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Home My WebLink About0028 ALBERTI WAY - Health y 28 Alberti Way 248-289 Centerville No. 4210 1/3 ORA Pendaflex Mum 10% ,� C T d a A (`� 1 i 8 { A r 1 I ,} �w Commonwealth of Massachusetts r w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c yey`bv 28 ALBERTI WAY ,i1 �M ♦I Property Address TONY NAKHLE W Owner Owner's Name I-+ information is BAR� CE �� -a required for every MA 02632 8-11-16 page. Clty/Town State Zip Code Date of Inspection .R1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, /aOYD use only the tab 1. In key to move your cursor-do not EDWARD HART use the return Inspector Name of Ins key. p ED HART TITLE V SERVICES LLC Company Name 75 ROCKYMEADOW ST Company Address MIDDLEBORO MA 02346 City/Town State Zip Code 6177191120 S113462 Telephone Number License Number B. Certification 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-11-16 41nors 'gnatu 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. ,�o (d (�S t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal SystePage 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,. 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every City(Town State Zip Code Date of Inspection page. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I 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: THE SYSTEM IS A SEPTIC TANK DISCHARGING INTO A D-BOX AND THEN INTO A LEACHING PIT. THE SYSTEM IS IN GOOD CONDITION AND PASSES AT THE TIME OF INSPECTION B) 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 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I t5ins.doc•rev.6/16 f' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form U -Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): 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, safety or the environment. 1. 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: ❑ 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 l5ins.doc-rev.IBM Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cont.) 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 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 or tributary to 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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 I ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool y ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every State Zip Code Date of Inspection page. cityrrown B. Certification (cont.) Yes No ❑ ® 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 water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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 2000gpd- 10,000gpd. ❑ ® 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 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 El ❑ 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 �r Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every BARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: 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 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 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. ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every BARNSTABLE MA 02632 8-11-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage d 30 GPD 9 ( Y 9 (gP ))- Detail: 2016 3000 GALLONS-2015 7000 GALLONS-2014 17,000 GALLONS Sump pump? ❑ Yes ® No Last date of occupancy: DOCeCUPIED Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts 190 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every BARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: PUMPED LAST YEAR Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 200 GALLONS gallons How was quantity pumped determined? Reason for pumping: PIT ONLY FOR INFULTRATION Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every BARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 OLD PERMIT BUT NO PLANS OR AS-BUILT. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 FEET feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): THE HOUSE HAS NO SIGNS OF ANY LEAKS OR BACK UPS. THE BUILDING SEWER PASSES AT THE TIME OF INSPECTION. Septic Tank (locate on site plan): Depth below grade: 1.5 FOOT 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: 10X5X4LIQUID Sludge depth: 1 INCHES t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts u u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE required for every MA 02632 8-11-16 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle APP 29 INCHES Scum thickness N/A Distance from top of scum to top of outlet tee or baffle 6 INCHES OF TEE ABOVE WATER Distance from bottom of scum to bottom of outlet tee or baffle 18 INCHES How were dimensions determined? GRADE ROD Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): THE SEPTIC TANK WAS DUG UP AND INSPECTED. THE OUTLET TEE IS CONCRETE AND IT IS IN PLACE IT IS 18 INCHES LONG. . THERE IS NO SIGNS OF ANY BACK UPS AND THE SEPTIC TANK PASSES AT THE TIME OF INSPECTION. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): N/A 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: Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required uired for every BARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert -0- 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.): THE D-BOX WAS DUG UP AND INSPECTED AND IS IN GOOD SHAPE. THERE IS NO SIGNS OF ANY CARRY OVER OR BACKUPS. THE D-BOX PASSES AT THE TIME OF INSPECTION.. 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.): N/A * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I' Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'" 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every gARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6 ROUND ❑ 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.): THE SYSTEM IS A SINGLE LEACHING PIT SURROUNDED BY STONE.. THERE IS NO SIGNS OF ANY BREAK OUT AND THE PIT HAS 6 INCHES OF WATER IN IT AT THE TIME OF INSPECTION. THE PIT PASSES AT THE TIME OF INSPECTION.. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A 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 ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'' 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs 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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form PAA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is BARNSTABLE MA 02632 8-11-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 NAk ao5e coj?&ue,L c JAW'se CozrjF•t O 2i- 1i.1 3 � 31 P T t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,e y 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every BARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8+FEET 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: NOTHING ON FILE AT ALL BESIDES PERMIT THAT SHOWS SYSTEM IN DIFFERENT LOCATION.. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I DUG TEST PIT WHEN EXCAVATING FOR D-BOX AND PIT.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 ALBERTI WAY Property Address TONY NAKHLE Owner Owner's Name information is required for every BARNSTABLE MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I : r w y 1 _ Awk MEn RwH- s� �e�w �i 3}}$1.� 'i x"�'r�., � r\. •+f r� � .. $fix �'°I• � t�,�h.. �. _ , � � ,�' 'rt{*�'\y k .�� t,4 " •1. ,�, �ifs �� r�� ,.��•''�- . r- , , � ��#k��'` y �� - .! i s x..� x� � 4..&�. r f6r ��i .x �'-- r �./7*•"Y ak. �. l "'"1, � -!_ �� C. •r � �� .d_�. � f 'mac` �t� � �Y >< • S 1,F 1i ��# y.R�,, ,ti ! 'fir'`� ,�r +y ,kr:`,ia7�lt1wY'w`�t»,`1f„ ,'a• ,� � s d' $c. , 71 e � •!• ,'/{'i•� "r4�•AJ;� P�f• � .:'�'�/��q�� i .1 �{�(�" .� # �n•".Y ,ikY�R�'q r Y +�, 6 �`,� IN V s g ,.�'. ). 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"� '��_�J!'' 5�� '�f,5'ys_. }+,'�' •zg � 6;��`,�•e' ,`.�° :•+ rSf. t.q -�j�4.�'Y...Z� y , ;� � '*`��r `�3im:a,. �"`•.�'K�.c•✓� ,ay}�fir - ��, �^ �� .tee. ,�, it'�'� W '9{�,.��'r" •A'.err'f ti � ' •h. ,��-� L•_ t.��.i ...,�. -�" � ��} ��rd.. .e'."` `r`6 r--�i '!��. r'c. a` �•r 4+� ;r�,K rsS vu � ,n�^gi`:Sh. ..r .vey�Q�. ..y'y`t w '8'�� , »s.. ,� • Y � .Y• �5�� o�✓^".r~y- �`°�y.��, .x?�'ta, „�y{ ��l��yw�� y.. � �'F �„w �r' .i,> �r r�r..�"r 'F°' _ • �"�^�, �'�,,�'" � uNW,,,;'� yr��+�I'3':(r"��W J�.fifr ��p,",} �l '"•'` K "•J 'S►+. :. , r�w�.�ram; r, "� ?,.�"*��'e�P�i,y��"'..�� :+'"�.l'R,r,,a'1"7E�s� ,.r• .•�.�� ''} �. .. a. -.�". � �4�� ti/nf 1 '�, "�' .�.•�/ .'yY`��•��''F)�plw+'�a/:1��= sr f �,G fey � i`t Jh"�'.. � :t�'r i"'}�+'` ...r,'., .may j<� ,�"��"��,gy',�`,• +., 'S[ __ � r_, •P�, �� '_• :`� r.hL• Lea. �_� � s_.r__.�>ffi!J I �T COMMONWEALTH OF MASSACI-f USETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTION PARCEL,`Z$ LOX 7 A Map:_2413_ Lot:_7A_ Par:_289_ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_28 Alberti Way _Centerville_ Owner's Name: Chris Beal_ Owner's Address: _same RECEIVEDDate of Inspection:_3/24/04_ Name of Inspector: Dion C. Dugan APR. 0 2 2004 Company Name:_ 1543 Main St. TOWN OF BARNSTABLE Mailing Address: Brewster,MA 02631 HEALTH DEPT. Telephone Number:_508-896-9390 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: . 6 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 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: *Recommend: Maintenance pumping 3—5 yrs. ****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 tinder the same or different conditions of use. i Page 2 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_28 Alberti Way _Centerville_ Owner's Name:_Chris Beal_ Date of Inspection:_3124/04_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I 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: B. System Conditionally Passes: N/A 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. Answer yes,no or not determined(Y,N,ND)in the 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 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Page 3 of OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_28 Alberti Way _Centerville_ Owner's Name:_Chris,Beal_ Date of Inspection:_3/24/04_ C. Further Evaluation is Required by the Board of Health: N/A 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. , 1. 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: 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 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 or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 coliform bacteria and volatile organic compowids 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. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_28 Alberti Way 1 _Centerville_ -� Owner's Name:_Chris Beal_ Date of Inspection:_3/24/04_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X— 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO_(Yes/No)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. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no —N/A_ the system is within 400 feet of a surface drinking water supply —N/A_ the system is within 200 feet of a tributary to a surface drinking water supply _N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 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. i Page 5 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _28 Alberti Way _Centerville_ Owner's Name:_Chris Beal_ Date of Inspection:_3/24/04_ Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection" _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components, excluding the SAS, located on site`' _X_ _ 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'? _X_ _ 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 _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_28 Alberti Way _Centerville Owner's Name:_Chris Beal_ Date of Inspection:_3/24/04_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms):_488_ Number of current residents: Does residence have a garbage-grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no): no[if yes separate inspection required] Laundry system inspected(yes or no):_no Seasonal use: (yes or no):_no_ Water meter readings, if available(last 2 years usage(gpd)): unable to get through to Centerville Water Dept. Sump pump(yes or no):_no_ Last date of occupancy:_OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: none owner Was system pumped as part of the inspection (yes or no): NO_ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy NO_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 components, date installed(if known)and source of information: _Installed_2/05/1986 (18 yrs. Old) B.O.H. Records Were sewage odors detected when arriving at the site(yes or no): NO i Page 7 of OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_28 Alberti Way _Centerville_ Owner'vName:_Chris Beal_ Date of Inspection:_3/24/04_ BUILDING SEWER(locate on site plan) Depth below grade:_29"_ Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): _Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_17" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_1000 Gallon_ Sludge depth _6"_ Distance from top of sludge to bottom of outlet tee or baffle: 24"_ Scum thickness:_3" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 11 How were dimensions determined:_by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Owner is having tank pumped clean.Tank and tees in good condition. No sign of leakage. *Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP:—N/A_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.): Page 8 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_28 Alberti Way _Centerville_ ' Owner's Name:_Chris Beal Date of Inspection:_3/24/04 TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0" 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.): D-Box is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A_(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 pumps and appurtenances, etc.): f 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: 28 Alberti Way _Centerville -' Owner's Name:_Chris Beal_ Date of Inspection:_3/24/04_ SOIL ABSORPTION SYSTEM (SAS):_YES_(locate on site plan,excavation not required) If SAS not located explain whys Type —X_leaching pits,number:_one 6' x 4' pit w/3'stone_ 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.): No signs of failure. CESSPOOLS: N/A_(cesspool must be pumped as part of inspection)(locate on site plan) 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 of hydraulic failure, level of ponding,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:_N/A(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.): r Page 10 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_28 Alberti Way _Centerville_ Owner's Name:_Chris Beal_ Date of Inspection:_3/24/04_ 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. t ,A -- C ` 16 A b - C 27 A c I I J vJ __7 Page I I of I I OFFICIAL INSPECTION FORM - NOT FUR VOLUNTARY ASSESSMENTS SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_28 Alberti Way _Centerville_ ' Owner's Name:_Chris Beal_ Date of Inspection:_3/24/04_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_>13_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_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 Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: By Perk test on 12/06/1985 13'deep,no groundwater encountered. No... l�.... . / t Fizz .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..-d..�i�/✓...._.OF...... .... �,,......................... 7 , pphration fur Mspaaal Morkii Tonstrnrtiun Famit Application is hereby made for a Permit to Construct C< or Repair ( ) an Individual Sewage Disposal Systemat., Y....�AX.......... ---------------------- --------..A...----------------------------- .... ... .................... Address or t No. Location- ................................ .Sr':........_.E I� %t!il`�t.-•-•----.... Own r Address a .. ^ l ...... ......--�-- ----------------------- --------------------- --------------------------------........... M Installer Address UType of Building Size Lot--- !-_ .g. ...Sq. feet ,-4 Dwelling—No. of Bedrooms.......... ..............................Expansion Attic Garbage Grinder Other—Type of Building No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .................................. . Design Flow.......... .30......................gallons per person per day. Total daily flow.............. c.........._._..gallons. WSeptic Tank—Liquid capacity.l 0.0egallons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No. .................... Width.................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I----------- Diameter....G.- ........ Depth below inlet.................... Total leaching area..4r71t4..sq. ft. Z Other Distribution box (x) Dosing tank ( ) 1"4 Percolation Test Results Performed 4!4'021-:vl�................ Date....a-Y14/k.r-........... 14 Test Pit No. I................minutes per inch Depth of Test Pit.-----.............. Depth to ground water..--.................--. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' ----------------------------------••----------------------•----.........--------•----•----••------•-......................................................... 0 Description of Soil..........................................................................................------------------------...................-•--------••---•-•............--- x V --•---•------------------------•------•-••-----------------------......-----••--•-•--------•--------•---•------------------•-------------------------.................................................. UNature of Repairs or Alterations—Answer when applicable.........................................................:..................................... --•----------------------------------------------------------------------------------------------------•••------------•--------------------------------------•------------••-----------......----...... Agreement: The undersigned agrees to instal the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT - 5 of the S e Sanitary Code— The undersigned further agrees not to place the system in p ration until C t sate of Co nce has be _n issue by the board of health. Signe�l —................... f-tn--•�� PPlicatio Pr B 1`2Z�G....... Applicatio I p o e owing reasons:------•--------•-----•-•-------•--------------------------------•------------------.....--------•-----.......... ....-•--------------•--..._..---..._... .....---------- --............---------.....-••.......----•----••------._........---•-•----•••-------•-------------------•-•-••-•......-------•--------------- Date PermitNo......... r•.... ............ ,v9--------_---. Issued....................................................... Date �.....�--=— - ..��.. _ .....�...o....W.�.._. ......----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH ApVftraffon for Ili-4poiitti Works Tontrnr#ion 11rrmi# Application is hereby made for a Permit to Construct ( ') or Repair ( ) an Individual Sewage Disposal System at .. ,. �i Location-Address --�//.. .I pi-�r •tr i ) ti T or Lot )-( rt a.� e!i _......................... ••-••--........................................ . ..._....•-•----�...----•.................. ....-•--.......-•-----•--•-.................. v DH r Address W Installer Address e of Building / d Type g Size Lot--- ....Sq. feet Dwelling—No. of Bedrooms..........- ..............................Expansion Attic (r..) Garbage Grindert(_c..) aOther—Type of Building .rt.e ._?_r ___ No. of persons............................ Showers ( ) — Cafeteria ( ) Q Other fixtures ... W. Design Flow.......... .......................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity. ..:r C<gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------- Diameter....l...'......... Depth below inlet.................... Total leaching area..�........`....sq. ft. z Other Distribution box (y() Dosing tank ( ) aPercolation Test Results Performed by..LZ_�............................................................ Date.... ................................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ ----------------------------------•---..........-----------•---.........._...........------.._...............................................................O Description of Soil........................................................................................................................................................................ W U ---••••-•••-•-••-•-••-----•••--•-----•------•••----......•--••-••••------•-....•-•-•............•--•----...•••--••----•-•---•••---...••••--••-•••--•--••=-•--•--------------------•---•--•--•--------... W --------------------••-------•--------------------------------------------...---------....----------------------------.---------------------------...------------......----------------------•-------- M. Nature of Repairs or Alterations—Answer when applicable.......................................___......_•___.....:_.:....._.__...___...________....._.. ..------•----------------------------------•---------------•---•--------------------------•-•-••---•-•••••••-•--•---•-•••-•------••••-•--•-•--•--•-•---••••-•-•-••-•••••••...••••...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I' 5 of the S to Sanitary Code—.The undersigned further agrees not to place the system in iperation until Cert sate of Co lance has been issued by the board of health. Signed... : ----- .........`............... '-------------•-•----•--- ---•,�...... PPlicatio pr B ......: '=-`�' :`� . == ==-� .� / Z �D, l- t Date Applicatio p o e owing reasons-------------•---------••-•------•-------------------•-----------•-----------------------._..........•-••----- ......-••---•----•..................... .........•...:. •--•-••-•---•--C-••...----•----•-----........_....•-•------••-••-•••-•--•---•---•-••...---••-••----•••••--•--•-..................-•---•----- �/ --7 Date PermitNo.._._...�--- / -.. Issued........................................................Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifirtttr of Tuntplianrr TIL,,US' IS TO-CFRTIFY, Tha the ndivi ual Sewage Disposal System constructed (X ) or Repaired ( ) by .....------ ------•-•...........:............•------•---.....•---------••......-•--••--.... _......•. .. Installer at. .............••-•- ••--•-•-••--•--•--.....•••----•---•-------�••••-•-----•••--•_... --•-------•---------------------------------•-•-••----------•---•--•--�------•-------••---------•- has been installAd in accordance with the provisions of TITLE j of jhe State Sanitary Codg.. as d7s ribed in the application for Disposal Works Construction Permit No.Z6...... ............... dated__..._. ..__,_..._-� -------•-------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FU CTION SATISFACTORY. �--� DATE.-•-•--.I :!-... _ ............................................ 1. Inspector------.f � .... THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ t ......................� .OF....... `. v5-r:< : No.-. ..�.__... .l FEE........................ Disposal Voekii Toni ion "Prr i# Permission is hereby granted ..... �,�'� . to Construct (� r Re air ( ) n ivld al Sewa Disposal System 5 eet as shown on the application for Disposal Works Construction 'Permit No..(��._-..C�..�. Dated......__._.�..---- ...�......-.. r n i',Q� ................................Board .. Health......................................._ DATE.......... .. =.. ::.:...�=.:... . FORM 1255 A. M. SULKIN. INC.. BOSTON ` ASSESSOR'S MAP NO. PARCEL q 7Y i0 CIA T ON SEWAGE PERMIT NQ. O_ VILLAGE `T uNS-TA LLER'S NAME ADDRESS " B U I L D E R .OR OWNER ol DATE PERMIT ISSUED D A T E COMPLIANCE ISSUED _ f �-- f � __ � ..L - •, �. Yr •t �Y � '� 1 � � , r � .t �' - �:� � _ _ �, - .�, i � Q ._ � - ! q� _ �`� ,. s. � ;,. ,� i r , A' I3EtJGH .N1��Ry�: DESIGN DATA Iv c8 t�1GL� PAM\�-�/ D�+JCL�\tVG -C.i3".O IV. I__O T' Co A T431 STRUCTURE SA ��\ a� -SO.C�d�L�S�I.N"t= DESIGN FLOW 3 0 8flRM�No Cs GR\NI7EFZ c-,t»�gnRr... py SEPTIC TANK USE \QO� Caul_. LEACHING RATES SIDE AREA Z•5 GPD/SF BOTTOM AREA I_OGPD/SF °I LEACHING FACILITY : Co'Cp X -+ 1_ P kl / 3 S'`ONE l Lis= o 12 x-4 3oR AL—UmgT1 2 xTr y8 \ 14 RSV "O ` y (I so Z•-S) +(113 X1.0�= 48� . GRD ` P PLAN REFERENCE= .97 •,, s �� ASSESSORS LOT NO.��'o ZO / �d ,� �/`� PROpOQP y� �T� �� / / �`1`JEDGE; �-� NOTE: I. ALL MATERIALS AND CONSTRUCTION METHODS Lai a � •_ � : � . �� _ � � TO CONFORM WITH COMM. OF MASS. TITLE� J _ _�'-V- -- _ _ "' -_ - r — = �{yy 1-�CrE1�1D ENVIRONMENTAL CODE 1 _ ` -- �1`1---— Hl y0 _ : _ _� �r�'oSE�..1.J�'CER SEFL�I IGE• µ `,� 0pNip? s8.5 OF DAVI . q�y o� . JO yGs C. Gn o PLAN.N TH IN o IS _._ � No. 9,976 " 0. 29874 ao SCALE Li,_.}q TEST PIT NO. TEST PIT .NO. Z F (Alf" vo`ti`� '�EGIS7ERE��gJ4. 5C� ELEV. 1-4 1.Z. ELEV. 35. 1 To P 1 Ex -T rats G a>= SOIL OBSERVATION PITS 'P-S1Lc Z ..0FL^7. I�OA \V DATE OF TEST DEL. Cc ,\9SS 5 � -- ---ice — -- r,nn• —_" l-o�ah�y suC3sc►�. R1=s��-�s of ENGINEERTI ul-Nm tuL 7•NUL.a1V � • 1.000: 3' M1=n. sa�.lD/�FZA�EL TESTS ON AoS, B.O.H.AGENT -1 COt�\�ONr p �LtEXCAVATOR 5.5 ' .� SEP_ .1 I W�3 S-fC.11vi= PERC RATE IN T.P.NO. AT3SFT.-L ZMIN.71N. SANK s.o yi{.(o ti4•z �; ' . - nAEID. saraD l-AY E RS o 4Q MASS k - •' . MED SAt�►D'� � � G � ELLIS & THULIN, INC: -ro LAND.` SURVEYORS AND CIVIL ENGINEERS BOT.TP Z.. . 35 _ CHI M EAST A Z o.W T�1Z. ".k f� 1 n. T te' r WA E N FZ t - r o• E:► CT. .z R• ON. H -� •SYSTEM ~, ::. 4 ��av::,_:� v. - .�_ is--