HomeMy WebLinkAbout0135 PALOMINO DRIVE - Health 135 Palomino Drive
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TROY, WILLIAMS _ �' S3
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection �1� 8� 85-1300
19 Hummel Drive ,(�J
South Dennis, MA 02660 JUN 16 2003
COMMONWEALTH OF MASSACHUSET STC)," dARNI TAs�E
EXECUTIVE OFFICE OF ENVIRONME E^',T r,��aT
-A�=IZ-rS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Propert) Address: 135 Palomino Drive `
Barnstable,MA
Owner's Name: John Magnuson
Owner's Addres,: 6 King"Street
Wakefield,MA 018.80
Date of Inspection: June 10,2003 O
Name of Inspector: Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
Telephone Number: South Dennis,MA 02660
(508)385-1300
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
apprm ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svmcm
Passes
Conditlonall\- Passes
Needs Further Evaluation by the Local Approving Authont)
Fails
Inspector's Signature:/ J.�.y ZJ,�.Q,�a:,.� Date 6 //O 3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or
DEP)within 30 days of completing this inspection. 1f the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification Is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
****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.
Title 5 Inspection Form 6/15/2000 Page I off'It
1 ,
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address:
135 Palomino Drive
Owner: Barnstable,MA
Date of Inspection: John Magnuson
June 10,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or ut 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be re c
ed or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of alth,will pass.
Ans%%,er yes. no or not determined(Y,N,ND)in the for the following statements. If" of determined"please
explain.
The septic tank is metal and over 20 years old'' or the septic tank(wheth metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is im ' ent. Svstem will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the oard of Health.
•A metal septic tank will pass inspection if it is structurally sound,no eaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out o igh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken settled .tt ed or ven distribution box.System will ass
approval of Board of Health): y P inspection if(with
broke 1pe(s)are replaced
ob ction is removed
istribution box is leveled or replaced
ND explain: -
The system re tred pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if tth approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
G ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
135 Palomino Drive
Owner: Barnstable,MA
Date of frlspectiuu: John Magnuson
C. Further Evaluationnis 0equi0red by the Board of Health:
Conditions exist which require further evaluation by the Board of Health ut order to determine if the system
is failing to protect public health. safety or the environment.
I. System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)( that the
system is not functioning in a manner which will protect public health,safety and the env' onment:
— 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 in
2. System will fail unless the Board of Health(and Public Wate upplier,if any)determines that the
system is functioning in a manner that protects the public he ,safety and environment:
_ The system has a septic tank and soil absorption tem(SAS)and the SAS is within 100 feet of a
surface %%ater supply or tributary to a surface water pply.
_ The system has a septic tank and SAS d the SAS is within a Zone I of a public water supply.
_ The s�stem has a septic tank an AS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic t • and SAS and the SAS is less than 100 feet but 50 feet or more front a
private waier supply well". ethod used to determine distance
""This system pass if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and voh organic compounds indicates that the well is free from pollution from that facility and
the presenc . ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure ' eria are triggered.A copy of the analysis must be attached to this form.
3. Other:
iY R I
r
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 135 Palomino Drive
Barnstable,MA
Owner: John Magnuson
Date of Inspection: June 10,'2003
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
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 _ due to clogged or obstructed pipe(s).Number
of times pumped
IX Any portion of the SAS,cesspool or privy is below high ground water elevation.
AYA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
— to, Any portion of a cesspool or privy is within a Zone 1 of a public well.
— aLA Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_. ALO Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. ]This system passes if the well water analysis,
performed at a DEP certified laboratory,for collform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system bliLs.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.
E. Large Systems:
To be considered a large system the system must serve a facility with a design w of 10,000 gpd to 15,000
gpd• I I
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria ab e)
yes no
_ the system is within 400 feet of a surface drinking wa supply
the system is within 200 feet of a tributary to a ace drinking water supply
_ the system is located in a nitrogen sensi ' e area(Interim Wellhead Protection Area—JWPA)or a mapped '
Zone 11 of a public water supply we
If yott liaye answered"yes"to any que n is Section E the system is con idered a significant.thl'ea1,or answered.
yes is Section 1)above the largo tam,ha;felled.The owner of opetttor o�any large systettt considered a
sigatcgnt threat under Sectonn r. tilad,undar Section Q abet i upgrade tho system m accgrdaace with 310 CMIt
15.304.The system owner ah d contact'the appropriate regional'of IceAof the Department v t
f � .
1 f X
4
Page 5 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
.CHECKLIST
Property Address:
135 Palomino Drive
Owner: Barnstable,MA
Date of Inspection: John Magnuson
June 10,2003
Check if the followinghave been done.You must indicate"yes"or"no"as to each of the followiiw
'y
Yes No
f'.:;rhing information was provided by the owner. occupant. or Board of I leald,
_.._ _✓ Were any of the system components pumped out in the previous two Nveeks
✓ 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 note as 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 die 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:
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)f 310 CMR 15.302(3)(b))
�E ".
� airy
5
Page 6 of 1 I
OFFICIAL INS 'EC' QN.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL$YSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
135 Palomino Drive -
Owner: Barnstable,MA
Date of inspection: John Magnuson
June 10,2003 'FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Nwnber of bedrooms(actual): I/
DESIGN flow based on 310 CMR.15.203(for example: 110 gpd x#of bedrooms): Yyo
Number of current residents: 0
Does residence have a garbage grinder(yes or no): ivo
Is laundn on a separate sewage system(yes or no):- (if yes separate inspection required)
Laundry system inspected(yes or no):Lv/,1
Seasonal use: (yes or no):Lvo
Water meter readings,if available(last 2 yearslrsabe(6Pd)): o(-o z = o _r(o s 02 -o 3 : /,000
Sump pump(yes or no):A
Last date of occupancy: tic.�� (-
4.�o�rox 3„,; ,+1, t w,11 occ�, �,o I ✓s-e-
COMM ERCIALANDUSTRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203):_-__ ,d
Basis of design flow(seats/persons/sgft,etc.): 61
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no): _
Non-sanitary waste discharged to the Title 5 Systemm cs or no):
Water meter readings, if available:
Last date of occupancy/use: -
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:�o �,,„, �,
Was system pumped as part'of the inspection(yes or no): _No
If yes, volume pumped: _gallons- How was duantity pumped determined?
Reason for purnping: --
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption systeur
_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):.
A roximate age of all components.date installed(if known)and source of information:
�.�,t� - ct-bole o...cA c;a- � ��a' ...,. 1 -><•a I1Ji.., b�� I }-r' .•- /1ls..ic► t!_cc,.�� fo,")- c a.�
�v�r197►. �
Were sewage odors detected when atq _•:.
arrrvtng at.4he site(yes or no): No � N
6 Y;� ,
Page 7 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE_ DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
135 Palomino Drive
Owner: Barnstable,MA
Date of Inspection: John Magnuson
June 10,2003
BUILDING SEWER(locate on site plan)
Depth beluti% grade: /�" f
Materials of construction: _cast iron Z40 PVC-,/other(explain): ��
Distance from pri%ate water supply well or suction line: _ ,rl g
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ,/ (locate on site plan) -
Depth below grade: I '
Material of construction: ✓oncrete_metal fiberglass_polyethylene
—other(explain)
_
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or'no):
certificate) _(attach a copy of
Dimensions:
Sludge depth: -- — y'' ------- --
Distance from top of sludge to bottom of outlet tee or baffle: .2'Al
Scum thickness: ,,/-7 ,
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: Pro 6� _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.).
....!..�. . Wur�t. -. _V✓ (�t /tip '
Eve Ri�vi t ,t—u—T ( as�{`�. s.� +✓ �.C^ �... c�y..�—(eL.:�) �"c>✓.. ./�_�t"h,fC w_4 S._�HO-f'
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal fiberglass_po thylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or balfl .
Distance from bottom of scum to bottom of outlet a or baffle:
Date of last pumping:
Comments(on pumping recommendation let and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of akage,etc.): '
7 S
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
135 Palomino Drive
Owner: Barnstable,MA
Date of Inspection: John Magnuson
June 10,2003
TIGHT or HOLDING TANK: (tank must be pumped at time of inspec ' n)(locate on site plan)
Depth below grade:
Material of construction: concrete metal__fiberglass lyethylene other(explain):
Dimensions: - ---
Capacity: gallons
Design Flo„: _ gallons/day
Alarm present(yes or no):
Alarm level:__ Alarm in working ord yes or no):
Date of last pumping:
Comments(condition of alarm and flo switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: —
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover. any evidence of
leakage
into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of mps and appurtenances,etc.):
t4
7�
t
.. JF..'.
+. s
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _
135 Palomino Drive
Owner: Barnstable,MA
Date of Inspection: John Magnuson
June 10 2003
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain wit).
T
leaching pits, number: a' � ' x c L�w�� �:►- 5 w',� 3 'S?a�,:� -
leaching chambers,number:
leaching galleries,number:
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.): J� l
2.L..�tr LCc�t_`.l.__�_(_ Wa.- ] �✓1� y W. ,a.1 f� VI S : �l L 7i` y
�.i 4D L)u �lc` t,,,��N� J..c..�.... --�� rc�.. / I� c. r �J t o✓ M+ 61ce.. 'b.
+ to.t t_'t"'i o h /l; F s ...J G✓` �j,.,r.o! C�✓� U�t
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate site plan) i 5 p.Q•. C-
Number and configuration:
Depth—top of liquid to inlet invert: _
Depth of solids layer: ---
Depth of scum layer:
Dimensions of cesspool___
Materials of construction: _
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs o draulic failure, level of ponding,condition,of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions: -- - --
Depth of solids:
Comments(note condition of soil,signs of hydraulic f ' re, level of ponding,condition of vegetation,etc.):
9 .
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued) MA r> Z 9—7
VN y- O 5 3
Property Address: 135 Palomino Drive L_07— �—
Barnstable,MA
Owner: John Magnuson P,0(4m—s-,
Date of Inspection: June 10,2003
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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51 F = i3 k. 31 � h-130k
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Page I I of I
OFFICIAL INSPECTION FORM— NOT. FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
135 Palomino Drive
Owner: Barnstable,MA
Date of inspection: John Magnuson
SITE EXAM June 10,2003
'
Slope
Surface water
Check cellar c/
Shallow wells
Estimated depth to ground water �'Gt` feet
- Adjuslcd high ground water clevaliou _ _feel
Please indicate(check)all methods used to determine the high ground eater elevation:
Obtained 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 I Iealth-explain:_
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: .41 i,J 'X,/_7 0—.2 3 t Z y,
You must describe how you established the high ground water elevation:
— .... -- - ----- mil. ��.,.,sb/��r`_,,. �,�c <t., w�;�., _L.3.._3 _� �_ --_-- _ w� �-F
c.2 G Id
—w, S_ / .. .12_._ c.•✓
• � � �J ICU ��../ b✓�yrt.c...i `tlG� -
jL
D J �
41
�'NP'p� AVJ t-1 G✓L —
This sport has been prepared and the system inspected as of the date.of inspection "This report is not 8 K .;
warranty or gualMee that the t3ysteln ywlll tundion properly In the futtare These have been rto warraltites or`-{
$uaraMees,either expt7@�ssed,written or lrr'plled,relating to the syatet i the Ingo" tnd/or this nepott.
' 11
L 6 /0 1
TOWN OF BBARNSTABLE g `�
LOCATION �, 5. 9/-�.(�/L�`�"�t �//t.tiiP-� SEWAGE #
VILLAGE D ��� ASSESSOR'S MAP LOT
INSTALLER'S NAME & PHONE NO. �1G
SEPTIC TANK CAPACITY td b
LEACHING FACILITY:(type) i / (sue)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER -� d��/ N/ L��IZ/�AJ?/y
DATE PERMIT ISSUED: q/7 "i J41;6
DATE COMPLIANCE ISS ED:
VARIANCE GRANTED: Yes No
13Ac /G-
a 6 y4r �
Old
AP
No.. .._ FEB....��y_0.........
THE COMMONWEALTH OF MASSACHUSETTS
` BOAR® OF HEALTH
TOWN OF BARNSTABLE
A#p iration for Uiiipas al Workii Tnnitrnrtiun Famit
Application is hereby made for a Permit to Construct ( ) or Repair (A an Individual Sewage Disposal
System at:
13 Ql�l w� w
.........-•---.............. ..... - ...........................................
Lot No.
Location-Address or
----7M°)---.__....yN... c.N. soYJ----------------------------------•--•-- ----_- - tsl --•--------------•-------------_--------------.-_---:.....---
Owner Address
a ..1k�! \ko-`..._..._...ads_�........................... Q• =•:-ate 23� CL�T 1�L
............. ..._-------------••-• ---•-
Installer Address
Type of Building Size Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms............................_...............Expansion Attic ( t) Garbage Grinder ( )
a Other—Type T e of Building ._.____. No. of ersons__________________________ Showers
Pa yP g -------------•-=---• P -- ( ) — Cafeteria ( )
d` Other fixtures -----------•----------------------------------------•-
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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.........................
fX Test Pit No. 2________________minutes per inch Depth of Test. Pit.................... Depth to ground water........................
0+ ..............................................................•-••...........................................................................................
O Description,of Soil...Q`Z---------. ............z"^...-----5' 'n�Y�
'-----------•--- --------•---------------------•-----------------------------._._._.--•------------------------------------....-----------------------..._..-•-------•-----------•--••-••••-•--------••--
V Nature of Repairs or Alterations—Answer when applicable.___�9`9........�? -------\k Oeo..... ^�� .....................
LEJ�cit `��� ------ �s1_�w ............SksS
------------------------------------------------------••••••--•••••-•........--•-•••.
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 been issued by the board of health.
Signed -- ------------------ ----------- ---4 ,e 4 ..
I I?a e
Application Approved By ............ .
Application Disapproved for the following reasons' ---------.'--------------------------------------------------------------------------------------------------------------------------
------------------------------------ ------ ------------ ------------ ---- -- --- ----------------
..................................................................................Date ....
Permit No. f���..-... Y�Ci Issued ----------------------------------------------------Date-----
No.. ;X/)•- •%5 jx _' FE....... _...."
ZZ;
THE COMMONWEALTH OF MASSACHUSETTS
`, . BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for �i� u 1 lark Cann rnr#inn p nti#
Application is hereby made for a Permit to Construct ( ) or Repair ( Jt) an Individual' Sewage Disposal
System at:
-
_ nq rr , r
�•--.......
.......... c�N.�' (�.C�
,.;.., -�- �• -- - ................................................
Location-Address or Lot No.
......................_......{MI!c C.�1la_S,,AY�.....----••............•............... ........
Owner Address
a1•l\C,L�St.........!bbNa. .................. Q:�: gC31� 2�_ ..^
Installer _ Address
UType of Building Size Lot............................Sq. feet
.—I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ---------------•-------••--••-•• .
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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.._-....--.----.---...-
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--....................
9 ---•----•----••---------•-------------•--•------..........-•-------•••......----•---.._..-•-----•---.........................................................
0 Description of Soil----lam-::L........... ............:ZL..------.S ....�> -.
x
W
------------------------------------------------------------------------------------------------------•••-••-•-----------•••--------•-•-•----------...---••---------------------•-••......-----------•-
U Nature of Repairs or Alterations—Answer when applicable---.. ......... ? .......K;no..0..... .�_Q�1.....................
-------------------------------------------------------------•--
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 been issued by the board of health.
Signed ------l:t�..t.,-..,.-,.k,.4.---�� .--.�_-:.=�--------------------------------- ------4 I-1 B'-i o
-------- ----------------
ApplicationApproved By ------------- . ---. .---...-------- --- ......... .............................. -------....... 'Ao
Due
Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------
------------------------ ------------------------------------------------------------------ --------------------...------------------------------------------------....------------ .............-------------------..-.--
Date
PermitN .c.................. Issued ................................................------f_1
......
Date,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
V6er#ifirate of Cgontylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by........... l�.c. C�1------------- �--"-5�------------............-....---....................-. ---------------------- ..............-------------------------- ----------------------- ------.----------------
Installer
at ......±.3. ....-..- �.�-vim-t uJ o----..-- ....
a - .
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. dated ........�../------------------- -------.... ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. /
DATE - �� ...... .... ...... Inspector
...... .. ---..................... m.....-
....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C� [� TOWN OF BARNSTABLE
No. !. ... I..C.,.C� FEE S.. ....
Disposal Works Tons#rnr#inn Prrnti#
Permission is hereby granted.....Ick 4........ s� Q'�
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to Construct ( _) or Repair ( an Individual Sewage Disposal System
at No...........K! ---... h �. any�......� _1. ............................... `rz V�.Cal 1.�~
Street
as shown on the application for Disposal Works Construction Permit No..70-7.Z Dated..........................................
...............•-••...-•••-••--- -=
�y 9� U Board'of Health
DATE............=�._-. ��._..../ ......................................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS