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Home My WebLink About0128 MARSTONS LANE - Health rliea r 128 MARSTONS AVENUE Barnstable A= 350 - 028 r F Commonwealth of'Massachusetts cSO Off$ Title.5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 128'Marstons Lane Property Address Ruth Blauer Owner Owner's Name information is Ba rnstable V/ MA 02675 6/15/2020 required for every page. City/Town State Zip Code Date of Inspection f; Inspection results must be submitted on this form. Inspection forms may not be alteredin any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information s�# ,yU0-,+ . ' on the computer, use only the tab Patrick Rutledge key to move your Name of Inspector cursor-do not Title Five Specialists use the return Company Name., key. Co Taft 4 „y Company Address Dorchester MA 02125 City/Town State ' Zip Code 5082374628 S114198 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);�I have personally inspected the sewage disposal system at the prope ty address listed above;the information reported below is true, accurate and.complete:as of the time of my, inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system:, 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6/26/2020 Inspector's Signatur 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>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 DER The original form should be sent to the system.owner and copies sent to the:buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of.use:at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use, t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth:Blauer Owner Owner's Name information is required for every Bamstable MA 02675 6/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2,.3, or 5 and all of 4 and 6: 1) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described'in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by .the Board of Health,will pass` Check the box for"yes", "no"or"not determined" (Y, N,ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass s 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. , ❑ Y ❑ N ❑ ND (Explain below): f . t5insp.doc•rev.7/26/2018 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. City/Town State Zip Code Date of Inspection . C. Inspection Summary (cont.) 2) System Conditionally Passes (cunt.): ❑ Pump Chamber pumpstalarms not'operational.System-will pass with Board of Health approval if pumps/alarms are repaired.. ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed . ❑ Y ❑ N ❑" ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑,N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with.approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ ,Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t , 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment, a. 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: , t5insp.doc•rev.7126Q018 TFUe 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marston Lane. Property Address Ruth Blauer . Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection.Summary (coat:) 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 b. 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 ortributaryto a surface water supply. ❑ 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less 5 ppm,provided that no otherfailure criteria are triggered.A copy.of the analysis must be attached to this form. c. Other. 4) 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 t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner -Owner's Name information is required for every Bamstable MA 02675' 6/15/2020 page. City/Town state Zip Code Date of Inspection C. Inspection Summary (cont.) . 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® 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 %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 a cesspool or privy is within a Zone 1 of a public water supply 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 waterquality analysis. [This system passes if the:well water analysis, performed at a DEP certified - laboratory,for fecal coliform bacteria indicates absent 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 . and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd ❑ ® . The system fails. I have determined that one or more'of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve'a facility with a design flow of 10,000 gpd to 159000 gpd: For large systems, you must indicate either,"yes"or"no"to each,of the following, in addition to the questions in Section CA. 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 JI of a public water supply well t5insp.doc•rev.MAM18 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128'MarstonsLane Property Address Ruth Blauer. Owner Owner's Name information is Barnstable MA 02675 . 6/15/2020 required for every ' page. Cityfrown State. Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes'to any question in Section CA above the.large system has failed The owner or operator of any large system considered'a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for a►1 inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available noteas'N/A) Was the facility or dwelling inspected for signs of sewage back up?' ® ❑ 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, 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: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 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(5)] t5insp.doc-rev.7/W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential flow Conditions: ` Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does*residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ® Yes ❑ No information in this report.) 'Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail:• Sump pump? . ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Marstons Lane Property Address. 'Ruth Blauer Owner Owner's Name information is Barnstable MA 02675 6/15/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes. ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Tank empty at inspeciton Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official In on Form:Subsurface specti Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Maistons Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank,distribution box,soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval_ ❑ Other(describe): Approximate age of all components,date installed (f known) and source of information: 1968 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ® cast iron ®40 PVC ❑ other,(explain): 96' Distance from private water supply well or suction line. feet Comments(on condition of joints,venting, evidence of leakage, etc.): No issues t5insp.doc•rev.7/28/2018 Title 5 Official insp ection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. Cityrrown State Zip code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete [].metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a.Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions,: Sludge depth: 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface pec6 Sewage Disposal System•Page 10 of 18 Commonwealth of Massachuse#ts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth'Blauer Owner Owner's Name information is k required for every Barnstable MA 02675 6/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information.{cont.} , 7. Grease Trap(locate on site plan): Depth below grader feet Material of construction: El 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, gate Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction` ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): r Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection For' m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marston Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. City/Town state Zip Code E Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank (cunt.) Alarm present: ❑ Yes 0 No Alarm level` Alarm in working order. ❑ Yes 0 No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of'current pumping contract(required). Is copy.attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): :Depth of liquid level above outlet invert .Level • Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Outlets equal, no carryover, no leakage, Bottom of d-box T-below grade 4 ( t5insp.doc-rev.7/2672018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont ) 10..Pump Chamber(locate on site plan): Pumps in.working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil.Absorption System (SAS) (locate on site plan, excavation not required): f F If SAS not located, explain why: Type: ® leaching pits number: 3 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ _ overflow cesspool number: innovative/altemative system { Type/name of technology:. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.i. No ponding, No issue noted, 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth.—top of liquid to inlet invert High water mark to outlets Depth of solids layer 0 0 Depth of scum layer Dimensions of cesspool 614' Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Graywater cesspool with leaching line and Cesspool to D-Box to leaching pit t5insp.doc•rev.7/28/2018 Title 5 Official Inspeclion Form:Subsurface Sews'a Dis g posal System•Page 14 of 18 I � Commonwealth of Massachusetts Title 5 Official Inspection Form k��,o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth'Blauer Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): i t5insp.doc•rev.MA12018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments .128 Marstons Lane Property Address Ruth Blauer Owner Owner's Name informa for every tion is required Barnstable MA 02675, 6/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Graywater pit A=51' B=55' #2 A=38' B=70' #3 A=27' B=119' D-Box A=18' B=108' #3 D-Box Graywater Pit #2 A g #128 Marstons Lane t5insp.doc•rev.7/26M18 Title 5 Official In Form:Subsurface a D' F Inspection Sevr�q Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form'-Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer. Owner Owner's Name information is required for every Barnstable MA 02675 6/15/2026 page. City/Town State Zip Code Date of Inspection D. System Information (cunt:) 15. Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth.to high ground water: '$1 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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 elevation: No inflow to cesspool Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 128 Marstons Lane Property Address Ruth Blauer Owner Owner's Name information is required for every Barnstable MA ; 02675 6/15/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: t ® A. Inspector Information:Complete all fields in this section. ® B. Certification: Signed& Dated and'.1, 2, 3,or 4 checked C. Inspection Summary:'>,. 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached -For 15:Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE U LOCATION SEWAGE # VILLAGE v°N�" �� ASSESSORS MAP � LO��,�t1 h INSTALLER'S NAME & PHONE NOO y„ � ��LS 7-7"a S{ SEPTIC TANK CAPACITY t LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes_ No ...w1 ;� i /� r /\/'� �� /� i e��a �� ,N M�y��, � � Q Ow No..•l��_• Fss... `. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH. TOWN OF BARNSTABLE Appliration for Disposal Murks Tow1rurtion 1krutit Application is hereby made for a Permit to Construct ( ) or Repair L., an Individual Sewage Disposal System at: ( 0p Y,r1CLY, �` � Off$ --•• ...................... ...... ..................................... .. ..................................... Location-Address r Lot No. ...... � M_� 4...r..: .............................. ---------••... ----------------•---------------•- .._1... .�>C?-.nnci__.S. v --------�- . ................... Own �� , m Address M Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 0.' Other fixtures ----------------------------------------------- ... 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--------------------- Diameter............---..... Depth below inlet----_------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 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...---.................. Pi ..................... --- O Description of Soil --- -------------------------•--------------------------------------------------------------------------------- V .------------------------------------------•-.........---------------------•--...--•-----------------••---------------------•----..........------ W -----------------------------------------------------------------------=-------------------------------------------------------------------r--- V Nature of Repairs or Alterations—Answer when applicabl .-._-- -- ------------------------------------------------------- �7 v� S ---------------------------------------------------------------------------I-� ---------- - ------------------------------------------------...------------------. 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 Co h nce h s been issued by the board f health. SigneS��O Dace q ApplicationApproved By ------------ ^. ..............-------------------------------------------------------------- Date Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------- ................................... ---------------------------------- ----------------------------------------------------------- Date q Da -------/Permit No. o-- ---� - ................ Issued ............. .........................----........................ Due 0 cl� . =� Fim THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirat on for Disposal Works Tnnstrnrtiun Vern it Application is hereby made for a Permit to Construct ( ) or Repair (._,)-n Individual Sewage Disposal System at Location:•Address --°-r-Lot No. t d�Za-_ (�,✓!C r)? `, - R1 P.................... Owner Address Installer� Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.............................. ....Ex anion Attic a g— __...__._. p ( ) Garbage Grinder ( ) Other—Type of Building____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures d ------------•---•-•----------------------------------------------- ....... -------- ------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow........._..................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a '--------------------------------------------------- •... --------------- •--------------------- -------- ---------------- •----- ...•------------------------------- O Description of Soil.........��'__ _ U ---------------------------------------••---------------------------------.....--•-------•-•-•-----------------...--------•-------------------- W --------------------------------------------------------------------------- ----- --------•----------------------- --------------- ••----...................--....................................... U Nature of Repairs or Alterations—Answer when applicable_______. - ?. "�.�.�...................:.................................. -----------------------------------------------------------------------------I-Q•b �••---•.....I........ '-=...-----------......-----------------------------------...........-------- 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 ra Certificate of Co pliance has been issued by the board of health. ' Signed\ �_ `; .-------( .QJv._c .�....................... -1 .. .................. ' Date Application Approved By ..............U0.� .. � -.. . � — ---.-Dale. ..1,..... n Application Disapproved for the following reasons: .......................... ----------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- Date Permit No. --------�/5 :.. y$. ................... Issued ................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ; 01-lerti ictt#E of (110mytiancie TRIP IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ` G .......mow................. ..... ...............---....------.....----------------...-... Installer f`7 ..,. .. .................................................................................................. 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. ........ ...-.....y.g.'�'�- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,--� ,.-DATE -......:f ........ ...,-....................................................... � �I.....----- Inspector ........--------- .... l _ c ..:. ; , C 9_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q TOWN OF BARNSTABLE No..y,./..�..:...� FEE........................ Dispo J ur s Tunstrwtion Vamit Permission is hereby granted.......! .. ..�..........1,....._........\�C':.!!.►.....a rl �.�:. ...... to Construct ( ) or Repair (L) anIdividual Sewage Dispo System atNo.................. .rN 0 .._..._.✓�!1r�.Y`.S' ................--------------------------.................---•---•............----------•---................. Street ] as shown on the application for Disposal Works Construction Permit No../r!. .Xj?... Dated.......................................... ............................... = ,...................................................- DATE.... i z .......-..Q...`-------------•--••-• Board of Health FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION, roL m VWLv- SEWAGE ?0_9A VILLAGE NS ASSESSOR'S a MAP & LOB p`� 0 INSTALLER'S NAME & PHONE NOC,rtLw �R fti�!t3 177-;tVj SEPTIC TANK CAPACITY 1 LEACHING FACILITY:(type) L + \ (dw Gc6o NO. OF BEDROOMS 'PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER `).\Gi DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: . VARIANCE GRANTED: Yes NO vp ,gyp S7� ,uz. http://issgl2/intranet/Propdata/prebuilt.aspx?mappar=350028&seq=I 3/4/2019