HomeMy WebLinkAbout0040 KEVENEY LANE - Health 40 KEVENEY LANE, BARNSTABLE p
oa _
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
aovemor e . .
Trudy Foxo e
S. t. EOEA
David B.Struhs e
ComrtJulona
SUBSURFACE SEWAGE••DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 40 v ny Lane Cummaquid Address of Owner:
9 (If-different)
Date of Inspection:t 2/ �
Name of Inspector.Joseph P. Macomber Jr.
Company Name Address and Telephone Number:
P Y �
J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632
5080775•-3338
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: '
XXXXPasses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 1r %��� Date: 1 2/2/9 5
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 the system owner and copies sent to the buyer, if applicable and the approving authority. _
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any information which Indicates that the system violates any of the failure criteria as der ined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
6) SYSTEM CONDITIONALLY PASSES:
4110 1 One or more system components.need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
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, cracked, structurally unsound, shows substantial infiltration or eAltration, or tank failure is
Imminent. The system will'pass inspection if the existing septic tank is replaced with a conforming septic tank as
w approved by the Board of Health.
(revised 8/15/95) 1 c
One Winter Street 9 Boston,Massachusetts 02108 FAX(617)556-1049 9 Telephone(617)292.5500.
U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 40 Keveny Lane Nmmaquid,Mas s .
Owner: Albert Alvordens
Date of Inspection:12/2/9 5
BJ SYSTEM CONDITIONALLY PASSES (continued)
NO Sewage backup or'breakout or high stati: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 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
A_ 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
ad 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The cvstem nds d �euUl tdllk d1'IU >ull db:.urP0U11 �Ysleivl and 6 \ti ithln 100 fCi i to a surface water supply C tr:v rta t�i a
surface water supply. "
(_yp The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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•
9
DJ, SYSTEM FAILS:
/Ilr1 I have determined that the system violates one or more of the following failure criteria as defined 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.
IUD Backup of sewage into facility or system component due to an 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. '
;(revised 8/15/95) 2
. 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 40 Keveny Lane Cummaquid,Mas s .
Owner: Albert Alvordens
Date of Inspection: 12 2/9 5
D1 SYSTEM FAILS(continued): • ,
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/Dday flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
I%ny portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
IyQ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
bO Any portion of a cesspool or privy is within a Zone I of.a public well.
&6 Any portion of a cesspool or privy is,within 50 feet of a private water supply well.
&a 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.
E1 LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
OUA_ The design flow of system is 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:
p19 the system is within 400 feet of a surface drinking water supply
((jT 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 (I
public water supply well; WPA) or a mapped Zone II of a
a
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 40 Keveny Lane Cummaquid,Mas s . ,
Owner: n Albert Alvordens
Date of Inspection: 12/2/9 5
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
one or 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.
ZAs built plans have been obtained and examined. Note if they are not available with N/A.
ZThe facility or dwelling was inspected for signs of sewage back-up.
4ZThe system does not receive non-sanitary or industrial waste flow
Zhe site was inspected for signs of breakout.
_k All system components,excluding the Soil Absorption System, have been located on the site.
_4/, 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 or
a proximated by non intrusive methods.
The facility ov.ner Land o-ccupants, if different from owner) were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 6/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Ad*ess: 40 Keveny Lane Cummaquid,Mas s .
Owner: Albert Alvordens
Date of Inspection: 1 2/2/9 5
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 5M gallons pak
Number of bedrooms: 3
Number of current residents:Q
Garbage grinder(yes or no):_a
Laundry connected to syst m (yes or no):
5
Seasonal use (yes or no): e- n� J
Water meter readings, if available: 19 w g7
Last date of occupancy:
COMMERCIAUI NDUSTRIAL:
Type of establishment:- fig
Design flow:-14—gallons/day
Grease trap present: (yes or no)_0
Industrial Waste Holding Tank present: (yes or no)�4
n-sanitary waste discharged to the Title 5 system: (yes or no)D-14
,,,ater meter readings, if available: X)A
Last date of occupancy: AJA
OTHER: (Describe)
Last date of occupancy: -AM
GENERAL INFORMATION
PUMPING RECORDS an sore of information:
System pumped as part of inspection: (yes or no)Q_0
If yes, volume pumped. Atli gallons
Reason for pumping: illy
TYPE O� SYSTEM .
Septic tank/distribution box/soil absorption system
04 Single cesspool
Overflow cesspool
AM Privy
Shared.system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
iage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 40 Keveny Lane Cummmaquid,Mass
Owner: Albert Alvordens
Date of Inspection: 1 2/2/9 5
SEPTIC TANK:jC.S
(locate on site plan)
Depth below grade:,,v
Material of construction: concrete_metal _FRP other(explain)
Dimensions: Z id
Sludge depth: ov �\
Distance from top of sludge to bottom of outlet tee or baffle: _
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: ;
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.) Pump tank once every 3 years ;Inlet & outlet tees are
structurally sound; Septic tank is s ruc uraiiy sound and has no signs
of leakage .
GREASE TRAP:&
(locate on site plan)
Depth below grade:
Material of construction:&Aconcrete _metal _FRP_other(explain)
a'1i�1
Dimensions: AJR
Scum thickness: JU'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom n) From t- bottom of outlet tee or baffle: 41
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural
k, integrity, evidence of leakage, etc.) A&f_
(revised 9/15/95) 6
®
SUBSURFACE SEWAGE DISPOSAhSYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property.Address: 40 Keveny Lane Cummaquid,Mass .
Owner: Albert Alvordens
Date of Inspection: 12/2/9 5
TIGHT OR HOLDING TANK. • '
(locate on site plan) •
Depth below grade:_&A
Material of construction:#Jficoncrete_metal _FRP_other(explain)
Dimensions: IJV%
Capacity: tlA gallons
Design flow: MR gallons/day
Alarm level:__
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOXIS
(locate on site plan)
f
Depth of liquid level above outlet invert: A16
,
Comments: '
�Ote i le\ an aistribu io i.,eyuai, evidence of solids carryover, evidence of leakage into or out of box, etc.)
is�rz�u ion tox is notr!Accessible. Large landscape boulders are on thee
zs rz u zon box. These wiilhave to be moved w ge
in thg box at any time.
PUMP CHAMBER:,
(locate on site plan)
Pumps in working order.(yes or no)_a
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/1S/95). 7
r
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 40 Keveny Lane Cummaquid,Mass . "
Owner: Albert Alvordens
Date of Inspection:12/2/9 5
SOIL ABSORPTION SYSTEM(SAS):,&5 a ,
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) '
If not determined to be present, explain:
Type:
leaching pits, number.Q
leaching chambers, number:Arf )o tJ "474 S�d►'s
leaching galleries, number._
leaching trenches, number,length:_ (0
leaching fields, number, dimensions:' C9
overflow cesspool, number:
Comments: note condition of soil, signs of hydraulic:failure, level of onding, condition of vegetation,etc.)
Loamy sand to clean medium sand;No signs of hydraulic failure or
pon ing, ege a ion is normal.
Cb COOLS: -
(locate on site plan)
Number and configuration: AI19
Depth-top of liquid to inlet invert:
Depth of solids layer.
'Depth of scum layer: AM
Dimensions of cesspool:
Materials of construction: AI
Indication of groundwater.
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic (ailure, level of ponding, condition of vegetation, etc.)
cwk.
PRIVY:,
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids: Ah?
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) A10AIw
(revised.8/1519s) 8
' l0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4.0 Keveny Lane Cummaquid,Mass .
Owner: Albert Alvordens
Date of Inspection: 12/2/9 5
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' .
Town water
'HIV b' 7 /(/Y a
r� ?i
DEPTH TO GROUNDWATER
Depth to groundwater: 4 : A it feet
method of determination or approximation: hr,j o water is 41 611 below the bottom
(revised 8/15/95) 9
v
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• " "'"�'"''""'^' -•'TOWN OF Barnstable BOARD OF !HEALTH
SUIISURFACE SEWAGE; DISPOSAL SYSTF,'M INSPECTION FORM -. PART D - CERTIFICATION
-� �•••�••;-T•Y:a-rdt.:••.T.Tnr.T..n•r.:rr1.:•ls•.�1:�"�1-r•t�:.-at.�tTT-'Tn-TC .
Tom+'-T7
-TYPE OR PRINT UEARLI•— � �''TTr "„'^-r•." -''
PROPERTY INSPECTED `
' 4
STREET ADDRESS _ 40 Kevenv Lane Cummaquid Mass
ASSESSORS MAP, BLOCK AND PARCEL # 2-
OWNER' s NAME Albert Alkord�s
PART D - CERTIFICATION r
NAME OF INSPECTOR -Zoseloh P. Macomber Jr..
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville Mass . 02632
Street Tovn or CSty
COMPANY TELEPHONE ( 508 ) 775 - 3338 st.t. L1P
FAX ( 508 1 790 _ 1578
CERTIFICATION STATEMENT ^°
I certify that I have personally inspected the •sewage disposal system_ at
this address and that the information reported is true, accurate, and
complete as of the time of ,insp'ection . The inspection was
performed
recommendations regarding upgrade , maintenance , and repair are consistentny
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
XXXXX Systeui PASSED
The inspection which I• have conducted has not found any information
which indicates that the system fails to adequately protect u health or tile 3
e environment as defined in 310 CMR 15, p blic
criteria not evaluated are as stated in the
this form. .FAILURE CRITERIA fsection of
System FAILED*
The inspection which; I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
1y
Inspector Signature u y
-- •-— Date
One copy of this c rtification must be( where ay�plicable ) and the BOARD of 11RALzovided to the OWNER, the BUYER
I the inspection FAILED, th'e- 'owner or•°'oparator ehall u
within one Year of the date of the inspection, unless 'allowed or
pgrade ' the .aystem
otherwise as provided in 310 chIR 15 . 305 • .. required
� z
S�j'Y 3r�1
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
y - -Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
E CERTIFIED TITL 5 INSPECTOR TEM Y
S S
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the • • ion of Water Pollution Control
4=
PWPERTY ADD RES - -��" f SS: 0 Keven Lane
---G mma c-uuj.d--------------
Mass a !�"s
------------ ----------
On the above date, I inspected the septic P is sy
stem stem at the
This y above address.
system consists of the following:
1 -1 500 gallon septic tank.
2-1-Distribution box.
3-4-Flow Diffussors .
•
Based on my inspection, I certify the following conditions:
1-This is a title five .septic system. ( 78 Code )
2.The septic system is in proper working .
order at the present time .
SIGNATURE: —
1
Name:_j_Q,upb_p_Macomber Jr.
Company: J_P_Macomber & Son INc.
Box 66
Address:
--------------------
��
nterville Mass . 02632 OF
-- C--------i------- 1
Phone:---508_77-5-333$.......
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARR N
�-- ' h
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
pr
TOWN OF BARNSTABLE
Lv ATiUN ��® yam-� 414 'SEWAGE #
VILLAGE ,,y�syptp��
ASSESSOR'S MAP LOT 3��7
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FA CILITY:(type) (sue)
NO: OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
L
t
I
V1 -
�i
C
_Ile\_
TOWN OF BARNSTABLE
x.
LOCATION SEWAGE #
VILLAGE 0 VV1 V\, t r` #0 ASSESSOR'S MAP Cz LOT .- Cf
INSTALLER'S NAME & PHONE NO. 14 PE L4APO 5'ep'tZ'
SEPTIC TANK CAPACITY (77D a-4
LEACHING FACILITY:(type) ;Q (size) X
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WA a�
BUILDER OR OWNER e-`a
DATE PERMIT ISSUED: �l
DATE COMPLIANCE ISSUED: " "
VARIANCE GRANTED: Yes No
r
'� U
t 4 `;.
v
THE COMMONWEALTH OF MASSAC�HUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
v Appliration for Disposal Works Tonstrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (V an Individual Sewage Disposal
System at:
L40 � � ��
Location Add re s ( or LoY No.
:,.......1L9. Q�1.._...... - :!. :_.\.:.../. C :1H.Yn.t�.....................................................
...............
�Orw�n/e�r DV�L /....�Cd�CI •'` ! l
Installer Address
Dwelling—gNo. Size Lot__
No. of Bedrooms______2_________________________________Expansion Attic ( ) Garbage Grinderq feet
)
U Type of Buildin
Other—T e of Building _.___.. No. of ersons____________________________ Showers —
a Other fixtures . ---------••---------------•-------•-•---•----.-•--------------------------------------- '.................................................Cafeteria
d -
W Design Flow____._____. ______________________ .� _�-__gallons per person per day. Total daily flow..........
WSeptic Tank—Liquid capacity___.__.__._.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq.ft.
� Seepage Pit No-_______1_________-- Diameter____.pag �_&....... Depth below mlet_____10.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( 6 ) t,
aPercolation 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........................
R+' ----•-------••--•---•--•---------•------....-•-••----------•-••-•....................................••-••_-•--- •------------..__...--------..........----
O Description of Soil -•-------------- '°
__........ _
x S stl'� 4
W 4lt `u: -
--------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._-__�_.I`E_ �\___:_k,__U?S�__.�C--e-�.qxT
�� ��vt - �`� CAS S• Q L--•................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in-accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee issued b th rd of h alth.
Signer--- —ate
----�-------------------------- .. --. . ........
Application Approved BY a . .. --------------- �.
e
Application Disapproved for the following reasons --------------------------------------------------------------------------------------------------- ----------- -- --------
- - -- ----------- --------...--------------....----...------------------------------
-------- - -----------
/• � Date
Permit No. ---- ------------------------- Issued
Dat
No _,
THE COMMONWEALTH OF~'MASSA%IUSETTS
2 _ d �. BOARDS - HEALTH ,,.
r
J 5 TOWN OF BARNSTABLE r f
Appliratilan for Disposal Works Tonutrnrtiun ri`mit
Application is hereby made for a Permit to Construct ( ) or Repair ( vj-'an Individual Sewage Disposal
System at
v
` Location Address \ or Lof No.
C �(>.`.__\................................ ^Y' ________....._...-•.---........................._.._
to -- -•--------- •--••......... .............•-----------•-••-(.........
Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms____.__?...................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers
a � yP g ---------------------------- P � ( ) — Cafeteria
d Other fixtures ---------------- ------ --------- --- -=
Design Flow_____..... _______________________________gallons per.person'.per day.. Total daily flow......:_• �-�U________._ gal
-•--;•--- Ions.
Septic Tank—Liquid capacity........____gallons Length---------------- Width................ Diameter__-_____--___•• Depih................
W Disposal Trench—No.................. . Width__._t.................. Total Length.................... Total leaching'area...................sq. ft.
x Seepage Pit No._______�_._________ Diameter.____4_p__.__.._ Depth below inlet.._. ..........
Total leaching area..................sq. ft.
Z Other Distribution box ( ) `` Dosing tank ( )
Percolation Test Results Performed by-•-------•--••-•--•-•-•------------------•----••...-------------T-•---•. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
4, t Test Pit No. 2................minutes per inch 'Depth of;Test Pit.................... Depth to ground water........................
:::... =
Descriptionof Soil---------------------------------•-•----........----•-------------------------.---- _
-------------- v - :, r;= = ........ -c., -- _..
U P � -_.. -------•--•--•
�,
Nature of Re aI s or Alterations-Answer when applicable:___ ..1`f S.A`�__ _-_ ••-�,.- �
-k
. .vt` v IG ... �St`<<�rc, C-e r__b0e)`__
. -� - = ------------------------------------------
Agreement:
The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with
'== the provisions�ofTTITLE 5 of the State Environmental Code-The undersigned further agrees not to place the
system-rn opra etion untll`a`-Certificate of�Co'mpli�ance has'�,be'e issued.:by-ahe board of health
Sig ed— --��'_':.. G--• . ...--
J l c
Application Approved By -- -° ..... . _.
-- ---------------- �'D�-
I
//�� DAe
!
Application Disapproved for the following reason sr'...................................: ............
IIJJJ
Da
�' , .,--....--'-----...---'-- Dace
qj...
Permit No. .......: ......,... Issued .............................
. - ...CT. -- f_--------------
Ile- THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
&z-ttftrate of (gontyltan e
THIS IS TO CERTIFY, That the•Individual S wale e Disposal System constructed ( ) or Repaired ( )
by.........---Y`............. -.. '�� .1.-+A f(�- ... G.t . . .c.. .. -- -• . ---- . ..............
"
Ins .,c.
--.....
has been installed in accordance with the provisions of TITLE f The Sit to IronmentalfPNWiC�Tld
as I r ed in
•, the application for Disposal Works Construction Permit No. _.. ...�...--�,�_. '... dated� �........./...........
a THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUAR H T THE
ti 4 � SYSTEM WILL FUNCTION�SATISFACTORY.
DATE Inspector ......:................ ... /-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No...•-•_...... FEE. .
� .... .........
f Iq
Disposal Work.5 Tuns#rudiun Prrutit
Permission is hereby granted...... ....... .. _!-•`--..........................................
.................
'to Construct ( ) or Repair (--'ran Individual Sewage Disposal System
at No........................... '!a lC -,t, s art
Street �
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Board',of ealth�
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FORM 36508 HOBBS&WARREN:INC..PUBLISHERS
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Oct. 6,1986
dN 50629 :.
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CE-WfIFY THAT TI•115_PLAN WAS PREPi
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TECHNICAL STANDARDS FOli,l'iitr I IZ/1(
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No.31295
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