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HomeMy WebLinkAbout0188 ANSEL HOWLAND ROAD - Health 188 ANSEL HOWLAND ROAD r Centerville A = 171 — 266 /l� RECYCIEp UPC'12643 0 �� Nomtom .53LOR HASTINGS,MFt r ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v' 188 Ansel Howland Rd Property Address Christie Short Owner �vvu required for every ner's Name information is /Centerville Ma 02632 7/18/2012 page. CitylTown 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, I use only the tab 1. Inspector: t key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. Capewide Enterprises ICI Company Name 153 Commercial St. Alf Company Address Mashpee Ma 02649 Cityrrown State Zip Code 508-477-8877 SI 4522 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 ' 7/18/2012 r'�> Inspector's Signature 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. ****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. sposal d5ins•11/10 Tilley Offidal Inspe F :Subsurface Sewage Di System•Page 1 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 188 Ansel Howland Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. The system was found to be in good working condition 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): 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 �M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 page. City/Town 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 page. City(Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) I 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•11/10 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 4 °M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 page. City/Town 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- 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 ❑ ❑ 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•11/10 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 ;M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd 1 � t5ins-11/10 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 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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): t5ins•1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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: original system 1981 I Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof 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: 1000 gallons Sludge depth: 6" t5ins•11/10 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 wM 188 Ansel Howland Rd Property Address Christie Short Owner Owner''§Name information is required for every Centerville Ma 02632 7/18/2012 page. City/Town 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 3' 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 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet invert, tank was not leaking and was structurally sound. 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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): 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•11/10 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 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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.): Distribution box was in good condition, no rot. Water level was even with outlet, no sign of past hydraulic overloading. 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: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leach pit was video inspected and found to be dry with a stain line approx 2.5' from bottom. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 page. City/Town 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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 �eAJ7 P< 3 I FJoO -I Z° D 30 A-Z ('0© Q-Z Z g i Ara ey t5ins•11r10 Title 5 Dfficial 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 °M 188 Ansel Howland Rd Property Address P Y Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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: 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: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•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 ;M 188 Ansel Howland Rd Property Address Christie Short Owner Owner's Name information is required for every Centerville Ma 02632 7/18/2012 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 188 Ansel Howland Road /67 _�G Centerville. MA 02632 Owner's Name: Estate ofRuth Woodward Owner's Address: `O Date of Inspection: March 23, 2007 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing.Address: P.O.Box 49 Osterville MA 02655-0049 Telephone Number: (508)862-9400 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:. ✓ Passes ;n Conditionally Passes ds Further Evaluation by the Local Approving Authority C0 ai 01 Inspector's Signature: Date: March 27 2007 The system inspector sha\subicopy 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 188 Ansel Howland Road Centerville. MA Owner: Estate of Ruth Woodward Date of Inspection: March 23 2007 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: 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: 2 Page 3 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate of Ruth Woodward Date of Inspection: March 23, 2007 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 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 aseptic 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 coliforin 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. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS AL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate of Ruth Woodward Date of Inspection: March 23 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due.to an overloaded or-clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year 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 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 System: To be considered a large system the system must serve a facility with a design now 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 _ 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 it 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate ofRuth Woodward Date of Inspection: March 23, 2007 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health: ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310.CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 188 Ansel Howland Road Centerville. MA _ Owner: Estate ORuth.Woodward Date of Inspection:. March 23, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable Sump Pump(yes or no): No. Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Pumped in 2006-per fmnily member 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 ✓ 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: Installed on 11112181 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate of Ruth Woodward Date of Inspection: March 23, 2007 BUILDING SEWER(locate.on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ 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 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" 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: 10" How were dimensions determined: Measuring stick Comments(.on pumping recom nendations,inlet and outlet tee or baffle condition,structural integrity,.liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present The liquid level was even with the outlet invert. There did not appear to be any signs.of leakage. GREASE TRAP: None (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 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate of Ruth Woodward Date of Inspection: March 23, 2007 TIGHT or HOLDING TANK: None (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: Qallons 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 broken down The D-Box was replaced after inspection see permit 2007-105 PUMP CHAMBER: None (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.): 8 f Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate of Ruth Woodward Date of Inspection: March 23, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'0000 gal.) 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 leach 12it had 6"of liquid on the bottom The scum line was approximately 2'up from the bottom. There did not appear to be any signs of failure The cover was 24"below grade The bottom to grade was 8.5' CESSPOOLS: None (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.): PRIVY: None .(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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 188 Ansel Howland Road Centerville: AM Owner: Estate of Ruth Woodward Date of Inspection: March 23. 2007 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. G Q - E3 � 5Y 20 3 a Go a$ 3 �y ag 10 I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 188 Ansel Howland Road Centerville, MA Owner: Estate ofRuth Woodward Date of Inspection: March 23, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water . 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 30'+/-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has.been inspected and passed as.of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. II 11 No. Q� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for �Diopozaf �&pgtem Con5trurtton Permit Application for a Permit to Construct( ) Repair(►upgrade( ) Abandon( ) ❑Complete System �Individual Components Location Address or Lot No./16 T ,&yG %'UC�I�i t 4 /, Owner's Name,Address and Tel.No. Assessor'sMap/Parcel i7I nY qvJeG ��Y Installer's Name,Address,and Tel.No. COV5 A. Designer's Name,Address and Tel.No. sod'- /�� • y�� yr�rn.`rrjriil �A_� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo rd of Health. l lea, Signed Date :`ha lv Application Approved by Date c Application Disapproved by: Date for the following reasons Permit No. ZQd (0 Date Issued ,No. Fee OG THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,- PUBLIC HEALTH DIVISION --TOWN OF'BARNSTABLE, MASSACHUSETTS Yes Zipplication for Migpogal *pgtem Cougtruction Permit Application for a Permit to Construct O Repair pVKUpgrade O Abandon O ❑ Complete System ©Individual Components Location Address or Lot No.,/ c Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �7� pl tvlo / V i Z,I f +�pn Cj I� fir.✓l!Y �� Installer's Name,Address,and Tel.��//No.60, rY�p f F �r��. Designer's Name,Address and Tel.No Type of Building: {�, Dwelling No.of Bedrooms N Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -1 /wet Date last inspected: i 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date ✓mil Z ,�y .�. Applic;41.ationApproved by Date -3/ali/° - Applicatiorr Disapproved by: Date for the following reasons *Permit No. 2 Q0 (o Date Issued 3. °7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that.the On-site Sewage Disposal System Constructed ( ) Repaired ( /Upgraded ( ) Abandoned( )by k-, at �y/1 rL /4cJ 4-1, 1',,,�.,,�.i/� has been constructed in accordance with the provisions of Title and the for Disposal System Construction Permit No. 2 U� "� �� dated 3/2) Installer i �F1r" �U'o lAe �m 1 Designer #bedrooms I1A Approved design flow I Ll I t gpd The issuance of this permit shall not be construed as a guarantee that the syste will func 'on a e�'e,. Date 4/ ) Inspector\�� --------------------------------------------- No. U 7 — Fee 1�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS ligogal *pgtem Con Aruction Permit Permission is hereby granted to Construct ( ,, rr) Repair ( Upgrade ( ) Abandon ( ) System located at / �� 9wfe C �s6ne,l P �r.� ��r✓.��� 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 th s permit. Date 3 / ? Approved b �J t TOWN OF BARNSTABLE LOCATION \SrG- A,s,, \k ,G( rA. SEWAGE# 2C07- %OC ('VILLAGE C-C4 rv.Ike. ASSESSOR'S MAP&PARCEL S �' INSTALLERS NAME&PHONE NO. rka\a CaAg � .ft Sag- 771-'13g9 SEPTIC TANK CAPACITY WO:) i LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER V1 P�', rw PERMIT DATE: -27-tl7 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 At-Sq A2` �a0 A3- grLi EF 53- 'LSD 2 •O G G T WN OF BARNSTABLE ^ LOCATION o O /'�ns� ���'� � SEWAGE # VMLAGE an tGwt t ASSESSOR'S MAP & LOT/7 / 966 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �u LEACHING FACILrN: (type) �' t G��' (size) UW NO.OF BEDROOMS BUILDER OR OWNER (IJ M2 lea,-< PERMITDATE: 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 facili ) Feet Furnished by ritS �'Fo'1 FD/� 3 a3 0� I� aFlck 02 � 16Y ao a. 6o as 3 �Y as LIO CAT ION ( - --- SEWAGE PERMIT NO. VILLAGE Centerville, MA. INSTA LLER'S NAME i ADDRESS Robert Our Harwich AMA. 9UIL0ER OR OWNER Alan E. Small, Inc. Box 536 Cen .Prvi 1 1 e¢ MA. GATE PERMIT ISSUED 10/26/81 DAT E COMPLIANCE ISSUED J�J�Z/81 ti E ol ;,or xO........A: yC h'ER.............. ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® ADF HEALTH i................O F.. -----------.--•------------------•---- Appliration for Biipnsal Works Tonstrn.rtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syat . ._... .. ............... -• ......... ......-•----------•----------------------- Location-A dress ��ot No. ...... ............... .... ................................................................ ..................... �.....(.� .-......_...--•---............................. �jO�wner �iddress a .._.d+CTS '• .......................................... .................. "�r'�.'"" Installer Address U Type of Building Size Lot_.l ,�l ----Sq. feet Dwelling—No. of Bedrooms..._.___................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No.' of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtur W Design Flow.......C/.Z...�--------------------gallons per person per day. Total daily flow..........ta...—S.-t..._............gallons. WSeptic Tank—Liquid'capacity/ �lgallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.49�!r."_.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' -•••------••-----------••-•--------------------•-----------..........------............_..................................................................... ODescription of Soil......................................................................................................................................................................... x W ---•--------------------------------------•-------------•--------...------------------------.-----------------------------------------------------------•-•-------•-------------------._....--------•- U 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 Ii'1''p of the State Sanitary Code— The undersign further agrees not to place the system in operation until a Certificate of Compliance has been i ue by thud f health. OW2 / Sied �.►....-•--•--•----------------------•--••----.---•- ..- ..- D Application Approved l° � Date Application Disapp v or t e following reasons:................................................................................................................ ................................ -----------•-•-------------------------••--- --•-------•--- Date PermitNo......................................................... Issued_...................................'.................... Date No....... .' Fzes........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ . ..............................OF......................................-•---..._...............----....................... , pphration for Elispoii al Workii Tonstratr#ion 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................__......_......................- .... --•-------•---------•---••--------- ------.---------------------------•-------------------.---------------.--------------------------- Location-Address or Lot No. ......................----•-....._ -- .......----••-••-.......-•-••-.............................. ••.......• --•.....••------•---•--••-•......_......•--••--------•••••......••...................... Owner Address W Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ct, Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__--------_.-__- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a.1 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--___-_-__--_-_-___--_-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •----•-••--------------------•----....._....-------•--.............------------.._..•---•-••...........-•-•-----------------------•-•--••••......••----.----- 0 Description of Soil........................................................................................................................................................................ x rJ •-•----------•----•---------•------------------------------------------------•----...------•-••-•----------•---•---•----•-•---...•-••--....--•---------•--•----••--------------•---•---•--•---•--------. W ----•-----------------------•-------•-•-----•-------------------------------•----•-----------------------------------------------•-----•--...--•---•-------------------•••-•--------•------....--.-•---- UNature 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 TITL' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si9ded....................... ----------------- e ApplicationApproved --------•-----------------------•--.....---------...---......_--•----- Date Application Disapprover t e following reasons------------------------------------------------------••----•-------------------•-•-------• ----•-------..._. ........................... ........................•--------------------------------------.....-----------••---•-----•------•----•-----••---------------------•--....----- Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.............................................. Tnrtifiratr of (wontpliFanrr T IS S T CERTIFY, That the Individual Sewage Disposal System constructed ( )4'or Repaired ( ) � .by.... ................A •. . ................. Inst er - r* . at ° r -+' ... .... - ------------------------ has been installed in accordance with the provisions of TITLE 5 of The State Sani y Code as escribed in the application for Disposal Works Construction Permit No.. 1-r.,t71....._.t/-._...._... �ted................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... .l j /.. Lr�/ Inspector......... 1.1 1. ............................................................ ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ............................................OF..................................................................................... Mop , I rkii 109111notra ion "truth Permission is hereby granted .----- . .... .. G.. ................ -- •--•----------•-----••--------••-----•..................................•-•- to Construct 00)�o_ Re i+ n I 'dual .wa :e D*,.o System atNo. T-�------ ....... -- --•----- ---------------••-------•----•-•-----•--•-------•---------------••-•----••----•-- Street as shown on the application for Disposal Works Construction Permit No.. ...... .... Dated.......... © ---------- / Board of Health �C ' DATE.....................................1_./..1-.: /...-•------------ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS M-1 S14;K1 t>Q,TA SI UG L-6 1=bAM L ' 3 T5MDZOaAA, : ham' . �-tOu)LAf b 1 . b,l1t t_�( t=l,..cW a 110 +� 3 s 33d G•�D ,.H ��•p0 6.P.v.1. t USA•' toOG� 6a�. _ y t c� �15Po5AL ;:PtT USE l oao c Lu_,• �•Z ,7-vewAL.L AZGA = 15,0 S.F. " . .:. ISo s� 2.S • 3�S �.>I?�: 37 t �ov�vDµ 33 gD OT CEO ss=, ;x t .o s' So S-F v. N.. TOTAL _DE__sl6W =425 G.P.D.; i 2 /'Roes 'o 1_To "D W t_�( F L.ow t 6. F•'D. <'° o rAvK 3'3D . . � i O V[:_VGDLQTlOLJ tZl.T•� : 1 W ImI Lf oz UVA. --- O 444 4•I`7 Of 45. ALAA. r' 44 'TI`5T FG 4- Y lint• 5 A wt � • Q��e 1 oec� iuv. '�+ 2�L -sox g&.(m Septic I c „? . I►N T-A W W. Sp�1A`� loop S5 4 tNK tW •t ' Grz,�,�t„ GAL. Sg•z s$-.4 :• c PIT �! S� . i �.p 1e.0• 5 C.EQTlF1ECU pLC'*" PL:Ata Przo7=-t L-fa _ { LOCATIO" I GGtZTtF°q THAT T44r-- I— 04; �T1oQ s"owU t-tC.j:t=o1.3 ,CC�Pt_�!S W ITI'� TNT,: �jID�..LI►-�Ez t A►lb SETe.AGIG ;:C,QuiCeAAE-"T4 O T►�� r, 4' O 4V Q OT= l�ATG TC u`(E I1,JG_ ` tZCGlStz:tZED LA1.1G 5V2VGYoeSc ''j THIS DLAI-1 IS UOT ZASCOA OSTEw1LLr-- o MASS. '� G TNL FC•'EZ-� I�GWLD iwyr�u�tnc_w� ,u� � � ,� � 5 ANPt_uCn.a.IT 1»'re ctit t►��= LOT t_I we ,_