2a time of i*ection)(locate on site plan)
Depth below grade:
Material of constru tion: concrete etal fiberglass_polyethylene other(explain):
Dimensions:
17
Capacity: a ns
Design Flow: llons/day
Alarm present(yes or no):
Alarm level: Al working order(yes or no):
Date of last pumping:
Comments(condition of arm d float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O
Comments(note if box is level and distribution to outlets equ4zany>evidence of solids carryover;any evidencezof
leakage into or out of box,etc.): n
,fox L 7- 4-t
J9 /Z
PUMP CHAMBER: yferi-oondition
plan)
Pumps in working order(y
Alarms in working order(y
Comments(note condition of pumps and appurtenances,,etc.):
s
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: w�X/ 9�✓ /2 t /
Cvrn/n 9 Svi
Owner: /- . 0-,
Date of Inspection: 3/ v /(/
SOIL ABSORPTION SYSTEM(SAS): / (locate on'site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
//leaching chambers,number: `� w F 1 /r q A 76'Q S
leaching galleries,number: r
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): /
/%/1 A%o /L S/� �ro o T Sro.✓c Ga w .��s i�✓r+ ���P n
9!/4/ S'01 .� X !/ X l S�� /U /�w O u 7- v.✓s.O�E r
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet vert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflo (ye or no):
Comments(note condition o soil,sign 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 H,si s of hydraulic failure,level of ponding,condition.of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR-VOL NTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPETION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: �'T P IV
Date of Inspection: s— s
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.
13
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10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: iva�� 9�✓ A l /
C!/ s''i 1-7 14
Owner: �r6
Date of Inspection: s X3 / o
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:
�btained from system design plans on record-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 local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water eleyation:
C-A.0,1 !.1.1g7FR / N loll
11 - ,
O OF BARN
STABLE
O: // SE AGE # J
VILLAGE, ASSESSOR'S MAP & LOT
6
INSTALLER'S NAME&PHONE NO. AV `f
SEPTIC TANK CAPACITY
LEACHING FACILrN: (ty (size)
NO.OF BEDROOMS
OR OWNER '
PERMITDATE: "� COMPLIANCE DATE: 2' '
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
TpOWN.OF BARNSTABLE
LCH ATION - ivy/'9"i 7`2 i SEWAGE # 7/_ 3
VILLAGE �� '''' '�► '� 5�~' ASSESSOR'S MAP & LOT33��a��-
INSTALLER'S NAME&PHONE NO. W/A
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 4t2 i v%i�2AT d s" (size) /d-
NO. OF BEDROOMS '7Z
BUILDER OR OWNERS
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
cry
,
(� G
13
D is f
y 13�o 3
G
cc�� P. I
No._.'1:.3�... Fss.... D��......_
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Disposal Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (t4 or Repair ( ) an Individual Sewage Disposal
• ystem at: - - ..........
Location-Address or Lot No.
Owner /^• r
a �� � ddress
�`; '�j C J�!2•.�-�-O-- -••---......•.....--`-."•......--•------ ...............
Installer Address
Type of Building Size Lot- _- � _._._Sq. feet
Dwelling—No. of Bedrooms___..._.....�...........:..............Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Buildin No. of persons............................ Showers — Cafeteria
Q' Other fixtures --------•------------------------------•--------------.---------------------------------------------------•---•---------------------------------------
d
Design Flow.............��___. : �r>V._..gallons per person per day. Total daily flow____-_.------_-4 .................gallon.
WSeptic Tank—Liquid capacity.��.gallons Length__e?'1G'__.. Width. N....`/__ Diameter................ Depth..s`e._.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........ ,--------- Diameter...._.�O...._._._ Depth below inlet......:.......... Total leaching area..Z!!_'?.,2._sq. ft.
I
ZOther Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......X.,_-��11 42.-'e .................... Date_,09k4�...._�_./-�`--&c..
0-4 Test Pit No. 1...G..�_._minutes per inch Depth of Test Pit.....t.& �i Depth to ground water..."°.............
Li, Test Pit No. 2_...4-r..minutes per inch Depth of Test Pit.....I6�..... Depth to ground water------------------------
a -------------------------------------------------- -----------------------
--------------------
----------------------------- ........................
. ----07..... r
W ---------------------------- ---------------------------------------- .-------- ---`--
U Nature of Repairs or Alterations—Answer when applicable................................................... ........................................
-------...------------------•----------------------------------------------------------•••---•-•--••----••---------------------------------------------•-------........._..------------......••-•-•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syst m in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersign d further grees not to place the
system in operation until a Certificate of Compliance hEs en issue he oard-of heap .
Signed . -- -------------------- ....................
Date
Application Approved By --- -------atvj-------�DGzn, ------------ -------- -----............................. -----
----------------------------------------
Irate
Application Disapproved for the following reasons- -------------- -------------------------------------------------------------------------------------------------- ------------
----- -------- ---------------------------- -------------------------------------------------------------------- ---------- --------------------------------------------------------------- . ----------------------------------------
Date
PermitNo. -----------7/----------3-1,5------------------ ---- Issued .----.....------------------. --------......-------------------..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works ToustrudWtt Fumit
Application is hereby made for a Permit to Construct (if). .or Repair ( ) an Individual Sewage Disposal
System at:
.........................................
Location-Address or Lot No.
.... '��� J�A7ZivS?f�/3 G --------------
----...-- ........................................................................... ---------------- ......----
Owner _ ddress �.
a .�., l 4 `�' •° d`.�.---S v, T c S�L / 4 �C1.-•---- .............................................
Installer V Address
Type of Building Size Lot..... d�?.....Sq. feet 2'
V Dwelling—No. of Bedrooms.........:_.4-----•-•-•--.-------------Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------•---•-------------• -
Design Flow..............� ------......_I.r-z----gallons per person per day. Total daily flow..............440..................gallons.
W Septic Tank—Liquid ca.pac ty_%�4?a.gallons Length.Z �'G" h s 4.---.. Widt ". ..Diameter.............. Depth... "/
-x _ Disposal Trench—No. .................... Width.....�............. Total Length.........._._..... Total leaching area....................sq. ft.
Seepage Pit No........7. ...dt_...._...... Diameter ! ....... Depth below inlet......6........... Total leaching area_./o!9..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
w ``
Percolation Test Results Performed by........ �1.. ���A?*(/G.................... Date.Ak4.....7•./.�`.8`..
aTest Pit No. 1....G. ---minutes per inch Depth of Test Pit-_--_�!1G 0 Depth to ground water....... ..'...............
Test Pit No. 2___.je�._Z..minutes per inch Depth of Test Pit-----/A!9�..... Depth to ground water.._.."'............. .r
•---•------•-------------------•--••---------------------------.........---•-•--•--•----•-----------.........................................................
0 /4"
Descriptionoo -----� S "................................................. ....................................... g
W ...................'...............................................................................................
U Nature of Repairs or Alterations—Answer when applicable----------------------------••-----_-_-•------------_�I '....................................
IF
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Agreeineent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of,.TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a'Certificate of Compliance has issued by he ,oard-of heal. L� /
Signed .1........-- ........... ........................................
Dace
Application Approved By ............ ...... -t a, .---/...................................................................... -------------- ate------. ------
Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------- --- - --
--------------------------------------------------------------- ------------------------------------------------...... ........................--............................................ ........................................
PermitNo. .. l ....... .................. Issued ..----------------------Dace-------. -----------------...............
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_{ TOWN OF BARNSTABLE
Cer#tftctt#e of C ontyliance
THIS IS TO CsERTIFY, That the Individual Sewage Disposal System constructed ( i/ ) or Repaired ( )
b -- .....----
Y.................... Installer
atf..9 _.. ................. /.1YZQ LQ:............}' tia�L �C..- ....------...-----------------------..........------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......� 47..... dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... ..... Tl.."..t..: .............-.................................. Inspector ........... ..����...............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�• ? TOWN OF-BARNSTABLE
No...l.. :.: /.�?. FEE i�/1......---•--
Disposal Works Tonstrur#iot f rrmit
Permission is hereby granted....... l_?..._... P..,A� � .
to Construct (I/ ) or Repair ( ) an Individual Sewage Disposal �System
lZ�� acJ:: `7zrm,.9 0 �n 1., �Q�:c=[.?�.................••----------•---.....-----...............................
at No.. , ... _ .. -• •--•-...... _......
Street
as shown on the application for Disposal Works Construction Permit•N\o.,� .� ✓ ... Dated..........................................
Board of Health
DATE................................................................................
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
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