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HomeMy WebLinkAbout0109 ALLAN ROAD - Health [09 Allan Road Centerville A= 194—001 — 007 QD S M E A D No.2-153LOR UPC 12531 smead-com • Made in USA lR �_ f' �—' a i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis Owner Owner's Name information is required for every Centerville MA 02632 February 27, 2012 page. Cityrrown State Zip Code Date of Inspection 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: C/ key to move your cursor-do not David D. Coughanowr, R.S. use the return Name of Inspector key. Eco-Tech Environmental _ ,&4Q Company Name 43 Triangle Circle Company Address Sandwich MA _ 02563 City/Town State Zip Code 508 364-0894 1328 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 main,tenanceW_on Sim sewage disposal systems. I am a DEP a g p y approved system inspector pursuant to 3'ection 15a340 Title 5(310 CMR 15.000). The system: Q ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority February 27, 2012 rn Inspector's Signature Date The system inspector shalltsubmit 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. "'*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. L�o 3,1 t5ins-11110 Title 5 Official Inspection F sudaco Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts _ -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Allan Road _ Property Address Antonios and Fotini Revis Owner Owner's Name information is Centerville MA 02632 February 27 2012 required for every , page. City/Town State Zip Code Date of Inspection 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity Is made or Implied by a passing determination. 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 Y ( � ) 9 determined lease explain. , P P 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis Owner Owner's Name information is required for every Centerville MA 02632 February 27, 2012 —__ .� page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts U1 - _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis_ Owner owner's Name information is required for every Centerville MA 02632 February 27, 2012 ._ page. Cityfrown State Zip Code Date of Inspection 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 I 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 ❑ ® 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 0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Re_vi_s_ Owner Owner's Name information is required for every Centerville MA 02632 February 27, 2012 page. Cityrrown State Zip Code Date of Inspection 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- 1 0,000g pd. ❑ ® 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. 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis Owner Owner's Name informatifor every on is required Centerville MA 02632 February 27, 2012 __.._... page. Cityrrown 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd 15ins-11110 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 109 Allan Road Property Address Antonios and Fotini Revis Owner Owner's Name information is Centerville MA 02532 February 27, 2012 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage,grinder? ❑ Yes © No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last ears usage d 462 gpd 9 . � y g (9p )): Detail: 2010, 2011 Sump pump? ❑ Yes ® 'No Last date of occupancy: current Date 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: !Sins-11/10 'ritle 5 Official Inspection Form;Subsurface Sewage Disposal System-Pago 7 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Allan Road _ Property Address Antonios and Fotini Rev_is_ Owner Owner's Name information is required for every Centerville _ MA 02632 February 27, 2012 __ ._ _ page. Cityrrown 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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): 15ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts -_- = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.. 109 Allan Road Property Address Antonios and Fotini Re_vis _ Owner Owner's Name information is Centerville MA 02632 Februar 27, 2012 required for every y 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: Age: 12+ years, Certificate of Compliance for Cultex system issued 6/15/1999. (permit#99-353). Were sewage odors detected when arriving at the site? ❑ Yes Q No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron D, 40 PVC. ❑ other,(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 1 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: 8.5 x 5 x 6 - 1000 gallon tank Sludge depth: 4 in t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Re_vis_ Owner Owner's Name information is required for every Centerville MA 02632 February 27, 2012 page. Cityfrown 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 30 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time, but maintenance pumping is recommended within and every 2 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet 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: Date 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis _ Owner Owner's Name information is required for every Centerville MA 02632 February 27, 2012 page. Cityrrown 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): 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 15ins•11r10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis Owner Owners Name information is required for every Centerville MA 02632 February 27, 2012 -_ _ _ _ page. Cityrrown 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 at 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.): D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Some solids in sump. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 Allan Road Property Address Antonios and Fotini Revis Owner Owner's Name information is Centerville MA 02632 February 27, 2012 required for every ry page. Citylrown State Zip Code Date of Inspection D. System Information (coat;) Type: leaching pits number: 1 ❑ leaching chambers number:. � leaching galleries number: 1 ❑ 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.): Soils above leaching gallery and leach pit appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the outlet end of the septic tank and was observed.to pass through in a rapid and unobstructed manner; and could be heard splashing down into the leach pit. An observation hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 6 inches below the top of the .peastone layer. Cesspools (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 ❑ No :Sins•11r10 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 109 Allan Road Property Address _ Antonios and Fotini Revis_ _ Owner Owner's Name information is required for every Centerville _ MA 02632 February 27, 2012 _ page. CitylTown 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.): 15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts r_n Title 5 Official Inspection Foram Subsurface Sewage Disposal System form - Not for Voluntary Assessments � ,.• ' 109 Allan Road Property Address Antonios and Fotini Revis Owner Owner's Name information is Centerville MA 02632 Februar 27, 2012 required for every .. _ y 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 1001 feet. Locate where public water supply enters the building. Check one of the boxes below: Z hand-sketch in the area below ❑ drawing attached separately t C ` Z Q' J LEqc-q 1 I � c � i t5ins•11/10 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 Y 109 Allan Road Property Address Antonios and Fotini Revis_ _ Owner Owner's Name information is required for every Centerville _ __ MA 02632 February 27, 2012 page. Citylrown 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: 20 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: previous inspection report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Previous inspection report indicates high groundwater is more than 20 feet below the surface. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 109 Allan Road _ Property Address Antonios and Fotini_Revis _ Owner Owner's Name information is required for every Centerville _ MA _ 02632 February 27, 2012 page. Citylrown 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 C&)- COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Property Information: MAP 194—PARC 001-007 ` 109 ALLAN ROAD — A 02668 0 0 AICC-UIt I�SL Property Address REVIS, ANTONIOS 0 Od O O Owner's Name 109 ALLAN ROAD Owners Address WEST MA 02668 Q—QWrown State Zip Code J U LY 19, 2007 Date 2. Inspector: JAMES D. SEARS Name of Inspector A & B CANCO Company Name 350 MAIN STREET Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2800 Telephone 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 7 Insp6ot6rs Signature: Date: The system inspector shall submit a copy of this inspection report to the�A-pplrovi g-Authority(Board of Health or DEP) within 30 days of completing this inspection. If the systeA is a s"fiared 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. * This report only describes conditions at the time of insp'eetion and lndeilthe 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. y ,-, Title 5 Official Inspection Form:Subsurface Sewage Disposal System Pagel of 2 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 109 ALLAN ROAD Owner's Address WEST BARNSTABLE• MA 02668 Cityrrown. State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection 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: 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. h for the following statements. If"not determined," Answer yes, no or not determined (Y, N, ND) in the � g 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 I� COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form d . e� Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 109 ALLAN ROAD Owners Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection B) System Conditionally Passes (cont.): NIA ❑ 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: C) Further Evaluation is Required by the Board of Health: NIA 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 3 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 109 ALLAN ROAD Owner's Address WEST BARNSTABLE MA 02668 City/Town State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection the Board of Health cont. : N/A C) Further evaluation is required by (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. El 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: ** d at a DEP certified laborato for coliform bacteria This system passes if the well water analysis, performed ry, indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 4 i COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments " e Subsurface Sewage Disposal System Form B. Certification (cont.) 109 ALLAN ROAD Owner's Address WEST BARNSTABLE MA 02668 Citylrown State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection D) System Failure Criteria Applicable to All Systems: N/A You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Q0 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 0 Liquid depth in leaching is less than 6"below invert or available volume is less than Y2 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 surface water elevation. ® N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] YES No The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd. 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 5 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 City/Town State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection E) N/A-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 ❑ Fj the system is within 400 feet of a surface drinking water supply ❑ the system is within 200 feet of a tributary to a surface drinking water supply ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered`yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 6 I _ COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityfrown State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No 0 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, including the SAS, located on site? 0 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: 0 0 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 7 COMMONWEALTH OF MASSACHUSETTS . d Title 5 Official Inspection Form a ye�,er Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 City/Town State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?[if yes separate inspection is required] ❑ Yes ® No Laundry system inspected? Yes No Seasonaluse? Yes No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ❑ Yes M No Last date of occupancy: N/A Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 8 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection General Information Pumping Records: Source of Information: 2006 Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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) Tight tank.Attach a copy of the DEP approval. ® Other(describe): Approximate age of all components, date installed (if known) and source of information: AROUND 1985, NEW LEACHING 1999 PERMIT#99-353. Were sewage odors detected when arriving at the site? ❑ Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 9 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNST ABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection locate on site plan): ✓ Building Sewer( p ) 9 Depth below grade: 8" feet Material of construction: ❑ cast iron 0 40 PVC other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ✓ ;o Depth below grade: feet Material of construction: ❑� concrete Elmetal ❑ 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: 1500-GALLON PRE CAST Sludge depth: V Distance from top of sludge to bottom of outlet tee or baffle 29" Scum Thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? ASBUILT—TAPE—SLUDGE JUDGE. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 10 ICI COMMONWEALTH OF MASSACHUSETTS • r Title 5. Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL, TANK & COVER AT 10". OUTLET BAFFLE AND TEE. NO SIGN OF LEAKAGE OR OVER LOADING. Grease Trap (locate on site plan): N/A Depth below grade: feet 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 Date 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): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ® fiberglass polyethylene ® other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of II COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection Tight or Holding Tank(cont.) 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 a copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): D-BOX IS 16" X 16" — 18" BELOW GRADE, ONE IN — ONE OUT. BOX IS CLEAN & SOLID, NO SIGN OF OVER LOADING OR SOLID CARRY OVER. Pump Chamber(locate on site plan): N/A Pumps in working order: ❑ Yes ® No Alarms in working order: ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 12 COMMONWEALTH OF MASSACHUSETTS i � d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: Type: ® leaching pits number: 1 © leaching chambers number: 4 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.): OLD LEACHING IS ONE (1) 1000-GALLON PRECAST PIT, PIT PIPED TO TANS. NEWER LEACHING PIPED FROM D-BOX IS FOUR COLTEXES. CAMERA LEACHING, NO SIGN OF OVER LOADING OR SOLID CARRY OVER. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 13 COMMONWEALTH OF MASSACHUSETTS r Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name J U LY 19, 2007 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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 No Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 14 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owners Name JULY 19, 2007 Date of inspection 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. - �o F1 � 0 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 • COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 109 ALLAN ROAD Property Address WEST BARNSTABLE MA 02668 Cityrrown State Zip Code REVIS, ANTONIOS Owner's Name JULY 19, 2007 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to NO ground water: 20 Please indicate all methods used to determine the high ground water elevation: QObtained from system design plans on record If checked,date of design plan reviewed: 1999 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: 20' NO WATER B.O.H. 1999. LOT HIGH. A,;F7-&114 ,LaA f4 � Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 �V �' JA/ y� Town of Barnstable �Op IME 1pk Regulatory Services ,Axr,srAsie Thomas F. Geiler,Director vQ MASS. vA,�1639n. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. l TOWN OF BARNSTABLE LOCATION 199 9 A 4 44 A 2 SEWAGE# VILLAGE �3 ' ►-C ASSESSOR'S MAP&PARCEL R49TRS NAME&PHONE NO. SEPTIC TANK CAPACITY -SS A /f C- /A✓ � 'C ��� LEACHING FACILITY:(type) (size) NO,OF BEDROOMS OWNER / IV .S PERNHT DATE: / ' �%'" 0 / COMPLIANCE DATE: Separation Distance Between the:. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY cr ol A)r r F CO'%E\10\�'� aI,TH OF MASSACHI SETTS EXECUTIVE OFFICE OF E:\'vIRONME\TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE XV NTER STREET. BOSTON DLA 0210S (61:) 292-550v TRUDY CONE Secreta-n ARGEO PALL CELLUCCI DAVID B. STRrHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 109 Allen R d..',= 0 Name of owner David. Mitchell _Alddress of Owner: Date of Inspection: W. Barnstable , 1V11� Name of Inspector:(Please Print)WM. E . Robinson Sr . I am a DEP approved system!inspector rsuant to Section 15.340 of Title 5(310 CNIR 15.000) Company Name: Wm. E . Robinson eptic Service MaBingAddress: PO Box T089, Centerville , MA Telephone Number: 7 7 —R 7 7 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-sitege disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails C� Inspector's Signature: ZV l, ` Date: `" 6 The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS R 1 8 1999 s ti revised 9/2/98 Page IofII `� Pr:rred on Recycled Paper . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' t PART A CERTIFICATION (continued) -ropertyAddress: 109 Allen Rd.. , W. Barnstable , MA Jwrw: David. Mitchell Date of Inspection: G /4 s '7 0 INSPECTION SUMMARY: Check 0 B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMM TS; B. SYST M CONDITIONALLY PASSES: ' 0 e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon co pletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 3 e v revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 109 Allen Rd.. , W. Barnstable , NIA Owner: David. Mitchell Date of Inspection:G-141-g 7 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 1 OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued) Property Address: 109 Allen Rd. , W. Barnstable , MA Owner: David. Mitchell Date of Inspection: 4.-/L -g D. YSTEIM FAILS: You us indicate either "Yes" or "No" .to each of the following: 1-have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. RGE SYSTEM FAILS: You ust indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offic of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 109 Allen R.d.. , W. Barnstable , MA Owner: David, Mitchell Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No t_,// _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ; As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _t// _ All system components, excluding the Soil Absorption System, have been located on the site. ✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: v/ _ Existing information. For example, Plan at B.O.H. ✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / (15.302(3)(b)] The facility owner (and occupants,if differeru from owner) were provided with information on the proper maintanaarii-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Irop"Address: 109 Allen Rd. , W. Barnstable., MA Owner: David. Mitchell Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:�g.p.d./bedroom. Number of bedrooms (design):—y— Number of bedrooms (actual): Total DESIGN flow U4,so Number of current residents:41 Garbage grinder(yes or no):/i-6 Laundry(separate system) (yes or noA,6; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):�i O 1998 236, 000 gal. Water meter readings, if available (last two year's usage(gpd): Sump Pump(yes or no)R- 4) a, !94, uuu gal. Last date of occupancy: ` /e-9 COMMERCIALIINDUSTRIAL: Type f establishment: Design flow: gpd ( Based on 15.203) Basis o desigri flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-so 'tary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last do of occupancy: OTHE :(Describe) Last d e of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) 4- If yes, volume pumped: 6 e-O gallons Reason for pumping: NLY -4 TYPE OVYSTEM L,/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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DER Approval Other r� APPROXIMATE AGE of all components, date installed(if known)and source of information: Al! a" r—�•,tf r� Sewage odors detected when arriving at the site: (yes or no)/L o revised 9/2/96 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cort roved) 'roperty address: 109 Allen Rd.. , W. Barnstable , MA ° Owner: David Mitchell Date of Inspection: BU IN SEWER: (loca on site plan) Depth elow grade:_ Materia of construction:_cast iron_40 PVC_other(explain) Distan a from private water supply well or suction line Diame er Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) tt Depth below grade: Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or.baffle: Scum thickness: 0 t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ,2 I How dimensions were determined: 6 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles , depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) I i_� ! d ex /` ✓(e J,A Y r 15 e) 4 g l;Z 42 60 c c- GR SE TRAP: (local on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimen ions: Scum ickness: Distan a from top of scum to top of outlet tee or baffle: Distan a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Com ants: (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage,etc.) revised 9/2/98 Page 7of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddress; 109 Allen Rd. , W. Barnstable ; MA . OWf1er: David. Mitchell Date of Inspection: < 'no n T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iloca a on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Oimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alarm evel: Alarm in working order: Yes_ No Date o previous pumping: Comm nts: (condi on of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of le kage into or out of box, etc.) - PUM CHAMBER:_ (locat on site plan) Pump in working order: (Yes or No) Alar in working order (Yes or No) Com ents: (not condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4opertyAddress: 109 Allen Rd.. , W. Barnstable , MA Owner: David. Mitchell Date of Inspection: 6 oC g I SOIL ABSORPTION SYSTEM(SAS): / (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of onding, damp soli, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) Number and configuration: v✓ )i Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: - Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Co ants: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI _ e (locat on site plan) Matef ais of construction: Dimensions: DeptP of solids: Com ants: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revise:; 9/2;9c8 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "+ PART C SYSTEM INFORMATION(continued) -,oWtyAddress: 109 Allen Rd.. , W. Barnstable , MA lwner: David. Mitchell Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 1.00' (Locate where public water supply comes into house) FS 3 P � 1 l w ~ l revised 9/2/98 Page 10of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 109 Allen Rd.. , W. Barnstable , MA Owner: David.. Mi�c �1. Date of Inspection: C,l NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells x Estimated Depth to Groundwaterq���Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record %bserved Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers --,,-/—Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) i revised 9/2/98 Page ttof11 ` TOWN OF BARNSTABLE LOCATION J©`� A 1 ; p� (� SEWAGE # VILLAGE �.1 eta fr�S-1'e�►�j l�, ASSESSOR'S MAP & LOT '0 1 7 INSTALLER'S NAME&PHONE NO. InI Lr 06;)5or) SEPTIC TANK CAPACITY —..'(D(.c LEACHING FACILITY: (type) re ye j (size) NO.OF BEDROOMS 3 BUILDER OR OWNER Z%4r-/1 e 1 PERMITDATE: ��q Lq� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by G 0 A No. s Fee $J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS F ZippYicatton for Mfigpaal *pgtem Conwtructton Permit Application for a Permit to Construct( )Repair(K )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 109 AllAn Rd.. ,W.Barnstable , MA David. Mitchell Assessor's Map/ParcelIgX �y 42 8_ 5 6 2 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wrfl. E. Robinson Septic Service PO Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) New 'leach system— D�-,box and. 4 cultex leach chambers . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Env' nment Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d o alth / Signed l Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued iY / No. - � Fee _$50 .. THE COMMONWEALTH OF MASSACHUSETTS Entered in combuter. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,.MASSACHUSETTS es 01pprication for Migpoga[ *pgtem ctCongtruction Permit Application for a Permit to Construct( )Repair(X )Upgrade'( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. %Owner's Name,Address and Tel.No. 109 AllAn Rd . ,W.Barnstable , MA David Mithhell Assessor'sMap/Pazcel Qpl, {307 428-7562 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Rm. E. Robinson Septic Service PO Box 1089, Centerville, MA Type of Building: „ Dwelling ,,i -No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons f Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �i. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) New leach system- DeboX and. 4 CillteX < leach chambers . Date last inspected: '+ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of;the Env` nment Code and not to place the system in operation%until a Certifi- cate of Compliance has been issued y this Bo lth / }�Signed Date 1! `_ / Application Approved by ! Date 10�aloo eo Application Disapproved'for the following reasons y` i Permit No. — Date Issued o THE COMMONWEALTH OF MASSACHUSETTS Mitchell BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned )by Wm• E. Robinson Septic Service at 109 Allen Rd . , W. Barnstable, MA has__been construe ed in accordan with the p visio of Title 5 and the for Disposal System Construction Permit No. '* dated i�m. Robinson Sr. Installer Designer ki W A q The issuance of this pe t shall be c'nstrued as a guarantee that the sy ' i�l function as designed. �Owyt Date � _ �� Inspector - No. � �G✓�--------------- Fee $5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mitchell Migogal *pgtem Congtruction Permit Permission is hereby gr ted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at T109 Allen Rd . , W. Barnstable , MA and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. , Provided:Construction must be completed within three years of the date of this � Date: ��""` �'" y Approved byG� / F 6 _ dr6 17 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, ,d �Zy;(cfd �— •Sd-Z,hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at Al I Zl- ,2,,, , meets all of the following criteria: •L,Zn"e failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. here are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system (•There is no increase in flow and/or change in use proposed Ls./There are no variances requested or needed. e bottom of the proposed leaching facility will not be located less than five feet above the ma..dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor me when applicable] 4'_ If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the ma.-imum adjusted groundwater table elevation, Please complete the following: A) .Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation =the MAX High G.W. Adjustment . DIFFERENCE BETWEEN A and B SIGNED DATE: Z"/P-V V (Sketch proposed plan of system on back]. q:health folder:cet `. JL � i rza 7Vl • r -50 Q s No....................... FRim.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... �...............OF......... . _ .............................. Appliration for Utspmal Warks Tonstrurtinn Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage, Disposal System at: ............ .u-.........�D-- .............----------............... .....L®T------- .•--------- ------------......------............----- CIE ocat •Addres or Lot No. Owner a Installer� Address Q Type of Building Size ...Sq. feet Dwelling—No. of Bedrooms___._.__. ______________________________Expansion Attic (✓f Garbage Grinder (14, aOther—Type of Building ................... No. of persons-........................... Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------- ----------------------•-----......------------------------------------------------------...---•-•-•-----•-•-•-•...--------•- W Design Flow.........•`Tc-�...........................gallons per person er day. Total daily flow-----------33_®..__.___._...........gallons. Wc Septic Tank—Liquid capa ityi.)baO.gallons Length_.__�'��`_ Width__Lf_.`'►°.. Diameter._�I/ f�..._. Depth.5_ �-T_ _.. x Disposal Trench—No... _____.___ Width.................... Total Length.................... Total leaching area-__--_---•.__-------sq. ft. Seepage Pit No.........I..._....... Diameter.......0......... Depth below inlet......t......... Total leaching area.A 6' .....sq. ft. Z Other Distribution box (vej Dosing tank ( ) a Percolation Test Results Performed by...........10M..� �r•__- Qw®�Y--_- .•----_-----_ Date....! '��_� ................. N�tif Test Pit No. 1................minutes per inch Depth of Test Pit..____._1 �.__ Depth to ground water...__1._F f� ..___.Test Pit No. 2...4_a-...minutes per inch Depth of Test Pit....... Depth to ground water... a ---------•--- -4 -----.-•-•- --------•--------------------•------------------------------------------------------------------------------------ O Description of Soil 6- t ,E7, M. ¢ r----------------------------------------------------- 4"._..__...-!"-!'�'' �f .�. -•------------------------------ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ._.. .----•-. -•--- •-•..................... A ent: T e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e ovisions of L .U 5 o State Sanitary Code— The undersigned further agrees not to place t sy tem in o tion u 1 a e t ompliance has been 'ssuedd by the board of health. Signed...... !!'_...... I..... ,�? ........... :. L to PP1' ti pproved BY------------ ------------ .............................................................. --• .. 'Z-k5--.._..._ ate plication Disapproved for th f 11owing reasons---------------••-•---------•-•---•------------------•-•---•-............----•----- •--------................... Date Permit No.__q...—' _ -- . Issued------------- ............................— ------- Date r No.---g..........` j Fms............................_ THE COMMONWEALTH OF MASSACHUSETTS --�—� BOARD OF HEALTH I ...._..... .4�}:±�................0F..........1 ....°.. .... 4 1_ Appliration for Eli,> pawl Warks Tomitrurtinn ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ...:........C-!/�kcLA4.......-.R.�.................................................. .....Ln_-t__........................._------............................................. Location-Address or Lot No. Owner Addr ........l�...........0-0s2............................................... . §.. kCt�� { { .S d -Installer Address Type of Building Size Lot...46... feet V Attic x E Dwelling—No. of Bedrooms......... ________________ ______________ p (sartage Grinder (� P4 Other—Type of Building -----!�/-A-_--_---_- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------••---------------•-----••-•-•------------•-•--------•-•-----------------••-----------------------------------.._..-•--------•----------------- Design Flow........5.S...........................gallons per person per day. Total daily flow-------.... gallons. WSeptic Tank—Liquid capacity47 o.Q.gallons Length.$._-�._:.. Width.+_._.j.P.._ Diameter... Depth_ i. ,. x Disposal Trench—No. ..[�A.......... Width.................... Total Length.................... Total leachln area....................sq. ft. Seepage Pit No........I_........... Diameter___...I ........ Depth below inlet...... .�......... Total leaching area.;p. .....sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by..........IQI'4.........CO3&.6 y......................... Date.... Test Pit No. 1---L.r`_.-.-....minutes per inch Depth of Test Pit........A..._.. Depth to ground water.. ...... PLI Test Pit No. 2_4.,'� __..minutes per inch Depth of Test Pit...... !___.. Depth to ground water... _ --_ j ---------------•---•-•---------------------------------------------------------------- •---------- -- ---------- O Description of Soil...d=�.------�_: ? 1! r..'S.��G�, eL.-•---•-•-•---------------- i V Nature of Repairs or Alterations—Answer when applicable............................................................................................... •-•-----•-----------•-------•-----...---•--•-------------------------------•--------........-----------.....-•--------------------------------•------------------•----•------------------...........---- Agr ent: e undersigned agrees to install the aforedescribed--Individual Sewage Disposal System in accordance with he ovisions of T TLE 5 o e State Sanitary Code—The undersigned further agrees not to place e system in o tion u a e i cat ompliance has bee issued by the board of health. igV- -. : ` 1t_1,� "'-r""..._.. jDate 1' tiroved BP PP Y - -- -----------------•------------------....----.------ ----•-• plieation Disapproved for the f llowing reasons: - - .......-•-•-•-•--------------•---------------•--•------------------------....-•-----------•----------..•.._......_....---•-----------------------••----------------------------------------------------•- Date Permit ......................_.... Issued------..... --- `xD fl ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtif irab of Tumplianre THIS IS Tio,, C RTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................. ... .v ......._..... Install- at................. - #-- --..... ` --------- 1 r�. . has been installed in accordance'with the provisions of TITLE 5 of The State Sanitary C de as described in the application for Disposal Works Construction Permit No:._._.. :.__..._.__ dated_.�_:.�. ......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARJkNTEE THAT THE SYSTEM WILL SUNCTION SATISFACTORY. DATE..... Le' ----- Inspector.. \\ 1 } THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEE........................ Disposal Marko 01,.unotrnrtivit "permit Permission is hereby granted-�''j`7';--------&.......Oy'<-------------------------------------------------------------------------------------------- to Const uctx( or Repair ( ) an Individual Sewage Disposal System ......................................... ................................... at No.__.L71........as shown-on-the application for Disposal Works Works Construction Permit P tAeQ .... Dated.0 .._ .p_ 5---------------- Board of Health / DATES -f ---•----•----•--•------------ FORM 1255 . M. SULKIN, INC., BOSTON — - , .f 2U��� 77 (Zl � s _ LAIO +r liff say 9a --- F t t¢ak L 81 ,40 15. C + — } ' 17. �• •z:+'p Q� , - �- �•'— � fir �--- __ �.__��- �I sy1 i .ft' 'r"'�" .1 �\ \ ter^ ry oz 4� �dew µ ✓- ` Y12! R 40 x ` I n T L 0 T q II-CMERT c B. EE_Dr-IOGE N a rt , t •r C tz' f LEGEND }¢ .. fnr �� CERTIFIED PL. PLAN EXlSTI.NO SPOT ELEVATION Ox0 OFr 5,-XISTI.N0. CONTOUR --- 0 — — — �s /o� Assgo LOT p FI41$HED `POT ° EVATION ' �' w > f a V i ivs�l cS HLL'eftl G �L�IY (^�R '✓/L F1NI=SH�D 'CONTOUR 0 A. `.I o MORSE a, APPROVED , BOARD OF HEALTH =>� ANO.10951 f Ap ` pn AGENTics ,� ,CALF= l ff-4y` /DATE , i. REDGE' ENGINEERING CO. IN M`c k" s CLIENT I CERTIFY THAT THE PROPOSED cis EGISTERE REGISTERED o C VI A JOB N0. $4' 7 BUILDING SHOWN ON THIS PLAN I L LAND �, CONFORIMS TO THE ZONING LAWS ' ENGINEER SURVEYOR DR.BY: � ' OF BARNSTABLE , M®s ?'I M A I N STREET "" CH:BY: � �� y y $ „ HYA'3JN 1 S� MASS Rµ � - SHEET OF Z TE REG. LAN® SURVEYOR t' �s.7-- 17�7 iv, IW f 13. 7 0 VIE�r "5 •ro*� 7. 7'0 4JTA 1>,E. VA. . 49PAF APC7 7 'Comc NA6 5�'r- 'IR01V 'c o V.-now, Sq,4 I-Z- a,= u Sc--o A>*l Vl-- AIA y FT., co YEfd N.O. CLEAN -5'A DoPWD L,-Yel- 2 -AY- 'PV e. PI PCZ41Y jN.PJr GAL. • WASHED STONE V4 -r I PArA PF SEPTIC rANX WASNFP STONE nr, 04 0 Os 0 7- P170R 415VLIIV A C-,-ry Iwo IJYMCA7 Z4E.V-47'1zW- S elg P P/lAm- 1,VVZA7- AT OZ114DINC, 159,2- Fr Owg:7AU/1-A 77)0��) f7. APIAM. INLETSA-PrIC r-4,VK /55-6 fT oV7j-&r SEPTIC 7ANN 'Fr GROUNDPteATER TABLE lAtLacr 4C)ll5?-R"l6i1r-"0JV BOX /'S 0VriZ7PJ 57W4&9r/0)Y BOX Y P7 lh'4,Cr JrACql)VCr JcV7- Fr 'V4%� JO/T L EA CHI w 01HArm-110N. A 4 -SCALEY4' -0 D 16N R5 CX17'E-NIA mv)w49zR Of BED mooAfs 3 F7- 3 v a,44.1pAy SOIL. .74657- A/ SOIL 7r-S7-,*2 AIUMAEA- 0.1c'ZffACXlN6 0/-4EX04- oi—AwL 4r4V /63 PA 0 r 5 0 1 J- TEST /t/'AqS S/DjF 4eACHjA,,o .4vERpjr. /7670 S(p, �-;r -rjy&ssrx> ArPm CO'��OAI V21" 0- A 0- 2_ 1 "AltfhO- XESUA.7S PVI iw lm.: .Sdi3SdrG.. P&it COL A r10,PV 4RA 7Ar jO AI/AV/NCH 17-07AL ZZACH111'Cr AREA -33- so. -7. jW Z Z"A MjV.1hVr-'V 2-0 AREA Stp. -7 Z- A I-LAN i;�vll 4-->L 0 s ALBERT E7/,�/7--C- P, _ Z 7T X A. r,4 E- Nit (77e MORSE V) om 5&W, NO.10951 0 77�* -7tZ MAIN -9-r, HyAAi)v.,-j, AYA.5-5, 1-FA17 Ro vvp kv,4 reX AWCoV.4oV7-Z�',4e—,=Z> EL C3 4GM0lJA0',0 AV-47Zr.V AT 46,LMI'l . ..... JOB AOV- -LOCATION �J _ / �°� SEWAGE PERMIT NO.' ' VILLAGE a t� INSTALLER'S NAME&ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED h/es DATE COMPLIANCE ISSUED < 5 S► p�-2.. v i �- � � � ��